Chiropractic Care Focus: Joint Manipulation Aka. “Adjustments”

Chiropractic care can take many forms and can help people in different ways. Many Chiropractors often claim to treat a variety of ailments from the more specific: muscle, joint, headaches and nerve conditions to more nebulous complaints such as low energy, digestion, allergies/post nasal drip and congestion, asthma, chronic infections, multiple sclerosis and unfortunately cancer. Many of these are challenging to treat with usual medical care as well. Often they do require medication and a consultation with more than one provider.

The most common method a Chiropractor treats a patient’s complaints is through adjustments. Adjustments performed by a trained practitioner involve pushing or pulling on the body. These moves are targeted at joints where two bones come together and move past each other. The force from the push or pull causes the two bones to move a part and space is increased between them. This causes the joint fluid (Synovial fluid below) to form a bubble inside of the liquid. This movement of two bones away from each other often results in a popping or cracking sound that is classically associated with Chiropractors: “I just need my back popped doc!”

There are different health care providers that will “gently” force joints apart. The technical term for this is joint manipulation. Some Physical Therapists may go obtain certifications to manipulate joints, Doctors of Osteopathy may also manipulate joints. Joint manipulation may involve wiggling bones at the joints, or a fast push/pull such as in a adjustment.

Joint adjustments/manipulations have been better studied in the last two decades as the evidence-based model of healthcare has become more prevalent. Currently, it is well established that spinal joint manipulation (applying to Chiropractors, PT’s and Osteopaths) is effective at conservatively managing low back pain, neck pain, and headaches safely. Neck pain and low back pain are one of the most common causes of permanent disability in the United States, and most people experience an episode of neck and/or low back pain in their lifetime.

Unfortunately, the funding for spinal manipulation studies is low, and these studies are limited in their quality. The quality standards for manual medicine is compared to that of pharmaceuticals/pills. The ability to blind everyone to what treatment is being delivered is impossible in a manual therapy because the person delivering the adjustment knows if it is a sham treatment. In a study for a drug, the doctor, patient and person analyzing the data can all have no idea if they got the test drug or a sugar/water pill. The inability to blind the practitioner means that many of the studies are automatically considered low quality. Therefore, a bias in evidence quality is inherent and until it is addressed, non-drug studies will be considered inferior.

With low funding, comes low participant numbers. Studies are considered higher quality/more meaningful when more people are included. Unfortunately a good study for spinal adjustments only has 25 -50 people in a test group and in a control group. These low numbers hinder the study quality. Multiple studies may be “pooled” together in a larger evaluation of past studies. This type of work is called a Meta-analysis. These are considered to be the best evidence because they look at multiple studies and can increase the number of patients. The problem with looking at many smaller studies is studies that some may be poorly conducted may skew results, or the measurements of pain and function may be different and can not be combined.

Despite the problems with research of joint adjustments, and based on best quality evidence, the current evidence supports the statement that joint adjustments in the spine help alleviate pain and stiffness, and also improve a persons ability to move and do their daily activities.

With the recent awareness of the opioid epidemic, the need for safer, conservative care options that don’t involve drugs or surgery has been in demand. As such, spinal manipulation, therapeutic massage (i.e. not relaxation/fluffy massage) and exercise are as effective, but much less harmful than drugs and surgery.

The most common risk of a joint adjustment is temporary pain and loss of function.

What does this mean!?

It means that a person can feel worse after an adjustment. A properly performed adjustment may actually make someone feel worse initially. Despite this, people in studies ultimately report benefit from a series of adjustments. It is important to note that this is more common (speaking from experience) in the earlier stages of care, especially when someone has never been adjusted before. The reason for this is unknown, but generally it is assumed to be an inflammatory response, but may also be a protective neurological response that results in spasm.

Typically a person may feel like the region or a joint is sore after getting adjusted. It is usually minimal and less than the discomfort or pain they had before coming to get treated. I often hear “I was pretty sore that evening/next day, but it was better than what it was before”, or “I was cursing you for the next/day evening, but it is way better now”.

Less commonly, a person will experience a significant flare up following an adjustment. This usually is a muscle spasm and it is more common in the neck. These can be traumatizing to a patient, but more so if they don’t know it can happen/it is normal/not predictable/possible with an excellent adjustment, albeit unfortunate and certainly not the intent. In these cases, icing and maintaining as much movement as possible, in a tolerable range is important. Often times a follow up adjustment may greatly help, but will at least help reduce the chance of the nervous system developing a chronically tight muscle that may produce low grade issues in the future. Muscle release techniques often are important as well in resolving this undesired side effect quickly.

In the event someone has a poor response it is important to remember that, as with any procedure, complications may require additional out-of-pocket treatment to manage. Please be kind to the practitioner who treated you, they mean you no ill will and certainly weren’t trying to hurt you. It is all to common that patients complain: “that other guy did it wrong and messed me up” or they “know someone” that a doctor “messed up”. Keep in mind that you can do everything right/well and still things don’t work out the way you want. Use your best judgement before writing a negative review of a Physician on Social Media. Talk to them first. Part of a comprehensive treatment plan is learning what adjustments work well, or may not work for a given person.

In conclusion, spinal adjustments are very safe and effective for managing neck and low back pain. adjusting is not without risks, but serious risks such as joint sprain, muscle strain, fracture, dislocation and disc herniation are extremely rare. More serious risks such as stroke are even more exceptionally rare.

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