Should chiropractors eliminate the cracking with spinal manipulation?

By James Lehman

I recently met with one of my colleagues to discuss a modern technology, which enables chiropractors to perform spinal manipulation without causing the audible release or cracking noise. He claimed the technology was more attractive to his patients, especially the individuals who did not appreciate manual manipulation of the neck. It was his opinion that this modern technology, which used sophisticated instrumentation, helped him to detect spinal joint fixations and treat them more effectively without pain or cracking.

Now, I admit that I am an old school chiropractor. After all, I graduated from Logan College of Chiropractic in St. Louis in 1972, prior to its evolution into a health sciences university. In those days, we were taught to perform a history and physical examination to determine a diagnosis. We used our minds and hands to detect the cause of spinal joint dysfunction. Consequently, we would use our hands to first treat myofascial trigger points with trigger point pressure releases, which was then considered as a form of Logan Basic Technique or Nimmo Technique. Following the soft tissue treatment, we would perform a diversified spinal manipulation, which would normally produce an audible release (cracking noise) and relief of the spinal pain. Like most chiropractors, if the audible release was accomplished, we felt confident that the spinal manipulation would reduce the patient’s pain and improve spinal function.

Research continues to support the use of chiropractic care for spinal pain and this year a study demonstrated that the use of non-pharmacological, chiropractic care to treat patients with low back pain reduced adverse drug effects. So, why should I consider spinal manipulation without the audible release? My colleague mentioned that possibly the reason only 9 percent of Americans use chiropractic care on an annual basis is related to the fear of spinal manipulation because of the cracking noise. In addition, he mentioned that many medical doctors were more comfortable referring patients when they realized the treatment did not involve cracking of the neck. Now, that comment got my attention.

Chiropractic providers are no longer limited to treating patients in private practices. It is true that chiropractors are finally integrating into community health centers and Veterans hospitals. These organizations require MD or DO referrals for chiropractic care. In fact, a recent study concluded that “Doctors of chiropractic are working in diverse medical settings within the private sector, in close proximity and collaboration with many provider types, suggesting a diverse role for chiropractors within conventional health care facilities.” So, I am wondering if there is a fear of referring patients for chiropractic care that might be related to the cracking noise and a perceived fear of injury. I could not find evidence of such a fear with a Pubmed search but I am now wondering if it is a problem.

Since I work in a Federally Qualified Health Center as a chiropractic specialist and a credentialed member of the primary care team, I am wondering if the primary care providers are concerned with the cracking of the neck with chiropractic spinal manipulation. Although I have not discussed such a concern with the referring members of the primary care team, I will start asking for feedback. Yet, I am wondering if the use of modern technology and instrumentation would enhance the delivery of chiropractic care and spinal manipulation while alleviating the fears of medical providers?

What evidence is there in the literature that will better educate me regarding the value of using instrumentation that avoids cracking of the neck? I found a few articles that discuss a minimum energy hypothesis of fixation (of the spine) resolution and patient response to multiple impulse therapy for musculoskeletal complaints. The first article claims that manipulative effectiveness takes only a minimal amount of energy to attain mechanical equilibrium. I do recall that Arlan Fuhr, DC, has offered for many years, a low force, hand held device that is used to reduce spinal joint fixations. Several of my colleagues switched to the hand held instrument because of injuries caused by their performance of manual medicine interventions.

Believe me, performing spinal manipulation is difficult and it requires manual dexterity and athleticism. A chiropractor who uses poor body mechanics or performs an excessive number of treatments per day is prone to injury and disability. A recent study found that Danish chiropractors commonly reported work-related, acute, physical injuries or overuse complaints. The overuse complaints usually involved injury to the low back, wrist, thumb, and shoulder and more common in women than men. Now, I am wondering if modern technology and instrumentation might prevent injuries to chiropractors that discontinue or reduce the amount of hands-on spinal manipulation and prolong my own career.

Evans and his colleagues suggested in 2002 that a computerized (modern technology) adjusting device, which uses multiple high-velocity, low amplitude impulse percussive therapy with a lighter force (no cracking) is an effective treatment. My spinal manipulation intervention with the use of my hands has been described as a high velocity, low amplitude force but it is certainly not a percussive therapy and there is definitely an audible release (cracking noise).

I ask is there any evidence that the percussive, multiple impulse technology demonstrates positive clinical outcomes?

A 2006 study aimed to document the response of patients to multiple impulse therapy for a variety of musculoskeletal complaints encountered in a clinical practice. The investigators concluded that the response of patients experiencing low back and neck pain appeared to be considerably faster than that obtained in three recent studies that used hands on spinal manipulation. Based upon my research, it appears that it is time for this old school chiropractor to consider the use of a modern technology that provides spinal manipulation without an audible release.