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Objectives: To examine beliefs about cracking sounds heard during high-velocity low-amplitude (HVLA) thrust spinal manipulation in individuals with and without personal experience of this technique.

Methods: We included 100 individuals. Among them, 60 had no history of spinal manipulation, including 40 who were asymptomatic with or without a past history of spinal pain and 20 who had nonspecific spinal pain. The remaining 40 patients had a history of spinal manipulation; among them, 20 were asymptomatic and 20 had spinal pain. Participants attended a one-on-one interview during which they completed a questionnaire about their history of spinal manipulation and their beliefs regarding sounds heard during spinal manipulation.

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Results: Mean age was 43.515.4years. The sounds were ascribed to vertebral repositioning by 49% of participants and to friction between two vertebras by 23% of participants; only 9% of participants correctly ascribed the sound to the formation of a gas bubble in the joint. The sound was mistakenly considered to indicate successful spinal manipulation by 40% of participants. No differences in beliefs were found between the groups with and without a history of spinal manipulation.

Conclusions: Certain beliefs have documented adverse effects. This study showed a high prevalence of unfounded beliefs regarding spinal manipulation. These beliefs deserve greater attention from healthcare providers, particularly those who practice spinal manipulation.

An audible pop is the sound that can derive from an adjustment in spinal manipulative therapy and is often seen as an indicator of a successful treatment. A review conducted in 1998 concluded that there was little scientific evidence to support any therapeutic benefit derived from the audible pop. Since then, research methods have evolved considerably creating opportunities for new evidence to emerge. It was therefore timely to review the evidence.

Five original research articles were included in the review, of which four were prospective cohort studies and one a randomized controlled trial. All studies reported similar results: regardless of the area of the spine manipulated or follow-up time, there was no evidence of improved pain outcomes associated with an audible pop. One study even reported a hypoalgesic effect to external pain stimuli after spinal manipulation, regardless of an audible pop.

Many chiropractic patients are familiar with hearing a popping or cracking sound when receiving SMT and this is often seen as a factor that differentiates mobilization and manipulation [6]. To the clinician delivering SMT, this sound is frequently associated with the perception of a successful intervention [6] and when it does not occur, some clinicians may apply another treatment thrust [7].

Whilst historical theories see SMT as primarily aiming to restore joint function and mobility, the exact mechanisms by which it achieves this, or whether such interventions are responsible for the documented decreases in pain and improvements in function [12], remain disputed or unknown. Other mechanisms invoking psychological reassurance from personal interaction and therapeutic touch by the clinician associated with inhibition of ascending and/or descending sensory neural pathways or reflex changes have been proposed [13, 14]. Indeed, Herzog [15] suggests that SMT produces reflex responses in muscle tone, with effects reaching locations that are distant to the treatment site.

One of the effects of an audible pop (AP) is believed to be its contribution to these muscle reflex responses [10]. However, such a mechanism was countered by Herzog [15], who showed that an AP can be elicited with a slow force application and is not associated with a corresponding electromyography response. This suggests that the AP may not be responsible for the reflex responses observed during SMT [16]. Whilst the AP is inextricably associated with SMT, there is currently no consensus on its clinical relevance.

This review was conducted to assess and update the evidence pertaining to the potential role of the AP in obtaining therapeutic benefits associated with SMT, specifically if the AP plays a role in decreasing pain perception. This is key to understand the mechanisms behind SMT associated clinical benefits and may help to inform strategies to improve the effectiveness of the treatment.

The study characteristics of the five included studies are summarized in Table 1. All studies aimed to investigate the effect of an AP during SMT on pain outcomes. Most assessed the influence of the intervention on existing musculoskeletal pain. Bialosky et al. [20] took a different approach by applying the intervention on healthy subjects followed by an external thermal pain stimulus to assess outcomes. One included study [21] was an RCT, whereas the other studies were prospective cohorts [20, 22,23,24]. Four out of the five studies [20,21,22,23] are secondary analyses of which the protocol and primary results are provided in detail elsewhere. All studies were carried out in the U.S.A.

Interestingly, Bialosky et al. [20], using a classic pain experimental set up for patients without spinal pain, found that hypoalgesia as measured using heat as external pain stimuli was associated with spinal manipulation in that there was a reduction in perceived pain post manipulation, but that an AP is not required for this effect to be generated. Even though the observed trend by Bialosky et al. [20] of greater hypoalgesia to temporal summation in the lower extremity with the presence of an AP was not statistically significant, the moderate effect size may still indicate potential importance due to underpowering of the study. The only evidence found in support of direct physiological effects of the AP during SMT is described by Clark et al [39]. who reported reduction in erector spinae muscle spindle stretch reflex activity occurred only when SMT was accompanied by an AP. However, this study included only twenty participants, both symptomatic and asymptomatic, and focused on the mechanics of SMT utilizing neurophysiologic assessment techniques which did not include measuring pain outcomes.

Beyond local neuromechanical treatment effects, clinical improvement during chiropractic care might be more fully understood using known mechanisms by which contextual factors within therapeutic encounters impact top-down pain modulation [14]. Increasingly, research that acknowledges the importance of such elements including the characteristics of the treatment on clinical outcomes is emerging [40]. Indeed, recent reviews suggests that these factors are very likely important modulators of outcomes in manual therapeutic approaches to pain [41, 42]. In this regard, none of the studies included in this review discussed the potential meaning to the patient of hearing APs during SMT.

In part of the Contextually Aided Recovery (CARe) model [14], the authors speculate that the degree of physical invasiveness of the therapeutic intervention may increase the impact of contextual factor driven analgesia. These authors hypothesize that increasing patient perceived invasiveness from simple touch through manipulation, injection and on to surgery may have increasingly powerful impact on top-down pain modulation mechanisms through increased expectation of therapeutic benefit. In this regard, it might be posited that SMT with an AP can be perceived as more invasive to patients than SMT without an AP. Interestingly, this is not borne out by this review as SMT with AP does not seem to have a stronger hypoalgesic effect compared to SMT without AP and this idea may deserve further investigation.

Limitations of this review include some common methodological problems in included studies, such as lack of blinded assessment which could weaken the evidence in these experimental studies. To separate physiologic effects from effects based on subject expectations, subjects must be fully and convincingly blinded to their treatment. Unfortunately, true blinding has proven to be very difficult to achieve regarding SMT; placebo physical interventions often differ too much to the physical experience of SMT making it potentially straightforward for the patient to identify shams.

Secondly, although this review found that an AP does not have an effect on perceived pain regardless of the area of the spine manipulated, we do not know if this is generalizable to extra spinal locations such as the wrist or ankle joint.

In summary, there is currently an absence of evidence that supports a relationship between the presence of an audible pop during the delivery of SMT and pain outcomes. So, whilst it is still unclear as to the factors that underly clinical improvement associated with approaches that include SMT, this aspect of SMT practice does not seem to be an important factor for the hypoalgesic effect. In terms of clinical practice then, this review supports the notion that clinicians need not overemphasize the presence of a perceived AP as an indicator of successful treatment. However, noting that some practitioners and patients still consider this aspect an important part of the SMT experience, further research would be helpful in fully comprehending the contribution to the perceived meaning of this phenomenon to both patients and practitioners.

In piranhas, sounds are produced through the vibration of the swim bladder wall caused by the contraction of bilateral sonic muscles. Because they are solely innervated by spinal nerves, these muscles likely evolved from the locomotor hypaxial musculature. The transition from a neuromuscular system initially shaped for slow movements (locomotion) to a system that requires a high contraction rate (sound production) was accompanied with major peripheral structural modifications, yet the associated neural adjustments remain to this date unclear. To close this gap, we investigated the activity of both the locomotor and the sonic musculature using electromyography. The comparison between the activation patterns of both systems highlighted modifications of the neural motor pathway: (1) a transition from a bilateral alternating pattern to a synchronous activation pattern, (2) a switch from a slow- to a high-frequency regime, and (3) an increase in the synchrony of motor neuron activation. Furthermore, our results demonstrate that sound features correspond to the activity of the sonic muscles, as both the variation patterns of periods and amplitudes of sounds highly correspond to those seen in the sonic muscle electromyograms (EMGsonic). Assuming that the premotor network for sound production in piranhas is of spinal origin, our results show that the neural circuit associated with spinal motor neurons transitioned from the slow alternating pattern originally used for locomotion to a much faster simultaneous activation pattern to generate vocal signals. ff782bc1db