Is cervical spine manipulation dangerous ?

Yes Cspine manipulation is dangerous, but not that dangerous...

The risk is about 1/1.5million. It seems quite a lot but in fact you have more chances to die being struck by lightning !

Taking pills (NSAID) may seem safer, but in fact 16000 deaths a year in the US alone are attributed to the use of these painkillers. This gives a ratio of 500/1m people dying from gastric bleeding from taking anti-inflammatories. I won't even start to talk about liver intoxication associated with paracetamol.

So what is dangerous about it ?
in fact the danger comes from the rupture of the cervical artery or from a migration of atherothrombosis during the cervical manipulation which leads to a CVA or death.
Caution must be taken with :

• patients suffering from High Blood Pressure (walls of arteries are more rigid and/or presence of cholesterol)
• patients suffering from high cholesterol
• patients suffering from hyperlaxity or connective tissue disorder (eg: Marfan syndrome)
• patients suffering from vertebral atery occlusion syndrome

At a more practical level the aim is to reduce the number of cervical manipulation. And believe me a painful neck is not necessarly a neck to be manipulated !!! I've been horrified to hear patients telling me that they were seeing their therapist up to 3 times a week to have their neck manipulated.

The cause of your neck pain may not come from your neck !
This little test can be performed on yourself or on your patient. The patient sits on the table and you ask him to look over the right and left shoulder, check the rotation and ask the patients to notice when they feel the pain. Now, place your hands underneath the diaphragm and gently lift it up (liver, stomach...) and ask your patient to rotate his head again. Any change in the rotation or in the pain indicate that there is probably no need to manipulate the Cspine, the problem is coming from somewhere else. Yes this may sound odd but a gastritis, an anterior tilt of the liver, a Csection scar... can create neck pain.

Is it a problem if I "crack" my neck myself ?
It is not such a problem if you manage to do it at the right spot ! Often we tend to manipulate the part which is painful and this is not necessarly the right vertebrae or part of the body to manipulate. By moving the vertebral joint you will make it looser, if you manipulate it too often this joint will become hypermobile. To stabilize it, muscles will contract, this is painful and you feel the urge to crack it again... a splendid vicious circle. In other words, if you keep "cracking" the same vertebrae I seriously doubt that this is the right one to move and this will cause you other problem on the long run.

(http://en.wikipedia.org/wiki/Spinal_manipulation#Risks_of_upper_cervical_manipulation
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=3239547&dopt=Abstract
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=8583176&dopt=Citation
http://www.bmj.com/cgi/content/full/316/7146/1724)

Physiotherapy, Chiropractic, Osteopathy: What to choose ?

The patient is often confused between these three therapies and doesn't know what to expect from these different approaches.


Physiotherapy : the physiotherapist is a specialist in rehabilitation. After an injury (fracture, surgery, CVA...) the physio will rehabilitate the patient with massages, mobilisations, ultra-sound, exercises or even teach a patient to use crunches. His approach is generally symptomatic and his recommendations are often statisticly based (eg : in chronic low back pain a series of 3 push ups, 5 sit ups and 7 pulls of the right ear lobe improve the symptom by 47% over a period of 7 weeks. Please don't try this at home, this is just an illustrative example !!!).

Why is this ? I believe that physiotherapists are the right hand of the medical field and have been formed to fit the medical way of thinking. Therefore anything they do must be proven effective and safe, even merely effective is fine as long as it is safe.

The problem is that proving something is hardwork, time consuming, money consuming, and often another study will few months later proves the opposite to be true. A study is often too specific or too global to be constructive.

This approach avoid to talk about the "Unicity" of the patient. It does mean that if two patients complain from the "same" areas or symptoms they will be given the same treatment regardless the root of the problem which is not necessarly the same. The outcome of the treatment is therefore not as effective as it could be : it does not address the root of the problem but the treatment is as safe as it can be.



Chiropractic : Here is a joke for you ... what is the difference between a chiropractor and an osteopath ? 60 000 $ a year.

Chiropractic has been developed in the US at the end of the 19th century by Dr Palmer. Chiropractors claims that the source of our problems comes from the nervous system. Therefore corrections of "subluxed" vertebrae tend to lead us towards balance and recovery. Chiropractors will use spinal manipulations, ultra-sounds, massages, TENS, or other "high-tech" equipments. Often the massage, US, TENS(...) is given by a PA (physician assistant), then here comes the Chiropractor who will manipulate the spine. The chiropractor may need to see you up to 3 times the first week then will decrease the frequency of the treatments.

Personnally I am far from convinced that a back pain necessarly comes from a "subluxed" vertebrae but if you believe that the key of your problem comes from your spine, well then go for it. If you are not getting any better then make your next stop the Osteopath ;)

Osteopathy : Any traumas, injuries, sugeries, infections you had in the past are affecting your body in some way today by creating some restrictions and series of compensations. After a while your body cannot compensate any more, you bend forward to pick up a pen and "click", a vertebrae moved a bit too much and you just suffer from an acute facet lock. Now, is it just a vertebrae or a whole pattern of compensations, interactions, fascial connections, visceral dysfunctions, nutritions(...) that is responsible for your agony ? I would like to believe that we just need to correct a vertebrae, as it would make the work a bit easier, but the human is a little bit more complicated.

Generally an Osteopath will spend between 30 and 40 min with you and only you. During that time at least 40% of the treatment is spent in diagnosis in order to understand where the problem is coming from, this allows a more accurate treatment.

Osteopaths only use their hands, as machines tend to be imprecise and often scare the patient.

Personally I will never see a patient more than once a week and rarely more than 3 times the first month. Some Osteopaths are even reluctant to do more than one treatment every other week. (for some more details about the treatment content please check the other posts !)

What ever therapist you see do no hesitate to try different ones and stick with the one you feel the most appropriate. If you do not feel any improvement after 2-3 sessions, look for another approach or opinion.

Structural, Visceral, Cranio-sacral Osteopathy ?

You can find a french translation of this article Here.

It is a sensitive thing to divide Osteopathy in different systems as any of these systems are inter-related. Some Osteopaths will even say that no such thing exist as "Structural Osteopathy", "Visceral Osteopathy" or "Cranial Osteopathy". I never really understood why. Maybe because from this notion comes the notion of "Cranial, Structural or Visceral" Osteopath and this can't be, because an Osteopath is not supposed to be specialised but to be holistic.

I do believe that we are all coming from different background and graduated from different schools which may differ from there lectures' content. Therefore we all practice differently and may have more affinities for one technique or another, for one field or another... Some Osteopaths may get a Master from the OCC, UK (Osteopathic Children Clinic) and I will certainly describe them as more "specialist" than I am in treating babies and children.
At the same time if I meet an Osteopath describing himself as a Cranial Osteopath, I would immediatly feel irritated/intrigued.

In the UK a great majority of osteopaths (from what I believe) are more focussed on the "structural and cranial field". In France maybe more on the "visceral and cranial field".

"Structural Osteopathy" :
is aiming at restoring movement through the Musculo-skeletal system (joints, muscles, fasciae, ligaments, capsules ...) by a combination of techniques. It may involve some "HVT/LVT" of the spine (the famous "cracking techniques"), articulation of joints, deep massage, trigger point inhibition, stretch, fascial unwinding...

"Visceral Osteopathy" :
is aiming at restoring the mobility and motility through the different organs of your body. This may sound strange but an organ can easily be the cause of a lowback, neck, shoulder (...) pain. It will do so by changing the posture of the patient (adoption of an antalgic posture) or by directly referring pain to an area of the body (liver/right shoulder, kidney/lowback pain...). The Osteopath will then mobilise, stretch, inhibit, unwind(...) the concerned group of organs. I do believe that at least 60% of the patients ' complaints do have a deep visceral cause. This means that if left untreated their symptoms are more than likely to reoccur.

"Cranial Osteopathy" :
is aiming at restoring the mobility and rythm through the bones of the cranium, spine and sacrum. This cranial rythm pulses between 10 to 12 cycles per minute and is believed to be the core mechanism of all the body functions. This is the approach of choice to treat babies (colic, reflux...), stress, anxiety, headaches(...). Cranial Osteopathy is still quite controversial even amongst osteopaths but is fast becoming a therapy in its own right.


Seeing, feeling, understanding and treating the body through these three fields make Osteopathy an effective holistic therapy.

What is Osteopathy ?

(You can find a french translation of this article here)

Osteopathy is a manual therapy which was developed at the end of the nineteenth century by Dr Andrew Taylor Still in the US. Dr Still based his discipline on 4 main principles :
- "Life is movement" : therefore any structures that are not moving in your body, are deteriorating or "dying".
- "The Structure governs the function" : and vice versa. If the structure of your body is affected so will be its function (a broken elbow results in a poor elbow motion for example). The opposite is also true : if you spend your life time lifting bricks, you will develope strong, fibrotic back muscles and probably degenerative discs and spondylosis in your lumbar vertebrae.
-"The rule of the artery is supreme" : blood flow is essential to our body and if any structures (muscles, joints, fasciae...) are stiff, rigid these will impair a good vascularisation which will lead to further deterioration.
-A.T. Still believed as well in the "self-healing mechanism of the human body", and that the Osteopath was not treating the patient, but was in fact sign-posting the patient's body towards a better way to "self-heal".

For an Osteopath, the aim of the treatment is to find the "restrictions" of your body and to mobilise them : "Find it, fix it and leave it alone".

"Restrictions" have many different names such as : "Osteopathic lesions", "Hypomobilities", "Somatic dysfunctions" (pseudo-medical term), "subluxations" (chiropractic term). They result from any micro/macro-traumas, environmental factors, diet, pathologies or simple adaptations.
The most important ones are called primary lesions and they will be responsible for a series of compensations called secondary lesions. Very often, the patients' complaints are secondary lesions. This is why a symptomatic approach is rarely effective on the long term ; because the primary lesion is still there and will recreate the same series of adaptations and therefore the same symptoms !
The Osteopath will tend to focus his treatment on finding and treating the primary lesion. By doing so, he's treating the cause of the symptom rather than the symptom itself.

OK, by re-reading myself it looks a bit confusing, let's give an example : A patient comes complaining of a low back pain, the case history reveals a fractured ankle 10 years ago. The patient had an Xray revealing some wear and tear at L5S1. He has been advised to have some physio (ultrasound, massage ...) on his back and to take some painkillers. Few month later the back pain is still pesistent with some gastritis (thanks to the NSAID). The Osteopath will test all the body and find some major restriction on his ankle. For 10 years the patient has been walking with a slight limp which developed an excessive compensation pattern through his pelvis and lumbar spine. As long as nothing is done to improve the mobility of his ankle no improvement can be expected for his back. His ankle restriction is his "Primary lesion", and the L5S1 joint the "Secondary lesion". The Osteopath will then mobilise his ankle as well as probably, knee, hip then low back and within few treatments we can expect a long term improvement.

Another Osteopath in Malaysia

That's it ! Another Osteopath in Malaysia Kuala Lumpur ! It took me 9 months to get my work permit. The main problem being that I was only 26, one year short for the Ministry of Health guidelines.

Everything started in December 2005 when my girlfriend and I went to do some volunteer work in Thailand, Surin (thanks to Starfish ventures ). There I worked within the rehabilitation department of Surin Public Hospital, directed by Dr Noi, and Dr Lee. The language barrier was a real challenge. By the end I succeeded to communicate on a basic level with the patient ( lie on your back : "none niai", lie on your tummy : "none kwam ") but of course my tone and accent were rarely precise enough and often instead of saying : "sit down" ("nang") I was actually saying : "cinema". You can imagine that certain patients were a bit confused... Dr Noi and Dr Lee had a lot of patience with me and were helped me out when going through the case history of each patient.

Too often in Europe we practice osteopathy in a private practice having no or very little indirect communication with any doctors or specialists, and working there really allowed me to be in contact with physiotherapists, acupuncturists, radiologists, orthopaedists as well as seeing more "challenging patients' complaints"
Once Dr Noi told me : "you know here, in thailand, in public hospital we are paid really little, we do our job with passion , whereas in private hospital they do the job for money, do it quickly and by quantity..." I know that in France it is definively the opposite, but i found that this statement was true at least in their department.

So a few months later we went to renew our visa in Kuala Lumpur, Malaysia . I visited the KLCC and discovered a medical center. I came in looking like a typical tourist (shorts, converse, camera, sunglasses) and got my first interview !