Spinal manipulation is a commonly used technique in the pain relief clinic for those with simple Back and Neck pain. It is used to treat areas of spinal segmental dysfunction where there are symptoms of painful muscle spasm and restricted spinal movements. In trained hands it is a safe, effective and comfortable treatment. It may be also used in those with certain types of Spinal Nerve Root Pain.
Specific Terms commonly used to describe the indications for spinal manipulation - Hypomobility, Motion restriction, Joint fixation, Acute joint locking, Motion loss with somatic dysfunction, Somatic Dysfunction, Restore bony alignment, Meniscoid entrapment, Pain modulation, and Reflex relaxation of muscles.
- A proper history should be taken which notes the mode of onset (sprain, postural, or spontaneous onset), progress over time, alleviating and aggravating factors, and red flags which may suggest nerve root involvement or other sinister causes.
- Past medical history and current medications should be noted to help exclude conditions which would make manipulation inadvisable.
- A general assessment of mental state is also advisable, noting abnormal pain behaviour, anxiety and depression - often called "yellow flags".
- Examination should be thorough to help eliminate serious red flag conditions. Neurological examination (reflexes and muscle power) should always be performed to exclude nerve root compression.
- Practitioners often use a system of examination called ARTT to look for signs of somatic dysfunction:-
- A = Asymmetry where there is an obvious difference in the appearance in an area compared to the opposite side.
- R = Range of motion where an area is either moving normally, in a restricted way, or is showing signs of hypermobility.
- T = Tissue texture where there is a difference between two areas when touching the soft tissues (skin, fascia, muscles).
- T = Tissue tenderness where there is a difference in the painful pressure threshold to touch in the muscles in an area.
- The whole of the spine should be examined as well as looking at leg lengths and pelvic alignment. Examination will often involve touching the spinal muscles looking for areas of spasm and pain, along with a functional assessment which includes looking at passive and active spinal movements, noting areas of reduced movement (hypomobility), and increased movement (hypermobility).
- Should the history and examination suggest red flags, then further investigation is necessary. Simple tests include full blood count, ESR, and X-rays. An MRI scan is also useful in cases of suspected nerve root involvement.
Spinal Nerve Root Pain
- Manipulation involves encouraging the "stiff" area of the spine to begin moving again, and comprises soft tissue massage, gentle mobilisation movements (articulation), and firmer carefully controlled movements (high velocity low amplitude thrusts - HVT's) which stretch the stiff part often accompanied by a series of "clicks" or "pops".
- Each "pop" or "click" represents a spinal facet joint being released from its restricted state. This is similar to clicking your knuckles. These maneouvres often result in a very rapid reduction in spinal muscle spasm and pain, accompanied by a noticeable increase in the range of spinal movements. Manipulation combined with regular specific exercises seem to the most successful at maintaining the mobility of a previously stiff area.
- For those who cannot relax, and where HVT manipulation is considered to be safe, intravenous sedation can be used. This may help both the patient and the therapist to achieve success.
- One would expect to see at least 75% improvement in symptoms with 3-5 treatments. If this is not the case then other techniques or further investigation should be considered.
- HVT Spinal Manipulation is a useful technique for a range of spinal nerve root complaints. However, whenever manipulation is considered in the presence of nerve root symptoms, these tests should always be performed to reassure the patient and the doctor that nerve root function is normal:-
- Normal reflexes
- biceps reflex = C5/6 nerve function
- brachioradialis reflex = C6 nerve root function
- triceps reflex = C7/8 nerve root function
- knee reflex = L3 nerve function
- ankle reflex = S1 nerve function
- Normal motor power
- normal power in the leg motor groups L1 to S1
- normal power in the arm motor groups C4 to T1
- No dural tension signs in the legs using the slump test (sitting straight leg raising with trunk flexion)
- No root pain down the arm using the nerve root provocation test (neck extension combined with side bending and rotation to the same side)
- Normal S2/3/4 nerve root function - normal buttock muscle tone, and saddle sensation
- If there is any doubt about neurological function, then an MRI scan should be performed before HVT manipulation is performed. See Contra-indications for more information about when not to perform HVT spinal manipulation.
- Disc Prolapse - after a bout of nerve root pain caused by annular tears and disc prolapses there is often persisting back or neck pain and restricted spinal movements (Spinal Dysfunction). After a series of Epidural Injections when the nerve root pain component has recovered, HVT Spinal Manipulation is a useful treatment for the spinal pain component.
- Spinal Stenosis - in this condition the internal diameter of the spinal canal can be reduced by excessive lumbar extension (backwards bending). Lumbar muscle spasm holds the spine in extension and therefore can worsen spinal stenosis. An exaggerated thoracic spinal curve (round shouldered posture) tends to produce a compensatory opposite curve in the lumbar spine (hollow backed), which can again worsen spinal stenosis. HVT Spinal Manipulation can be useful for reducing lumbar extension caused by lumbar muscle spasm. Freeing up the thoracic spinal movements can also unlock the movements in the lumbar area, reducing the hollow lumbar curve.
- Foraminal Stenosis - narrowing of the spinal nerve root exit holes can be worsened by additional paravertebral muscle spasm, worsening the degree of spinal nerve root irritation. HVT Spinal Manipulation can be a useful technique to reduce the local muscle spasm, allowing the foramen to open up again, giving the nerve root more room as it exits. If there is severe nerve root pain with weakness, an MRI scan would be advisable, and either an Epidural Injection OR Nerve Root Block for pain relief before considering manipulation.
- Spinal Muscle Spasm and Facet Joint Syndrome can cause Non Nerve Root Referred Pain in the arms and legs. HVT Spinal Manipulation is the treatment of choice for this condition once a annular tear / disc prolapse has been ruled out.
These can be divided into absolute and relative:-
Where it is more likely that the risks of HVT spinal manipulation will outweigh the potential benefits:-
- Bone problems - tumours, infection, fractures, bone weakness (long term steroids/osteomalacia, severe osteoporosis), severe inflammatory types of arthritis (not osteoarthritis).
- Nerve problems - spinal cord compression, moderate to severe nerve root compression from a disc / spondylolisthesis.
- Blood vessel problems - aortic aneurysm, severe coagulation deficiencies, severe vertebro-basilar insufficiency (see below).
- Diagnostic problems - where the exact cause of the pain is unclear.
- Consent problems - where the patient is unable to understand clearly the aims of treatment, or are unable to give written or verbal informed consent.
- Co-operation problems - where the patient is unable to co-operate with treatment, or is unable to relax sufficiently (see yellow flags below).
- Hypermobility which is severe enough to produce frank instability - lax ligament syndromes / spondylolisthesis.
Where it is less clear whether the risks of HVT spinal manipulation will outweigh the potential benefits:-
- Adverse reactions to similar treatments in the past.
- Disc prolapse - where there has been shown to be a prolapse (usually on MRI scanning) which is large enough to be compressing (not just irritating) a spinal nerve root.
- Pregnancy - HVT spinal manipulation at its risks need to be discussed in relation to precipitating a miscarriage (in the first 3 months) or premature labour (in the last 3 months). The overall risks are low during the middle 3 months where gentle techniques are advised.
- Mild osteoporosis
- Vertigo or mild vertebro-basilar insufficiency (see below).
- Hypermobility with ligamentous laxity (see below).
- Psychological dependence on "clicks".
- HVT spinal manipulation is a safe treatment for hypomobile (stiff) areas of the spine. In certain individuals excessive laxity (hypermobility) exists in part of the spine.
- The cause of the hypermobility can be congenital (inherited condition affecting all ligaments), traumatic (spinal ligaments disrupted / stretched during an injury), or degenerative (spondylolysis / spondylolisthesis).
- Excessive movement in the spine occurs because of laxity of the supporting ligaments which normally control the anatomical range of spinal movements.
- Pain often comes from two sources - sprained ligaments and protective muscle spasm. HVT's in the hypermobile area can further stretch the supporting ligaments, causing worsening of the hypermobility, and even producing frank instability.
- Clinically a hypomobile area may be adjacent to a hypermobile area, and it may be impossible to treat just the hypomobile area without also treating the hypermobile section next to it.
- Alternatives - consider prolotherapy for hypermobility, and surgery for frank instability.
HVT spinal manipulation requires a fair degree of understanding and co-operation during treatment. It should be avoided in the following circumstances:-
- Where the patient is not able to give informed verbal or written consent.
- Where the patient is not able to understand the nature of the problem or its treatment.
- Where there is a high degree of anxiety which precludes adequate relaxation or co-operation.
- If the patient is displaying disproportionate pain behaviour.
- VBI occurs most commonly in the elderly, where tipping the head backwards into extension causes dizziness, vertigo and even blackouts.
- The cause is due to arteriosclersosis (hardening of the arteries) affecting the two small vertebral arteries that run upwards in the neck to supply the balance centre in the brain stem. These arteries are more likely to kink when the head is tipped backwards, temporarily reducing the blood flow to the balance centre, causing the balance centre to stop functioning, leading to dizziness and vertigo. The situation is normally resolved back bringing the head back into line with the trunk again. Some elderly people already have one artery blocked due to severe arteriosclerosis.
- Excessive force during HVT manipulation of the neck can sometimes produce a small tear in one of these vertebral arteries, and if the artery clots off afterwards, this causes permanent reduction of blood flow to the balance centre in the brain stem, and permanent symptoms of severe vertigo afterwards.
- A new type of surgery is available where the blocked vertebral artery can be bypassed using a graft similar to that used in coronary artery bypass surgery in the heart. This is a new technique and therefore the risks and benefits have not yet been determined.
- Osteoporosis affects the structure and strength of the bones. Caution is urged in patients with severe osteoporosis due to the risk of causing a vertebral / rib fracture during treatment.
- In skilled hands gentle HVT spinal manipulation is safe in those with mild osteoporosis, where the risk of fracture is much lower.