WHY MANIPULATION?
Or…Do I really need to get cracked?...AKA DJD, disc degeneration, arthritis, spondylosis and stenosis….
When you're under the care of an Interventional Chiropractor, the answer is often yes, you do need to be “cracked”. The cracking sound that's heard during a successful adjustment (or manipulation) comes from the FACET JOINTS, and it’s just air escaping from the solution within the joint. These joints are on the back side of the vertebral column, there are 48 of them in total, because at every one of the 24 movable joints in the spine there are two facet joints, right and left. (see fig. 14) That's why the chiropractor will often adjust (or manipulate) both sides of the spine. However, one of the most important things to know about performing manipulation is WHEN NOT TO. (Fig. 5 shows how the tension in the “locked” joint is reduced by the manipulation, and Fig. 6 shows where in the spectrum of range of motion we have to take the joint to to perform the manipulation) A joint that is repeatedly manipulated when it is not truly locked (it’s being manipulated to make noise and give the patient TEMPORARY relief, over and over and over) has the potential to become hypermobile. A hypermobile joint is one that has had its supporting ligaments stretched beyond their normal anatomical length (whiplash or other injury, including fighting gravity in the presence of poor alignment), causing laxity (looseness) and creating guarding in the surrounding, supporting musculature. (see figs. 11 and 12) These are the small muscles that are "called in" when the ligaments can no longer support the spinal joint, keeping it aligned and functioning normally. But unlike the ligament that should be doing the job, these muscles stay in a contracting, guarding state. So, very often, the hypermobile joint will present to our office as a very STUCK joint, because the muscles are guarding it, pulling it into itself, causing it to become locked and creating arthritic degeneration as well as fibrosis within these muscles. This is however NOT a reason to manipulate it OVER AND OVER AGAIN. This is usually the patient that responds very well to Prolotherapy, a procedure that uses injections directly into the ligament that has become lax, causing an inflammatory response and resultant repair of the ligament. This leaves the ligament thicker and stronger, able to once again do its “supporting” role. Many of my patients over the years have gotten tremendous relief from this type of hypermobile condition under the hands of Dr. Robert Wagner, MD at Capitol Spine and Pain.
So, with what you've already learned about FIBROSIS, imagine what happens to these tight, short muscles that are guarding and staying in a contracted state around the spine….YES, they become hypoxic (low in oxygen) causing inflammation (consisting of goo and collagen fibers) within the muscle, resulting in the dried goo and collagen fibers once the inflammation resolves, resulting in fibrosis within the muscle, making it less like filet mignon and MORE LIKE BEEF JERKY. And you now know that a simple cracking of the joint won't magically make these muscles return to a normal state. They must be treated specifically. It takes a specific touch and a LOT of tension (created by positioning the body specifically, sometimes using a special table for this) to create the leverage that it takes to remove this fibrosis from these little, powerful and important muscles, thus allowing the disc to remain hydrated once the joint is unlocked. Active Release Techniques coupled with specific manipulation are the only things I've found in twenty years that can actually accomplish this. The old “Pop and Pray” method over and over and a little ultrasound or stim or TENS or ice/heat to the area just can’t accomplish this.
The reason it is so important to have motion from segment to segment at every level of the spine
becomes evident as we learn more about the disc. (see fig 15) The disc is not a poker chip that slips in and out of place. It is a shock absorber and a spacer, but its anatomy is more complex than is usually explained. The analogy of the Jelly Donut as it is often described really falls short. The disc (vertebral disc) is made up of a nucleus of a "crab-meat" like center, TIGHTLY compacted by rings of concentric ligaments that hold it so tightly that it acts like a ball sitting between two plates. These "plates" are the endplates of the vertebrae above and below. The disc remains hydrated by fluid that comes through the tiny holes in these endplates during motion, keeping it healthy and plump. Some hydration also takes place when we lie down, if the joint is not locked. The rings of ligaments have fibers oriented in such a way as to make them incredibly strong. They’re cross-hatched. (bottom part of fig. 15) But, with months or years of reduced motion, the disc becomes increasingly dried out and weakened and the nucleus is driven by forces placed on it (fig. 14 again) that it can no longer withstand, and it breaks through these annular ("around") fibers that compose the disc and produce a bulge or a full-on tear to the outside called a prolapse. (figs. 3 & 13)
So what do we do if the disc is already torn through? Some say traction is the answer. To this I say, beware. Beware of the type of tear you have, and how far gone the disc actually is. Traction to certain types of disc conditions is a waste of time and money. The educated eye will spot this on MRI, and the educated doctor will show it to you and explain it. There are limitations to matter, and when you reach a certain point, manual means and traction will fail. Supporting Article “manip9” explains this in detail, the bottom line being that the tears in the disc heal with granulation tissue (fibrosis) and nerves grow in along this fibrosis causing constant firing, making the muscles continually guard and lock the joint, bringing about more fixation and degeneration.
Non-operative procedures exist that are performed by physical medicine doctors like those at Capitol Spine and Pain (www.treatingpain.com) often with remarkable results. These include
Interdiscal Prolotherapy and interdiscal procedures such as IDET, performed by Dr. Dan
Kendall, DO. But if the disc is further along in the degenerative process, it may require surgery, and we're very lucky to have some really talented ones in the DC Metro area. My two favorites are Dr. Donald Hope MD (www.drhope.net) and Dr. Tushar Patel MD (www.c-o-r.com) who have helped many of my patients over the years to regain their lives.
So Why Manipulation?
