Introduction - What is chiropractic?
Spinal manipulation is not a new or recent concept. Records show that manipulation of the spine can be traced back to the time of Hypocrites (1, 2). Since the inception of chiropractic in 1895, chiropractors have held as a primary tenet, that biomechanical and structural derangement of the spine can affect the nervous system. Because the nervous system is so intimately related to the spine from an anatomical standpoint, identifying and restoring spinal structural integrity can improve the health of the individual by reducing pressure on sensitive neurological tissue. This tenet of chiropractic continues to be the emphasis that many chiropractors embrace and consumers seek. Doctors of chiropractic do not utilize drugs or surgery in their practice. However, there are times when they will recommend that the patient consult another practitioner if these or other methods of treatment are indicated.
The research status of manipulative therapy was reviewed in a 1975, NINCDS (National Institute of Neurological and Communicative Disease and Stroke) conference held in Bethesda, Maryland that included experts from many of the disciplines that utilize manipulation (3). Dr. Joseph Janse, DC, who was president of the National College of Chiropractic at the time, was the spokesperson representing chiropractic.
In his presentation, Dr Janse reviewed the literature from the time of the founding of chiropractic in 1895 to the 1975 conference date. From that review, various hypotheses were identified and research recommendations were drafted in order to dispel the myths and/or to support the tenets of the chiropractic hypotheses established at the 1975 meeting. Much of the research conducted to the 1975 date support the proposed hypotheses while others continue to be investigated.
This article will focus on the topic of low back pain, which is included in the biomechanical hypothesis and carries perhaps the greatest level of research evidence.
Overview – how does chiropractic fit in an overall care plan?
There appears to be firm literature support for chiropractic treatment of low back pain. Many of the published guidelines recommend spinal manipulation to be included in the treatment plan early in the care of low back pain (7-15). It is difficult to discuss the relationship of chiropractic to the treatment of low back pain without addressing the history and concepts behind the profession. Therefore, another purpose of this article is to introduce to the reader some of the concepts of chiropractic and address the issues surrounding a typical chiropractic visit.
What Does a Doctor of Chiropractic (D.C.) Do?
All health care providers use a standard procedure of examination to diagnose a patient’s condition in order to arrive at a plan of treatment. Chiropractors use many of the same time honored methods used throughout the various health care professions including consultation, case history, physical examination, laboratory analysis and x-ray examination. Therefore, the patient usually perceives very little difference comparing an initial chiropractic and medical consultation. However, the examination of the spine to evaluate structure and function and the treatment focus on the spine separates chiropractic from other health care disciplines.
When accidents, falls, tension, over-exertion or other injuring mechanisms occur, the inability of the spine to compensate can result in minor displacements or derangement of one or more vertebrae, causing irritation to spinal nerve roots directly by pressure or indirectly through reflexes. The treatment concept of chiropractic manipulative therapy is to re-establish normal spinal mobility, which in turn alleviates the irritation to the spinal nerve and/or re-establishes altered reflexes (4).
The treatment concept of chiropractic manipulative therapy is to re-establish normal spinal mobility, which in turn alleviates the irritation to the spinal nerve and/or re-establishes altered reflexes (4). Subluxation. The term “subluxation” is used by chiropractors to depict the altered position of the vertebra and subsequent functional loss, which determines the location for the manipulative treatment. “Subluxation” has been defined medically as: "a partial abnormal separation of the articular surfaces of a joint" (5). Chiropractors have described the term to include a complex of functions (i.e., the subluxation complex) as "an alteration of the biomechanical and physiological dynamics of contiguous structures which can cause neural disturbances. It is a process and not a static condition, a state of living tissue undergoing constant change. These changes include hyperemia, congestion, edema, minute hemorrhages, fibrosis, local ischemia, atrophy and eventually rigidity and adhesions which form not only in joint capsules, but also in ligaments, tendons and muscles themselves" (6). The Houston Conference Classification categorizes spinal subluxation as follows:
A. STATIC INTERSEGMENTAL SUBLUXATION
Lateral flexion malposition
Altered Interosseous Spacing (increased or decreased)
Osseous Foraminal encroachment
KINETIC INTERSEGMENTAL SUBLUXATION
Hypomobility (fixation subluxation)
Hypermobility (unstable subluxation)
Aberrant motion (paradoxical motion)
Scoliosis and/or alteration of curves secondary to muscle imbalance.
Scoliosis and/or alteration of curves secondary to structural asymmetries.
Decompensation of adaptational curves. Abnormalities of motion.
Costovertebral or costotransverse disrelationships
How Do Doctors of Chiropractic Locate the Problem?
The patient history identifies the area(s) of complaint. Questions about family history, dietary habits, past history of other treatment(s) (chiropractic, osteopathic, medical and other), occupational history, psychosocial history, and other areas will be asked to help determine the nature of the illness.
Following the consultation and case history, a physical examination that may include laboratory analysis and x-ray examination, will be performed in accordance with the chiropractor’s clinical judgement. There are many different methods of determining the spinal segments that require manipulation. Most commonly, static and motion palpation techniques are utilized for identifying spinal segments that are hypomobile or fixated. Another method of locating subluxations is the use of x-ray, where segments classified by the Houston Conference approach (previously described) are identified and treated with manipulation.
Some chiropractors utilize a device that detects the temperature of the skin in the paraspinal region and spinal areas with a significant temperature variance are identified as areas that require manipulation. Many chiropractors utilize a wholistic, biomechanical concept of treating the bipedal structure in its entirety, in an attempt to balance the structure from the feet upward.
Identifying weak links in the kinetic chain, sometimes quite distant from the area of complaint, are treated. This process may include both articular manipulation as well as muscular balancing through strengthening of under-active muscles and/or inhibiting over-active muscles to acquire a balanced structure. It may also include stabilizing the pelvis by placing a small heel lift in the shoe on the short leg side (which is determined radiographically). Pelvic stability can also be achieved by the use of corrective prescription arch supports if ankle pronation, pes planus (flat feet), and/or subtalar instability are present. Combinations of any of these treatment approaches along with exercises that strengthen the weak, under active muscles of the trunk and pelvis and stretch the tight, overactive muscles usually results in a more beneficial, long term result.
In the assessment of low back pain, differential diagnosis utilizing a "triage" concept of classifying low back injuries into one of three categories helps to guide the chiropractor (7). These categories include: Potentially serious: tumor, infection , fracture, major neurological (cauda equina) Sciatica: Nerve root Non-specific: mechanical LBP (most common type of presentation)
Goal setting is driven by the patient’s pain and disability issues and activity intolerance. Patient education is important to reduce anxiety levels that often accompany intense low back pain. The guidelines recommend a treatment plan of 3-5 visits/week over 1-2 weeks. If no demonstrable improvement is noted, the compliance and sincerity of the patient should be evaluated and the risk factors that may prolong recovery identified followed by discharge, referral or the initiation of a different treatment approach at 3-5 visits/week for 2 weeks (7). Consistent among all guidelines of low back pain treatment is the prevention of chronicity. The use of active care (care that is patient-driven such as exercise, activity modification, ergonomic modifications, etc.) are emphasized to accomplish this goal (7-22).
How Does a Chiropractor "Adjust" My Spine?
The term "adjustment," refers to the specific manipulation applied to vertebrae that have abnormal movement patterns or fail to function normally. The objective is to reduce the subluxation, which results in an increased range of motion, reduced nerve irritability and improved function.
The adjustment consists of a high velocity, short lever arm thrust applied to a vertebra, which is often accompanied by an audible release of gas (joint cavitation). The audible sound that is generated when a manipulation is applied is caused by the release of oxygen, nitrogen, and carbon dioxide, which releases joint pressure (cavitation) (23). The sensation is usually relieving, though minor discomfort has been reported (that usually lasts for only a short time duration) if the surrounding muscles are in spasm or the patient tenses up during the procedure. There are times when joint cavitation or cracking does not occur and this is often due to either significant muscle splinting or the patient may simply not be adequately relaxed during the procedure. At times like this, it is sometimes best to apply ice, rest, electrical stimulation, and massage prior to attempting spinal manipulation.
Objective effects of an adjustment have been investigated and reported. More specifically, a single adjustment produces both sensory and motor effects as well as sympathetic nervous system effects. The sensory and motor effects include: increased joint ROM in all 3 planes and reduction of pain (24, 25) increased skin pain tolerance level (26) increased paraspinal muscle pressure pain tolerance (27) reduced muscle electrical activity and tension (28)
Sympathetic nervous system effects include: increased blood flow and distal skin temperature (fingertips) (29) blood pressure reduction (30, 31)
Blood chemistry changes include: increased secretion of melatonin (32) increased plasma beta endorphin levels (33) elevation of Substance P and enhanced neutrophil respiratory burst (34) pupillary diameter changes (35).
There are many different techniques a chiropractor can choose from and there is a certain skill level and “art” involved with high velocity, low amplitude adjustment or manipulation. It is perhaps more important for the chiropractor to determine when not to apply the adjustment, which is the reason for the extensive academic load placed on the chiropractic student (4 years of college plus 4 years at a chiropractic college). The number of treatments required for the particular patient varies significantly due to the degree of the injury, the biovariability between patients, and co-morbid risk factors of chronicity (anxiety, depression, poor coping strategies, financial distress, low educational attainment, and others) (36, 37). For example, the treatment plan of a grade 1, lumbar sprain/strain rarely demands greater than 4-6 weeks to manage in an uncomplicated case with no co-morbid factors.
Will Physiologic Therapeutics Be Used With My Condition?
The spinal adjustment is what makes doctors of chiropractic unique in their approach to treating patients with spinal complaints. The adjustment, however, may not be the only procedure a chiropractor may employ in the course of care and case management.
The chiropractic profession has utilized drugless therapeutics (natural therapies) since as early as 1912 (6). Natural agents such as heat, cold, water, massage, light, and exercise, - are some of the physiological therapeutic measures that are often utilized by chiropractors. When controlled, these elements exert a beneficial influence on body functions.
There are other forms of physiologic therapeutics that employ the use of electrical stimulation, ultrasound, traction, dietary management and other natural procedures which are known to have specific physiological influence on the body. These may or may not be utilized by the chiropractor in the course of a patient’s case management depending upon their specific needs. Utilizing specific manipulations (adjustments) in conjunction with these procedures, the goal is to remove structural or nervous system irritation that may be a major contributing factor in a patient’s presenting complaint(s).
In the course of the treatment, the chiropractor may recommend some procedure(s) that should be employed at home and/or at work. The success or failure of obtaining patient satisfying outcomes may be directly related to an ergonomic/job-related activity or a hobby-related irritating activity at home.
Cardiovascular and strengthening exercise are important in the management of low back pain (7). If a patient has a history of heart problems, it is important for the patient to consult with their primary care physician to be certain that they can tolerate cardiovascular fitness promoting activities. Specific instructions are given with respect to proper exercise for the patient’s condition before beginning any exercise program. In general, a reasonable amount of exercise performed daily utilizing activities that are enjoyed is recommended. This may include walking and also, many forms of work and/or household tasks can function as an exercise program.
In general, exercise helps promote proper digestion, keeps the muscles in proper tone and promotes better circulation. Walking briskly around the block at least once or twice is a convenient and popular activity. The important point is to exercise!
With respect to low back pain, there are many applicable exercises that are available. One can classify the patient into a flexion or extension biased category to determine the variety that is best for that patient (38). For example, if a patient feels best when bending over (flexion biased), exercises that promote low back flexion such as pulling the knees to the chest, posterior pelvic tilts, bending forward from a sitting position and others are usually helpful. If the patient is least symptomatic in extension, especially if leg pain centralizes or diminishes (extension biased), prone press-up type exercises usually yield the best results. Strengthening of the pelvic stabilizing muscles (trunk muscles), stretching of the hamstrings, adductors, and other overly short or tight postural muscles, as well as proprioceptive or balance promoting exercises also can result in a greater patient satisfying outcome.
Is There a Reaction Following an Adjustment?
In the course of being treated for spinal derangement or subluxations, certain reactions may be experienced. The most common reaction is aching or soreness in the spinal joints or muscles. This should not be alarming, as it is sometimes a natural tissue response to an adjustment. In my experience, if this occurs it is usually within the first few hours post-treatment and does not last longer than 24 hours. An ice pack often reduces the symptoms more quickly
On the most extreme side, vascular accidents have been reported and critics use this by recommending no spinal manipulation of the cervical spine (39). Critics of cervical manipulation emphasize the possibility of serious injury, especially to the brain stem. However, documented reports of the incidence of this is very rare and in experienced hands, cervical manipulation usually renders beneficial results with few adverse side effects. Several authors have reported a very infrequent incidence rate of vascular accidents that include statements such as, "there is probably less than one death of this nature out of several tens-of-millions of manipulations" (40). Cyriax states "the risk works out to about one in ten million manipulations, and is no argument against manipulative reduction in suitable cases" (41). Similar low risk is reported by others (42-44).
Reactions following a chiropractic adjustment vary greatly from person to person. These may vary from a great sense of exhilaration and well being to the reactions previously described. Discussion concerning reactions to spinal manipulation is encouraged between the patient and the treating chiropractor. Obtaining consent for treatment is recommended in writing once questions are addressed.
Research concerning the benefits of spinal manipulation and low back pain
There have been many studies conducted to date that consistently report beneficial responses to spinal manipulative therapy (7-22). The Agency for Health Care Policy and Research (AHCPR) recommend treating low back pain with spinal manipulation in the first four weeks of symptoms, with or without non prescription pain killers and in conjunction with mild exercise such as walking or swimming, followed by conditioning exercises after about two weeks (7). They stress the importance of resuming normal daily activities as quickly as possible and found that more than four days of bed rest can be counterproductive.
The United Kingdom’s Clinical Standards Advisory Group CSAG (12) advocates conservative care consisting of simple analgesics and physical therapy including manipulation, active exercise, and physical activity. They specifically did not recommend inactivity or a policy of "wait and see" by stating-
"Responsibility for primary management: The main responsibility for preventing chronic low back pain and disability lies with the family doctor, occupational health service, physiotherapist, osteopath or chiropractor who is caring for the patient at this early stage. Early active rehabilitation is highly effective in preventing long term pain and disability."
Other studies conducted by the RAND Corporation and authored by Shekelle et al, published for the first time that members of the medical community went on record stating that spinal manipulation is an appropriate treatment for certain low-back pain conditions (13). Additional studies comparing treatment methods, costs, time off work, and other issues have also been published but will not be elaborated at this time (please note references for additional information) (14-22).
The pre-chiropractic education is currently in transition from a 2 to a 4-year undergraduate/college prerequisite with state laws and college entrance requirements phasing in presently. Of the 4 years of chiropractic training, 2 years of basic sciences are required followed by the need for a successful completion of National Boards, Part 1. The next 2 years include the clinical sciences after which National Boards, Part 2 is required. There is a part 3 of the National Boards that is necessary if the chiropractor plans to use physiological therapeutics in practice. An internship of 1 year at a college clinic is also required.
Preceptorship programs are optionally available after the boards are taken, the internship requirements are completed and prior to licensure. In the program, the chiropractor learns many of the skills included in a private practice setting by working in a clinic outside the teaching institution. A National Board, Part 4 is currently being considered to replace the need for separate state board examination though this has not yet been fully adopted.
On a post-graduate educational level, the state of Wisconsin requires 40 hours of approved course work credits every two years, and this is also similar in other states. There are also post-graduate residency programs available where chiropractors can work towards the goal of gaining board certification. These programs are offered at many of the chiropractic colleges in 1-3 year programs or can be taken while in active practice at various sites throughout the U.S. The course work includes 300+ hours, with a minimum of 5 years in practice, followed by successful completion of a written followed by an oral examination. These programs include: 1. Orthopedics 2. Neurology 3. Radiology 4. Sports medicine 5. Rehabilitation 6. Nutrition 7. Family Practice 8. Pediatrics (being considered)
The future of health care is dependent upon the cooperation between the various professions that offer non-surgical care in the treatment of low back spinal pain. The health care consumer is demanding more with respect to the type and quality of health care service they receive. For this, as well as other reasons, a new market is developing where it is becoming more common to see the integration of health care providers into multidisciplinary groups. In this scheme, the consumer can benefit from a multi-professional approach to their health care issues in one location thus minimizing referral delays and postponement of appropriate care.
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