Spinal Manipulation: When Do You Use Multiple Cracks Vs. Specificity

Happy Tuesday, everyone. This is Dr. Scott Gray. Back to you again with another episode of the Redefining Physical Therapy podcast.

And so today, I want to start off talking a little bit more about spinal manipulation. And so, there’s a lot of different camps out there.

Some are specific to the segments involved, while others are about multiple cracks and multiple pops. So, let’s not lock anything up.

But, when do you use those particular manipulations versus the other, right? And so, I want to answer that today.

But let’s backtrack a little bit first, and let’s talk about when you should manipulate, right? And, why.

So, there’s really a couple of different reasons why you should manipulate someone.

The first one is to get someone out of pain, right?

So we know that when you manipulate it can help patients get out of pain and it allows you to get them moving and healing, right?

The second reason why we manipulate is to reduce muscle tone and guarding, right?

As you know, as we manipulate, stimulates the different mechanoreceptors that cause a reciprocal inhibition of the muscles that may be guarding or in tonic spasm.

So, that is another reason you want to manipulate.

The third reason you want to typically manipulate is to improve mobility and function, right?

So if a joint is stiff or stuck, you can mobilize it or you can do a grade five thrust, right?

So, you can crack it.

And so, the way I explain this to my patients and students and clinicians that I am currently training, I tell them like a door that is stuck, right?

So if a door is stuck and it’s not moving, you can gently mobilize it, right? See if that improves.

But if it’s stuck, sometimes you need to crack a joint. And so, that’s where your grade five thrusts come into play.

Now, I would also add in another reason why should we be manipulating and that’s to help with patient expectations and a placebo, right?

So, sometimes patients just want to hear a crack because they think that something had happened to them.

It gets them to think that maybe you put something back into place, even though we know that’s typically not true.

But these are things that you need to be using in your arsenal to deliver better outcomes.

But, let’s jump into when do you use the specific type of grade five thrust, right?

So if I have a patient that is just generally hypermobile, they don’t have any red flags, guarding, or anything like that.

Well, sorry, I take that back. You do actually want to manipulate if they do have to guard.

You want to do then the multiple pops and cracks, right?

Now, conversely, if I say, for instance, I had someone come in with a disc injury, they are guarded.

I don’t want to manipulate that segment, right?

That’s going to be in question because I could potentially irritate that, especially on the hot disc, right?

But I can manipulate the segments above or below it. And so, that’s where I want to be really specific.

And so, people will say, well, you can’t really be specific. And I think that’s a bunch of nonsense because if you study the best manual therapist and you learn these skills and the art of manual therapy, you can lock out specific segments.

And I will tell you just based on when I’ve lockout things, you feel the pop right underneath your hands.

And so, you just don’t want to skip several segments along those lines when you’re trying to be specific.

So another case you might want to be very specific about is if they have a hypermobile segment, and they have relatively hypomobility adjacent to it, right?

So you want to manipulate the hypermobile segments, but you don’t want those hypermobile segments to move, right?

So you think of people that have a thoracolumbar syndrome or dysfunction, where the L1, L2 they’re typical, I would say, almost hypermobile.

They’ll have a crease with their moving just at those segments.

So you don’t want to manipulate there per se, you want to manipulate above and below it.

So you’d want to lock that segment out and then manipulate it.

So there you have it, those are just some things to think about when you’re manipulating.

When do you want to lock everything out and be precise and specific?

Maybe then, when do you want to get multiple pops to make the patient feel like that you’ve done something to them, or they just have general hypomobility across all of their spine or those segments.

So, that’s my take on when to use each. And I used both in clinical practice, it’s just another tool and you just need to apply your clinical reasoning when you want to use one versus the other.