Clicks, cracks and crunches: no thanks!

In Osteopathy, Research and Practice (1910), the originator of osteopathy, Dr. A.T. Still, wrote:

‘One asks, “how must we pull a bone to replace it?” I reply, pull it to its proper place and leave it there. One man advises you to pull all bones you attempt to set until they “pop.” That “popping” is no criterion to go by. Bones do not always “pop” when they go back to their proper places nor does it mean they are properly adjusted when they do “pop.” If you pull your finger you will hear a sudden noise. The sudden and forceful separation of the ends of the bones that form the joint causes a vacuum and the air entering from about the joint to fill the vacuum causes the explosive noise. That is all there is to the “popping” which is fraught with such significance to the patient who considers the attempts at adjustment have proven effectual. The osteopath should not encourage this idea in his patient as showing something accomplished.’

Just read that last line again please: The osteopath should not encourage this idea in his patient.

Yet some new patients clearly expect me to make their spines make “cracking” noises. They think something has “clicked out” (the “cause” of their pain) and should be “clicked in”, to the relief of all. And since these are usually people who have previously been to other practitioners, and since they have obviously gained the impression that this is osteopathic reasoning and that the “crack” is what defines an osteopathic treatment, my only conclusion can be that the profession is indeed guilty of “encouraging this idea” in its patients.

But the whole idea is wrong (and it is not osteopathic reasoning). Spines do not click in and out like a broken part of some old-fashioned mechanical toy.
Spines sometimes click. They sometimes strain. Sometimes they click at the same time as they strain. Sometimes they don’t. The click means nothing. Spines are complicated. Spines are intelligent. Spines learn behaviour. They are sophisticated and intricate computer-commanded biomachines, not clockworks. Would you hit your expensive laptop with a hammer when it’s not working properly? Maybe you’d like to, but that wouldn’t solve any problems!

Remember: The osteopath should not encourage this idea in his patient.

So why are some of my colleagues doing this? Are they being taught this themselves? If not, where did they learn it? I have no answer to this. All I can do is explain my own attitude to these techniques.

“Bone-cracking” techniques (technically “high velocity low amplitude thrusts” or HVLAT) were not especially prominent in early osteopathy. Indeed Dr Still seemed to have preferred to use other kinds of techniques. HVLAT gained in prominence during the twentieth century, to the extent that graduates of certain schools seem to use them as standard and to be aware of little else in the osteopathic toolbox.

There are indeed a few occasions in which the rapid reduction of acute pain that HVLAT sometimes produces cannot be matched by other kinds of techniques. It is also quick, saving time for the busy practitioner, who often however, would do better by the patient by giving a more complete treatment. But mostly, I think, its popularity is because the noise produced by the joint when rapidly opened is somehow psychologically satisfying to both patient and practitioner. The feeling that something has been achieved.

The osteopath should not encourage this idea in his patient.

“Bone cracking” has important disadvantages. I treat mainly chronic cases (formally defined as symptoms of more than six months duration). In chronic conditions bone-cracking is usually useless, and can even do harm. Indeed, I have seen a fair few patients who have previously been harmed, or felt they have been harmed, by injudicious, clumsy, too frequently repeated, or indiscriminate HVLT manipulation. Sometimes, I fear, it is used as a “shotgun” technique when a practitioner does not know or cannot be bothered to identify clearly what needs to be done.

Chronic dysfunction in tissues is characterised by long-standing stiffness, and ingrained habit. It involves the whole body in compensatory muscle activity, postures and movement patterns. These too become hardened, ingrained habits. Treatment of chronic conditions should be viewed as a gradual, gentle unwinding of the whole body, not knocking isolated bits of it “back into place”.
The very idea would make me laugh, if it didn’t make me so annoyed that some of my colleagues encourage this idea in their patients.

The osteopath should not encourage this idea in his patient.

As a technique HVLAT lends itself to application according to wrong criteria such as “manipulate the painful joint” or “manipulate the stiff bit” or simply “manipulate to make a satisfying noise”, without taking into consideration
the whole body pattern which needs unwinding. “The painful joint” or “the stiff bit” rarely has a purely local cause. This vital work never gets done if the focus is on single bits in isolation, or on the production of satisfying “clicks” or illusory quick fixes.

Biological tissues should not be forced. If a joint has to be thrust forcefully in order to “adjust” it, it is not ready for “adjustment”. When it is ready, it does not need to be thrust. Why use HVLAT when gentler, effective and risk-free alternatives abound? It defies sense and defies, I would say, responsible practice.

Unfortunately, the rise of HVLAT has been such that many people identify osteopathy with this technique. I have a very satisfied patient who once told a friend of his that he had been going to an osteopath for his back pain.
“Did he crack your back?” the friend enquired. “No? You must be mistaken then. He can’t be an osteopath.” Another patient, a rally driver, asked me after his first treatment, “Aren’t you going to manipulate my back?” I explained that I had just spent half an hour doing just that. “But I know that a good osteopath always cracks the spine”, he said. I suggested then he’d better go to a “good” osteopath.

Good practice and good treatment is defined by its approach to human problem-solving, not by techniques.

The osteopath should not encourage this idea in his patient.

Eddie Izzard on bone cracking.