Audible Popping During Spinal

Manipulation: Plausible Mechanisms and

Clinical Relevance
The mechanisms and clinical relevance of the audible popping or cracking sounds during highvelocity low-amplitude (HVLA) thrust manipulations of the spine or extremity joints are still not
well understood. Many practicing physiotherapists, chiropractors and osteopaths believe the
audible popping during HVLA thrust manipulations to be an important part of the technique
delivery and partly suggestive of positive outcomes for some conditions and some patients;
however, academics have published a couple of papers that found the popping sound to have no
relationship to outcomes in pain and disability.
Over the past 45 years, there have been several proposed theories regarding the underlying
mechanisms of the audible popping during HVLA thrust manipulation. Perhaps the most widely
known explanation was provided by Unsworth et al1 in 1971. After taking radiographic images of
MCP joints before and after traction manipulations, Unsworth et al described a rapid increase in
joint volume, which they hypothesized dropped the intra-articular partial pressure to below that
of carbon dioxide dissolved in the synovial fluid. This pressure change resulted in a phase
change from liquid synovial fluid to gas, forming a bubble within the center of the joint space
and causing an audible popping sound upon collapse. However in 1995, Brodeur2 proposed that
the cavitation process was generated by an elastic recoil of the synovial capsule as it snaps
back from the capsule-synovial fluid interface. More specifically, Brodeur believed the capsular
ligaments were drawn inward while the joint was being gapped to maintain a constant joint
volume, but the capsular ligaments eventually reach a critical limit and snap back from the
synovial fluid, thereby causing popping or cracking sounds. Recently in 2015, Kawchuck et al3
used real-time cine MRI to investigate the mechanism of the audible popping during MCP
distraction manipulations. Contrary to what has traditionally been accepted, as the traction forces
increased, MR images revealed the cavity inception occurred simultaneously with the joint
separation and the popping sound production. These results offer experimental evidence that the
audible popping or cracking sounds during HVLA thrust manipulation are associated with cavity
inception rather than collapse of a pre-existing bubble. These observations are consistent with the
tribonucleation theory, a known process where opposing surfaces resist separation until a critical
point where they then separate rapidly, creating a phase change from liquid to gaseous cavities.
Although there has been conflict regarding the mechanisms responsible for the audible popping
sounds during spinal manipulation, there is agreement that a 15-30 minute refractory period
follows the cavitation of the MCP joint.1-2 The refractory period is believed to be due to the
presence of a collapsed gaseous nucleus or micro-bubbles in the synovial fluid that have yet to be
reabsorbed in the joint, a phenomenon that is accompanied by an increase in resting post

cavitation joint space (i.e. decreased intra-articular density), that prevents re-cavitation for at
least 15 minutes.1-2
CAVITATION IN SPINAL FACET JOINTS HAS NOT YET BEEN VISUALIZED
Notably, the majority of the studies that have attempted to explain the mechanism responsible for
the audible popping during HVLA thrust manipulation have investigated the MCP joints, not the
facet joints of the spine. In 2003, Cascioli et al4 used CT scans and X-rays to see if facet joint
volume or density changed in 4 scenarios: premanipulation, premanipulation with traction, post
manipulation, and post manipulation with traction. Importantly, they reported no changes in facet
joint space and there was no evidence of intra-articular gas immediately after HVLA thrust
manipulation. Therefore, Cascioli reintroduced the Capsular Detonization Theory that was
originally proposed by Sandoz in 1969, whereby collagen fibers of the joint capsule are thought
to be stretched beyond their threshold and rapidly lengthened without being torn.5 Subsequently,
during lumbar HVLA thrust manipulation, Cramer et al6,7 found increased gapping of the facet
joints that was accompanied by audible popping which may support the cavitation theory;
however, there was no investigation for the presence of intra-articular gaseous bubbles as has
previously been reported in MCP joints.
IS THE AUDIBLE POPPING CLINICALLY NECESSARY?
Several studies have previously examined the mechanical,8 biochemical,9 neurophysiological10
and hypoalgesic11 effects of HVLA thrust manipulation. After critically appraising the literature
to determine the therapeutic benefit of audible popping, Reggars14 reported that there is a paucity
of scientific evidence supporting the role of the audible popping during HVLA thrust
manipulation techniques but conceded, there is ample empirical evidence to support some
therapeutic benefit from the audible release. In contrast, Flynn et al15,16 published two secondary
analyses using data from a CPR study that has since been found to not be valid17-19, and
concluded that audible popping during spinal manipulation is not necessary for successful
outcomes in patients with low back pain. Cleland et al20 also reported no relationship between
audible popping following thoracic HVLA manipulation and reduction in pain, disability, or
improved AROM for patients with mechanical neck pain; likewise, this thoracic CPR was also
later found to not be valid21. Additionally, and of concern, only 27% of patients in the Flynn
study reported a dramatic improvement in pain following treatment,15 and the patients in the
Cleland study did not exceed the minimal detectable change for the NPRS in patients with neck
pain.20,22 Thus, while both Flynn and Cleland downplayed the importance of audible popping
during HVLA thrust manipulation, poor treatment strategy and/or even poor manipulative
technique delivery may have actually marginalized their physiologic relevance.
HVLA thrust manipulation that is typically accompanied by audible popping has been associated
with improved joint ROM,23-25 decreased muscle hypertonicity,26,27 brief electric silence,28
reduced pain24-26,30 and cellular changes.31,14 Additionally, Bialosky et al32 found greater
hypoalgesic effects (to temporal sensory summation or C-fiber mediated pain) in the lower
extremity following lumbar HVLA thrust manipulation in those subjects that experienced audible
popping when compared to those subjects without audible popping. Furthermore, TeodorczykInjeyan et al33 observed a reduction of proinflammatory cytokine secretion in participants

receiving HVLA thrust manipulation with audible popping in comparison to those without
audible popping.
According to Dunning et al,24-25,34 most practitioners anecdotally believe that the popping sounds
are an indicator of the successful delivery of an HVLA thrust manipulation; furthermore, this
may explain why researchers often perform repeat HVLA thrust manipulations if they do not feel
or hear popping sounds on the first attempt.24,35-38 Interestingly, many patients appear to want
and/or expect popping sounds to accompany thrust manipulative procedures. As Sandoz opined
in as early as 1969, Any patient readily learns, even without being told, that the crack is a
necessary condition for a successful manipulation, and conversely that a failure to obtain the
crack means an unsuccessful manipulation. And we must frankly admit that for the manipulator,
the crack represents also an important, although not an absolute nor a sufficient, criterion for a
good manipulation.5 Moreover, two recent studies published by Dunning et al24-25 examined the
effectiveness of HVLA thrust manipulation versus non-thrust mobilization in patients with
mechanical neck pain and cervicogenic headache, respectively. Notably, upper cervical and
upper thoracic HVLA thrust manipulation was found to be appreciably more effective than nonthrust mobilization in reducing short-term pain and disability for patients with mechanical neck
pain24 and at reducing headache intensity, duration, frequency, disability and medication intake at
3-month follow up for patients with cervicogenic headache.25 While the presence of audible
popping was required in the methods for each of these studies, no firm conclusions can be drawn
about the clinical relevance of the audible pop without a direct comparison. Yes, more high
quality research needs to be conducted to directly compare pain and disability outcomes in those
with and without audible popping during spinal manipulation; however, the commonly taught
assertion in entry-level physical therapy programs that the audible pop is not required for a
successful HVLA thrust manipulation is not supported by Sacketts 3-pillars of evidence-based
practice;39 that is, most patients and practicing clinicians alike (i.e. 2 of the 3 pillars of evidencebased practice) believe audible popping is a necessary part of correct technique delivery for a
successful HVLA thrust manipulation.
AUTHORS
Alan Manning, PT, DPT, OCS, MTC, Cert DN
Physical Therapist & AAMT Fellow-in-Training
New River Wellness Institute, Okatie, SC
Raymond Butts, PhD, DPT, MSc (NeuroSci), Dip. Osteopractic
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Senior Instructor, American Academy of Manipulative Therapy
James Dunning, DPT, MSc (Manip Ther), FAAOMPT, MMACP (UK)
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Senior Instructor, Spinal Manipulation Institute & Dry Needling Institute
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Quimioterapia para la leucemia en nios

La quimioterapia (quimio) es el tratamiento principal para casi todas las leucemias

infantiles. Este tratamiento consiste en medicamentos contra el cncer que se
administran en una vena, en un msculo, en el lquido cerebroespinal (CSF) o que se
toma en forma de pastillas. Excepto cuando se administran en el CSF, estos
medicamentos de quimioterapia entran en el torrente sanguneo y alcanzan todas las
reas del cuerpo, haciendo que este tratamiento sea muy til para los tipos de cncer
tales como la leucemia.
El tratamiento de la leucemia usa combinaciones de varios medicamentos de
quimioterapia. Los doctores administran la quimioterapia en ciclos, con cada perodo de
tratamiento seguido de un perodo de descanso para permitir que su cuerpo se
recupere. En general, el tratamiento de la leucemia mieloide aguda (AML) usa dosis
mayores de quimioterapia durante un periodo de tiempo ms corto (usualmente menos
de un ao), y el tratamiento de la leucemia linfoctica aguda (ALL) utiliza dosis menores
de quimioterapia durante un periodo de tiempo ms prolongado (usualmente de 2 a 3
aos).
Algunos de los medicamentos usados para tratar la leucemia en nios incluyen:
Vincristina (Oncovin)
Daunorubicina, tambin conocida como daunomicina (Cerubidina).
Doxorrubicina (Adriamicina).
Citarabina, tambin conocida como arabinsido de citosina o ara-C (Citosar).
L-asparaginasa (Elspar), PEG-L-asparaginasa (pegaspargasa, Oncaspar).
Etopsido (VePesid, otros).
Tenipsido (Vumon).
6-mercaptopurina (Purinetol).
6-tioguanina
Metotrexato
Mitoxantrona
Ciclofosfamida (Cytoxan).
Prednisona
Dexametasona (Decadron, otros).
Probablemente los nios recibirn varios de estos medicamentos en diferentes
momentos durante el curso del tratamiento, pero no recibirn todos.

Posibles efectos secundarios de la quimioterapia

Los medicamentos de quimioterapia atacan a las clulas que se estn dividiendo

rpidamente, razn por la cual funcionan contra las clulas cancerosas. Sin embargo,
otras clulas en el cuerpo, tales como aquellas en la mdula sea (donde se producen
nuevas clulas sanguneas), el revestimiento de la boca y los intestinos, as como los
folculos pilosos, tambin se dividen rpidamente. Estas clulas tambin se pueden
afectar por la quimioterapia, lo cual ocasiona los efectos secundarios.
Los efectos secundarios de la quimioterapia dependen del tipo y dosis de los
medicamentos administrados, as como de la duracin del tratamiento. Estos efectos
secundarios pueden incluir:
Cada de pelo
lceras en la boca
Prdida del apetito
Diarrea
Nuseas y vmitos

Aumento del riesgo de infecciones (debido a los bajos niveles de glbulos

blancos).
Formacin de hematomas y sangrado fciles (debido a la baja cuenta de
plaquetas).
Cansancio (causado por los bajos niveles de glbulos rojos).
Al principio los problemas con las cuentas de clulas sanguneas frecuentemente son
causados por la leucemia misma. Estos problemas podran empeorar durante la primera
parte del tratamiento debido a la quimioterapia, pero probablemente mejorarn
conforme las clulas leucmicas son eliminadas y las clulas normales en la mdula
sea se recuperan.
Los efectos secundarios descritos anteriormente suelen desaparecer cuando finaliza el
tratamiento. Frecuentemente existen maneras de reducir estos efectos secundarios. Por
ejemplo, se pueden suministrar medicamentos para ayudar a prevenir o reducir las
nuseas y los vmitos. Se pueden administrar otros medicamentos conocidos
como factores de crecimiento para ayudar a mantener ms altas las cuentas de clulas
sanguneas.
El sndrome de lisis tumoral es otro efecto secundario posible de la quimioterapia.
Puede ocurrir en pacientes que tienen un gran nmero de clulas leucmicas en el
cuerpo antes del tratamiento. Cuando la quimioterapia mata las clulas leucmicas,
stas se rompen y liberan sus contenidos al torrente sanguneo. Esto puede afectar a
los riones, los cuales no pueden eliminar todas estas sustancias al mismo tiempo. El
exceso de ciertos minerales tambin puede afectar el corazn y el sistema nervioso.
Este problema puede evitarse asegurndose de que el nio tome muchos lquidos
durante el tratamiento y administrando ciertos medicamentos como bicarbonato,
alopurinol y rasburicasa, que ayudan al cuerpo a eliminar estas sustancias.
Algunos medicamentos de quimioterapia tambin causan efectos secundarios
especficos que no se incluyeron en la lista anterior. Asegrese de preguntar al mdico o
enfermera de su hijo sobre cualquier efecto secundario especfico al que usted debe
estar atento y sobre lo que puede hacer para ayudar a reducir estos efectos
secundarios.
La quimioterapia administrada directamente al lquido cefalorraqudeo (CSF) que rodea
el cerebro y la mdula espinal (conocida como quimioterapia intratecal) puede causar
tambin efectos secundarios, aunque stos no son comunes. La quimioterapia intratecal
puede causar dificultad para pensar o incluso convulsiones en algunos nios.
La quimioterapia puede ocasionar algunos efectos secundarios a largo plazo. Estos
efectos se discuten en la seccin Qu sucede despus del tratamiento contra la
leucemia en nios?.
Para ms informacin sobre quimioterapia, lea nuestro artculo titulado Una gua sobre
quimioterapia.