Spinal Manipulation: Over-Used, But When?

May 1, 2012

Most neck and low back pain sufferers are unaware that so many can very successfully self-treat and recover quickly. To do so first requires undergoing a standardized mechanical spine assessment that identifies whether or not the underlying spinal disorder has a directional preference (DP); most disorders do. A DP means patients can perform repetitions of a single direction of end-range spinal bending that rapidly centralizes and eliminates their pain, greatly hastening recovery.

Further, patients who so easily learn to effectively self-treat are then empowered to become independent of health care providers, both in their recovery from their current painful episode as well as knowing how to quickly self-eliminate any returning symptoms in the months and years ahead. Being able to conveniently and frequently apply such effective targeted mechanical treatment when needed during the day makes a huge contribution to this effectiveness.

Unfortunately, striving for patient independence is not the goal of most physical therapists and chiropractors. Most prefer to keep patients coming back: the more visits, the greater the income. Many have extensive training in delivering manual care, i.e. spinal mobilization and manipulation, and that becomes their favorite treatment and their chief source of income.

Unfortunately, our current reimbursement methods of paying for treatments and not outcomes creates a real conflict-of-interest because teaching patients to effectively self-treat and become independent decreases the number of office visits and lowers the practice income.

It’s well-known that spinal manipulation typically provides only short-term pain relief. Patients routinely say: “it helped for that day (or 1-2 days) and then the pain was back.” They then understandably return again and again, seeking more of that same temporary pain relief, like taking a mechanical pain pill.  Before long, they have become dependent on that clinician and that treatment for pain relief.

So manual clinicians keep doing what they know to do and what best financially supports their practice. There are even some who promote continued manual care after the patient has recovered, teaching that such care for prevents the return of “that terrible pain”.  There is no evidence to support that practice.

Such tactics, along with the short-term pain relief, begins to benefit the clinician more than the patient, who often makes little or no progress toward recovery.

There is however one legitimate indication for manual interventions in painful spinal disorders: when patients cannot generate enough end-range force themselves to commence or complete their own reversal process. Some can begin to centralize or eliminate their own pain (the reversal process) but cannot complete it. More force applied to their spine in the proper direction is often helpful and only temporarily needed, just to bet things started.  Once the pain is fully centralized or abolished, patients can then usually and successfully take over their own mechanical care and maintain the benefit gained from the manual intervention. They are then able to continue improving, including preventing their pain from returning, and take themselves on to full recovery.

So the role of manual therapy is not just pain relief. Its primary role should be to simply restore to patients their ability to self-treat. Most have a reversible, “directional” mechanical problem that they can learn to treat themselves, but some need temporary help.

For patients who can effectively self-treat, manipulation should be avoided in order to teach independence and effective technique in their self-care. With low back pain so often recurrent, patients will always return to what worked before. If they perceive that to be manipulation, they’ll return to that. But if they eliminated their own prior pain, they have been taught to draw on that experience to do it again.

Robin McKenzie, PT, the champion of mechanical assessment and self-treatment, has often said: “We cannot justify manipulating everyone just to benefit the very few who actually need it.”

There is abundant scientific evidence that most neck and low back pain sufferers can effectively and rapidly recover with self-treatment. To ignore that attractive and very effective self-treatment solution in favor of delivering passive manual interventions that so often yields dependency is a disservice to most patients.

Perhaps Thomas Szacz’s said it best in advising patients undergoing session-after-session of spinal manipulation: “Don’t bite the hand that feeds you unless it is keeping you from feeding yourself.”

But Abe Lincoln’s advice also applies to physical therapists and chiropractors who routinely begin their care with spinal manipulation: “You cannot help men permanently by doing for them what they could or should do for themselves.”

So spinal manipulation is only occasionally needed and its indications are easily determined by each patient’s pain response to mechanical testing.

So always pursue SelfCare First. I welcome your comments and questions at: info@selfcarefirst.com. You can learn more by visiting our website and accessing other educational material.


One Response to “Spinal Manipulation: Over-Used, But When?”

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