Over-Manipulation Syndrome

Can Massage Break the Cycle?

By W. David Bond

We have all had the client who cannot stop cracking his back, chest, fingers, or neck. Even during the intake process, he is continually rotating his head in a circle and scrunching his shoulders around his ears, or twisting his low back to show you what movement he can no longer do. He may even thrust his chest forward and arms backward, trying to get a good crack. In the chiropractic business, he’s called the “self-manipulator,” the “self-adjustor,” or the “do-it-yourself chiropractor.” I call it being “addicted to crack.” 

The problem is known as over-manipulation syndrome (OMS), and for simplicity, I will focus on the syndrome as applied to the cervical spine. A client with OMS usually comes into my office with severe neck pain and a feeling of stiffness combined with an obsession and compulsion to wrench his neck around in an effort to get it to pop. Previously, he might have made family members cringe with how loud he could make his neck crack, but he’s come to my office asking for relief in any form, as he recently found he can no longer elicit any “snap, crackle, or pop” from his spine on his own. 

In my years as a chiropractor, I have seen hundreds of these people. They usually start years earlier after discovering that they could stretch their head to the side to get a “pop” out of their neck, and immediately any muscle tension and joint pain would disappear. This relief might have lasted for some time, but eventually this person would repeat the process over and over, like a lab rat with a food lever. Over time, an addiction sets in, and instead of self-adjusting at a frequency of once a week or once a month, it becomes a once-a-day, or more, compulsion. The period of relief also lasts for less and less time, so they become accustomed to adding increased force and rotational torque to try to get the same level of joint release. 

Chiropractic work utilizes high-velocity (speed of the mobilization) and low-amplitude (how deep the force is applied) manipulative procedures. If done correctly through the joint plane (line of drive), then there is less force necessary to make the release. Also, chiropractors may utilize moist heat, muscle stretching, massage, and other soft-tissue release procedures prior to the manipulation to relax the resisting musculature. 

When a client self-manipulates, however, there is no line of drive through the joint plane and usually no warming or relaxation of the musculature; therefore, there is the addition of more force, more rotational torque, more neck hyperextension, and a higher amplitude—all of which mean trouble. Over time, the increased force produces inflammation and spasm of the muscles and muscle insertion of the neck’s stabilizing muscles, and you may also get laxity of the supporting ligaments of the spine. Research has shown that noxious stimulation of the back muscles, interspinal ligaments, dura mater, and zygapophyses joints can produce local and referred pain.

The primary symptoms are constant muscular pain and the feelings of spinal joint tension and pain. The client usually says he just feels like he needs a good crack in the neck. The pain manifests as sharp, bilateral pain and stiffness with a deep, aching pain around the spine. There is usually no loss of active or passive spinal motion, but there is pain associated with movement and lots of subjective complaints of stiffness. Passive movement may produce pain at end range. Palpation usually reveals moderate to severe tenderness and hypertonicity laterally at the scalene insertions, as well as at the insertion of the levator scapulae, trapezius, splenius capitis, and splenius cervicis. There may also be a radiation of pain into the suboccipital region or to the upper extremities in a non-dermatomal distribution. Muscle weakness and other neurological signs such as reflex deficit and sensory loss are not present. 

I tell the client his body is trying to splint the area. Like putting on a cast for a broken bone, the body is trying to tell you to stop moving the body part in response to the joint inflammation. Also, the joint receptors are firing away, and because of the laxity of the ligaments, there is a loss of stability resulting in the muscle overcompensating to keep you from moving it. I also tell my clients that there is a pleasure center in the brain that is stimulated by the adjustment. The self-adjustment may work by releasing endorphins, the body’s natural opiates, into the bloodstream. The endorphins find the pleasure center, and there is a profoundly good feeling produced following the manipulation. However, eventually OMS is created, developing a need to pump more and more endorphins into the system. At the same time, there is more of a contrast between the good feeling and the pain. The client becomes aware only that his neck is tense and hurting, not that he is hurting himself by perpetuating the addictive process.

First I attempt to instill in my clients is that they need to admit they have a problem. It may sound strange for a chiropractor to tell his patient that cracking the neck is the problem, but part of being a chiropractor is also knowing when not to adjust. Instead of a 12-step program, there is a two-step program, and the treatment is always the same. First and foremost, the client must stop self-manipulating the spine. All the ligaments and muscles are screaming to stop, and the inflammation is rampant. I tell my clients that ligaments are meant to stabilize the spine, not to be continually stretched and never given a chance to heal.

 It takes roughly four weeks to stop feeling constant pain, as it reduces by about 25 percent per week. During this time, the client may need anti-inflammatory treatment. (I suggest taking homeopathic muscle-relaxant medicine and applying ice to the neck when the urge to crack the neck appears.) It generally takes another four weeks to fully get over the need to self-manipulate, so the rule of thumb is absolutely no self-manipulating for two months. The first week is always the hardest, especially for those who work in front of a computer. I also try to wean my clients off of coffee during this time, because a stimulant can cause more nerve irritation and muscle tension. There are lots of work cues and postural stresses that will make the self-manipulator want to start cracking again, too, and they may also need a new pillow for home use. Another option is OPTP’s McKenzie Cervical Roll, which can be placed inside the pillowcase of most conventional pillows. 

Step two is to get rid of the inflammation and spasm. Massage and stretching of the upper trapezius/levator scapulae, scalene, sternocleidomastoid, and especially the splenius cervicis musculature, is indicated. Long axis traction with postisometric stretching of those muscles also helps with trigger point therapy and muscle tension release techniques. During rehabilitation, it is OK for the client to stretch the neck, just not to go to the extreme range in order to elicit the crack. As massage therapists, your work with the client’s soft tissues can relax muscles and relieve tension in the crack-addicted areas, helping subdue the client’s urge to crack. After the first month of no cracking, the client’s range of motion improves markedly and pain subsides; within two months, my guess is that your client will be happier, pain-free, and, best of all, no longer addicted to “crack.” 

  W. David Bond, DC, DNS, DAAPM, has been a practicing chiropractor in Southern California since 1988. He is the founder and director of the Essential Chiropractic Center in Sherman Oaks and specializes in chiropractic pain management and soft-tissue/myofascial treatments. Contact him at www.essentialchiropracticcenter.com.