Along with the noteworthy advances of chiropractic research and documentation over the past 20 years have unfortunately come a number of highly publicized slings and arrows. Many are without sufficient basis, and there are enough to conjure up visions of St. Sebastian. One particularly troublesome impediment is the issue of disk herniations, which turn out to be the most common cause of chiropractic malpractice lawsuits.1 On top of this comes the statement in the most recent and widely consulted Merck Manual on health problems: "Manipulation ... may aggravate an arthritic joint or further rupture a disk and should thus be used with caution."2
We all know that urban legends are built from far less copious and visible citations than the two just cited. And so once again, your loyal scribe has attempted to lance a boil built upon logic and evidence that can be called into question. It would be best to start with a logical sinkhole.
The concept of a disk rupturing during manipulation may have had its origins with the assertion made by Farfan over 34 years ago to the effect that rotational stress causes disk failure. This study demonstrated that in rotation, normal disks withstand an average of 23 degrees and degenerated disks an average of 14 degrees before failure erupted.3 However, posterior facet joints limit rotation to a maximum of 2-3 degrees and would have to fracture to allow any further rotation to occur.4 Any disk failures produced experimentally by torsion are caused by peripheral tears in the annulus, rather than prolapse or herniation,4 so one can readily see that there appears to be a (pro)lapse of logic in this argument.
It's the evidence that should connect the dots here, however. In an outstanding systematic review and risk assessment,5 Oliphant demonstrates that, compared to accepted medical treatments for lumbar disk herniation (LDH), spinal manipulation emerges as an attractive alternative. Citing the risk estimates of LDH from 19 references, Oliphant calculates the net risk of a clinically worsened disk herniation or cauda equina syndrome from 6245 million patients studied over a 40-year period who present with LDH to be less than one in 3.7 million excluding anesthesia (1.8 million including anesthesia).5
Taking this number and running comparisons to other modalities, you have to like the odds for spinal manipulation:
Let us look at the actual outcome studies themselves. Two randomized trials currently support the wisdom of considering spinal manipulation as a treatment option for this condition. One study involving 51 cases of myelographically confirmed disk herniation compared rotational mobilization to conventional physical therapy (e.g., diathermy, exercise and postural education). The manipulation group demonstrated greater improvement in range of motion and straight leg raising compared to the physical therapy cohort, leading Nwuga to conclude that manipulation was superior to conventional treatment.15
The second trial examined 40 patients with unremitting sciatica diagnosed due to lumbar disk herniation with no clinical indication for surgical intervention. Subjects were randomized into two treatments: chemonucleolysis (chymopapain injection under general anesthesia) and manipulation (15-minute treatments over 12 weeks, including soft-tissue stretching, low-amplitude passive maneuvers of the lumbar spine and the judicious use of side-posture manipulations). Back pain and disability were appreciably lower in the manipulated group at 2 and 6 weeks, with no improvement or deterioration in the chemonucleolytic group. By 12 months, there were improvements in both groups with a tendency toward superiority in the manipulated cohort. Costs of treatment in the manipulated group were less than 30 percent encountered by the injected patients; furthermore, the latter group averaged expenditures of £300 (approximately $540 U.S.) for treatment failures, with no such costs experienced by the manipulated population. Thus, in terms of outcomes, absence of side-effects, and cost in treating herniations, spinal manipulation appears to have scored a trifecta victory.16
Additional support for manipulation in the treatment of disk herniations is provided from several prospective studies.17-21 The largest involved 517 patients diagnosed with lumbar disc protrusion, 77 percent of these having favorable response from pain after manipulative therapy.20 A literature review from Cassidy22 suggests that an additional 14 of 15 patients with lumbar disc herniations experienced significant relief from pain and clinical improvement after a two-to-three week course of side-posture manipulation.
Taking all of these viewpoints into account, I began asking what universe we are in, and quickly drafted a letter to the Merck Manual to challenge the quotation at the beginning of this article. A reply from editor Mark Beers, dated July 27, happily pointed out that "the statement you objected to is no longer present." He thanked me for my "interest in improving the quality of The Merck Manual." This particular episode may come to a Hollywood ending for now, telling us that being armed with the proper research evidence and using it judiciously is a necessary, but not always sufficient, first step to address these grievances. This is precisely where the Foundation for Chiropractic Education comes in with its concern for developing and applying research evidence to correctly document chiropractic health care. Unfortunately, as we all know only too well, there are a multitude of other dragons to slay. The support of FCER by the chiropractic community and any patients concerned with proper health care is absolutely essential for this effort to continue.
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
