Don't Fear "The Crack"

Why you shouldn't fear chiropractic manipulation of the neck
Dr. Steven Scappaticci, B.Sc. (Hons.), CSCS, DC

                  I have had numerous patients present with chronic neck pain and the first thing they say to me is “I don’t want my neck cracked”. They often dislike the “cracking” sound or have heard stories through the grapevine about neck adjustments that make them want to avoid them altogether. I can understand a patient’s concern when it comes to having their neck manipulated. For someone who has never experienced it before, there may be uncertainty as to what to expect, or perhaps they’ve read “horror stories” in an online forum about stroke and chiropractic care.
 
            However, there has been an extensive amount of research conducted regarding neck manipulation and the possible adverse events associated with it, namely stroke. It should be noted that there are no known premanipulative tests that are effective for determining if someone is or is not a candidate for neck manipulation, according to Dr. Pierre Cote, a prominent Canadian researcher. Tests such as Houle’s, Wallenberg’s, and deKlien’s tests, aim to assess the patency of the vertebral artery, often by placing the patient’s head in an extension-rotation position. These premanipulative tests are not valid and have not been shown to improve health, as they do not meet any of the criteria to be implemented in clinical practice (Cote, 1999).     
            So if there are no manual tests, what can chiropractors do to ensure the safest practice measures when adjusting the neck? Well, first and foremost, a proper and thorough history (i.e. DAN questions for all my colleagues) and physical exam, which includes vitals (i.e. blood pressure and pulse) as well as assessment of known risk factors for stroke some of which include: hypertension, smoking, atrial fibrillation, previous transient ischemic attack, and diabetes mellitus (Cote, 1999).
            Dr. Cote emphasizes that a key piece to providing proper care is the explaining and obtaining of the Canadian Chiropractic Association’s (CCPA) informed consent. The consent form states that current medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke. What commonly occurs, is the artery is already damaged and the patient was progressing towards a stroke when the patient consulted the chiropractor (as stroke may present as a headache and/or neck pain). This is referred to as a “stroke-in-progress” and can happen whether one seeks care from their medical doctor or their chiropractor. Regardless of the practitioner, it is up to them to do everything they can to rule out the possibility of a stroke-in-progress. The process of obtaining consent allows for the patient to be fully aware of all the risks and gives them the opportunity to ask any questions.
 
            As for the efficacy of neck manipulation, Gorrell & colleagues (2016) conducted a study assessing the effects of two different cervical manipulation techniques for mechanical neck pain (manual manipulation vs. instrument-applied manipulation). The study found that manual manipulation provided improvements in subjective pain scores and neck range of motion at the 7-day follow-up. Interestingly the study demonstrated that not all manipulative techniques have the same effect on outcomes, which can be seen in the results between manual manipulation and instrument-applied manipulation.   
 
            Circling back to my chronic neck-pain patients, I always assure them that if they do not want their neck adjusted, I understand their concern/preferecnes. Although I may recommend neck manipulation and may include it in the treatment plan, I always list them many other forms of care that I can offer them to treat their neck pain some of which include: mobilizations, acupuncture, soft tissue therapy, and rehabilitation. 
 
            I hope this blog has helped to educate the reader and perhaps settle some myths about neck adjustments. If you or someone you know are suffering from neck pain, I encourage chiropractic care to be sought.
 
Dr. Steven Scappaticci, B.Sc. (Hons.), CSCS, DC is a chiropractor at AEGIS MD. He aims to implement a evidence-based, multimodal, functional approach to care. His goal is to work with you to get you feeling better and moving better.  
 
Reference:
 
Cote, Pierre. (1999). Screening for stroke: let’s show some maturity. Journal of the    Canadian Chiropractic Association. 43(2), p 72-74. 
 
Gorrell, LM; Beath, K; Engel, RM. (2016). Manual and Instrument Applied Cervical    Manipulation for Mechanical Neck Pain: A Randomized Controlled Trial.        Journal of Manipulative and Physiological Therapeutics. 39 (5), 319-29.