Manipulative medicine

Manipulation uses techniques designed to affect the musculoskeletal sys­tem (muscles, bones, joints and connective tissue) and is usually targeted mainly at the spine. The word manipulation is derived from the Latin word manipulare, ‘to handle’. The use of manipulation can be dated to the writings of Hippocrates in Roman times. Galen (AD 131–202) describes how a lack of sensation and tingling in the fingers were cured by treatment of the neck.

Bone setters employing simple manipulative techniques were popular in both Europe and America in the nineteenth century. From these observations and experiences, the techniques of osteopathy and chiropractic developed in the USA. Both are fairly recent disciplines.

Osteopathy was developed by the American doctor Andrew Taylor Still (1828–1912), who believed that the spinal structure governed the health of the whole body. He developed a theory that mis­alignments of the bones in the spine were either the cause or the result of specific illnesses, and correcting the spinal abnormalities could cure almost all illnesses, including infections.

Daniel David Palmer developed chiropractic in 1895 in the USA. At the time he was a non-medically qualified ‘magnetic’ or hypnotic healer. He believed that the body was filled with a vital force, which he described as ‘innate intelligence’ and that correcting the mis­alignments or subluxations (partial dislocations) in the spine would enable the nervous system to work most efficiently and could cure almost any illness.

Both osteopathy and chiro­practic had philosophical origins and practitioners believed that the ‘life force’ underpinned well-being. Although most modern manip­ulators no longer support these concepts but see their discipline more as a question of solving mechanical problems, some chiro­practors and osteopaths still hold to the notion of a vital healing force.

WHO MANIPULATES?

There are four professional groups who often use many of the manipulative techniques inter­changeably: osteopaths, chiro­practors, physiotherapists and medical practitioners.

Osteopaths and chiropractors are both statutorily registered and undergo four- or five-year full-time educational courses. Manipulation is also used widely by physio­therapists and medical practitioners. Physiotherapists usually learn simple manipulative techniques as part of their undergraduate course and can go on to develop this skill through various courses in their postgraduate training. Doctors, through organisations such as the British Institute of Musculoskeletal Medicine, can also learn manipula­tion and can obtain postgraduate qualifications as orthopaedic physicians.

It used to be the case that chiropractors tended to use more force with short, sharp, high-velocity manipulative thrusts, whereas osteopaths and physiotherapists would use gentler, more repetitive techniques best described as ‘mobilisation’. Now the differences between the professions using manipulation have become blurred. Although osteopaths in the UK are solely manipulative, in the USA an osteopathic qualification is of equivalent status to a medical qualification and an osteopathic doctor might not use manipulation, but would in effect practise conventional medicine.

DOES MANIPULATION WORK?

Various problems are said to respond to manipulation, although inevitably the scientific evidence lags behind the clinical recom­mendations made by most manipulators.

Spinal manipulation may help patients who have headaches and facial pains that may originate from their neck. Spinal pain, whether it is neck or low back pain, or pain referred from the spine into the tummy, pelvis or down the leg (sciatica) can also benefit. Sprains, strains, bursitis and ‘tendonitis’ in the hips, shoulders and peripheral joints may also respond.

GPs are recommended by their own Royal College to refer patients with uncomplicated low back pain (back pain that does not need a surgical opinion) to an appro­priately trained manipulator within six weeks if the pain is persistent. There is considerable research evidence to support this, par­ticularly in relation to chiropractic. Large well-constructed clinical trials suggest that patients receiving manipulation for their back pain are less likely to have a back problem both immediately after the treat­ment and a year later.

It is unclear whether simple physiotherapy techniques are actually better or worse than manipulation for patients with back and neck pain. As with many other complementary therapies, there is some good scientific evidence that manipulation is of benefit, but these techniques are certainly used far more extensively than would be indicated solely on the basis of the research available.

HOW DOES MANIPULATION WORK?

The rather fanciful ideas that osteopathy and chiropractic can treat almost anything have now been rejected by the manipulative profession. Manipulators see many of their treatments in the context of a mechanical model. The main aim of these techniques is to restore normal joint movement as quickly as possible. They get rid of pain by improving joint movement and overcoming muscle spasm and any nerve irritation that may be occurring.

Clearly, if a bone is broken, or if a disc is prolapsed and pressing on a nerve, or if there is an active bone infection or inflammation of a joint (for instance, in rheumatoid arthritis), then manipulation is unlikely to be effective and may be harmful.

WHAT DOES THE TREATMENT INVOLVE?

At your first appointment, you need to give a clear history of your problem and the manipulator will examine you carefully. Chiro­practors tend to work more swiftly than osteopaths, but usually a first appointment with a manipulator will take between 15 and 45 minutes. The manipulator will need to make a clear diagnosis of whether your problem is musculo­skeletal and, if so, which part of that system needs treatment.

You will usually need to get undressed to your underwear so that you can be examined and treated properly. Simple acute back pain usually needs between two and eight sessions. If yours is a chronic, repetitive problem, it may need more treatment.

The essence of good manipula­tion is a thorough and complete examination. The act of manipula­ting your spine should occur only after the manipulator has arrived at a proper diagnosis. The diagnosis will sometimes involve taking X-rays and usually involves examining your muscles, bones, joints and nervous system. While the majority of manipulators spend most of their time treating the spine, the peripheral joints, such as knees, hips, elbows and shoulders, can also greatly benefit from these techniques.

Chiropractors tend to suggest that patients come back for preventive adjustments. This means giving you treatments when you are symptom-free every three or six months just to keep you well. Osteopaths may want to see you only when you have symptoms. It is difficult to know which is the best approach, as there is no good evidence upon which to base a choice.

IS MANIPULATION SAFE?

Manipulation is one of the areas of complementary medicine where adverse reactions are known to occur. It is vital that you are examined properly and a clear diagnosis made before any mani­pulation begins.

Manipulation of the neck has been reported to cause stroke and spinal cord injuries, and sometimes these are simply not predictable. Estimates for how frequently these severe reactions occur suggest less than one case per one million manipulations. Temporary adverse reactions are quite common; about a quarter to a half of patients who have had manipulation experience some increased pain or discomfort after the procedure, although the vast majority of these adverse reactions will disappear in 24 hours and are actually part of the treatment process.

There are a number of situations in which manipulation should never be given (contraindications), and these include a fracture, an inflamed joint, a ruptured or unstable ligament in the joint, a mechanically unstable neck, compromised blood circulation in the neck and an inflamed or compressed nerve, either in the spinal canal or coming from the spinal canal. Sometimes, manipulation will need to be carried out very carefully after an operation or in people who have osteoporosis (thinning bones). If you are taking anticoagulants to thin your blood (for example, in heart disease) or you have a very distorted spine, then manipulation would need to be carried out very carefully.

An arthritic joint in itself is not a contraindication to manipulation, and indeed many people who suffer from persistent pain may benefit from treatment. In well-trained hands, manipulation is generally a safe and beneficial procedure.

WHOM SHOULD I SEE?

Osteopaths and chiropractors are statutorily registered and governed by bodies that can strike them off their register if they fail to comply with proper professional standards and ethics. If the practitioner you wish to see is on the lists provided by either the General Osteopathic Council or the General Chiropractic Council, then you can be assured that they are properly registered and qualified.

Lists of doctors who manipulate can be obtained from the British Institute of Musculoskeletal Medicine.
The Manipulation Association of Chartered Physiotherapists will pro­vide information about appropriately qualified physiotherapists. Details of all these bodies can be found in ‘Useful addresses’ (page 99).
In reality, there may be little to choose from between the manipulative skill and expertise of a physiotherapist and an osteopath or chiropractor and that of a medically qualified orthopaedic physician. What is important is that you feel comfortable with the manipulator whom you see and that their par­ticular approach is of benefit to you.