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Chiropractic

(What you should know)

 



Introduction Conditions chiropractic can't help
Chiropractic training Tests and procedures to avoid
Things chiropractors are not allowed to do Warning- Leave my neck alone!
Disagreement among chiropractors Lack of research supporting chiropractic
Causes of back pain Appropriate Chiropractic practice
Conditions chiropractic might help Conclusion
Why chiropractic might work Where to find more information

Introduction

Chiropractic was founded in 1895 by Daniel David Palmer, a grocer and "magnetic healer" who believed that all diseases are the result of misplaced spinal bones. According to his theory, "subluxations" (misalignment) of spinal vertebrae cause disease by interfering with the flow of "nerve energy" from the brain to the body's tissue cells. Spinal "adjustments," by restoring vertebrae to their "proper places," allow brain energy to heal the diseased condition.

Chiropractic claims that analysis and correction of "subluxations" will restore health without the use of drugs or surgery. Many chiropractors claim that regular spinal adjustments are essential to maintain normal health. The term "analysis" can include the use of X-ray and other analytical instruments generally used in the practice of chiropractic.


Chiropractic training

Chiropractic training generally requires at least 3 years of college and 3 years of chiropractic training. Schooling typically costs $40,000- $50,000. Many in the healthcare profession, including some chiropractors, believe chiropractic schooling to be deficient in that it has not kept pace with continued scientific and medical progress instead continuing to focus on the subluxation theory of health and disease.

The scope and depth of both normal function as well as disease states taught in conventional medical schools is simply not present in most chiropractic schools. Chiropractic students simply do not receive sufficient training about the recognition and treatment of many disease processes. Chiropractic schools do no have access to patients with a wide range of medical conditions seen in medical schools. Chiropractic organizations and licensing boards have not actively supported or promoted additional residency training after graduation as is standard for medical school graduates.

Furthermore, lawsuits have been filed and damages awarded against several chiropractic colleges by students who were required to recruit patients to the chiropractic school as a prerequisite for graduation. [6 ]


Things chiropractors are not allowed to do

Although chiropractors are recognized as "Doctors of Chiropractic" they are not medical doctors. Under current law chiropractors are considered "limited providers" in that there are restrictions on their scope of practice. They can not perform surgery or other invasive procedures nor can they prescribe medications.

A recent state court decision in Pennsylvania prohibits Chiropractors from calling themselves "Physical Therapists" or "Specialists in Physical Therapy" because Physical Therapy is a separate profession with its own training and licensing requirements.

Chiropractors are not supposed to make claims that they can cure specific diseases such as diabetes, asthma, heart disease, cancer, etc.. However, enforcement against false claims is not very stringent in some states.

Although many states require health insurance companies to reimburse for certain treatments this is a legal standing due to very effective lobbying of both congress and state legislatures by chiropractic organizations. This does not indicate acceptance by Medicare and other insurers that chiropractic treatment is effective nor that chiropractic theory scientifically valid.


Disagreement among chiropractors

There is currently significant disagreement among several branches of chiropractic practice. Although philosophy and treatment vary greatly from one practitioner to another, most of today's 50,000-or-so chiropractors can be classified as "straights" or "mixers." [10]

Straights adhere to Palmer's doctrine that most diseases are caused by misaligned spinal bones ("subluxations") correctable by spinal adjustment. Some straights, however, maintain that they neither diagnose nor treat diseases, but confine themselves to detecting and correcting vertebral subluxations, thus "restoring" normal health.

Straights tend to disparage medical diagnosis, claiming that examination of the spine is the proper way for chiropractors to analyze their patients.

Mixers acknowledge that factors such as germs and hormones play a role in disease, but they tend to regard mechanical disturbances of the nervous system as the underlying cause of lowered resistance to disease. Mixers are more likely to diagnose medical conditions in addition to spinal abnormalities, and to refer patients to medical practitioners for treatment.

In addition to spinal manipulation, mixers may prescribe nutrient concoctions, homeopathic products, and various types of physiotherapy (heat, cold, traction, exercise, massage, and ultrasound).

Some practitioners claim that chiropractic treatment is effective against nearly the entire range of human ailments. A small percentage of chiropractors reject Palmer's dogma and treat only musculoskeletal problems.


The Elusive Subluxation

The term "subluxation" has never been defined by the profession in a way as to have universal acceptance within the chiropractic profession. Chiropractic "subluxation" is not the same as medical subluxation, which represents a partial dislocation of joint structure and would be a contraindication to "adjusting" or "manipulating" the joint structures. [7] Chiropractic "subluxation," not having universal definition, and, thereby, not having received universal scientific status of existence, has evolved into a metaphysical status. That is it is claimed to exist even though it can not be measured.

In an elegant experiments performed on the spinal columns of fresh cadavers ranging widely in age it was shown that extensive ranges of motion and force on various vertebra did not produce nerve impingement unless significant and measurable displacement of the vertebral bodies or intravertebral disc occurred. No dislocation means no displacement. [3,4,5]


Causes of Back Pain

Causes of back pain are variable and can include:

  • muscle sprain or spasm
  • ligament injury
  • arthritis of spinal joints
  • vertebral disc herniation
  • joint impingement or locking
  • fibromyalgia (numerous intensely painful "tight" areas about the neck, shoulders or low back)

Manipulation, chiropractic or otherwise, is absolutely contraindicated (not to be done) in patients with known symptomatic vertebral disc herniation and with actual subluxation/dislocation of one vertebral body on another. It is relatively contraindicated in persons with moderate to advanced arthritis affecting the spine. Caution is advised in patients with vertebral disc herniations that are not causing symptoms of nerve impingment.

It is ironic that chiropractic treats perceived but not true nerve impingement.


Conditions chiropractic might help

Chiropractic has long survived on successful PR and "testimonials" from satisfied clients. However, scientific evidence has been lacking. Several recent studies have demonstrated spinal manipulation to be of value in treatment of low back pain under certain circumstances.

However, this is not a blanket endorsement of chiropractic therapy nor does it in anyway prove that "subluxations" are the problem.

Outcomes for treatment of low back pain appear similar for patients treated by chiropractors, family doctors, orthopedic doctors, and physical therapists. Chiropractors and physiotherapists tended to have higher patient satisfaction with the overall experience. Whether this is due to better rapport with the patients, a hands on approach or both factors is not known.


Conditions chiropractic may help

Joint locking

Most of use have experienced a joint temporarily "locking" or catching at some point in our lives whether it be the knee while walking or running or a "crick" in the neck or lower back. We may also recall the relief we felt upon experiencing a crack or pop after twisting or turning a certain way.

A certain percentage of persons suffer low back pain due to catching or locking of the sacroiliac joint (this is where the tail bone and pelvis join together). Although pain in these joints can indicate a more serious condition, such as ankylosing spondylitis, a vast majority of cases are benign and very responsive to manipulation twisting the waist from side to side. This condition tends to episodically reoccur. Although any health care provider can perform this manipulation ( a patient can easily be taught to do it themselves) this is the bread and butter procedure for chiropractors- they do a good job at recognizing and "correcting" this condition.

Similar "locking" can occur in the vertebrae of the neck. We do not endorse cervical (neck) manipulation due to the very small, but real, chance of injury to the vertebral arteries supplying the brainstem. Injury to these arteries from forceful manipulation, estimated between 1:20,000 to 1:1,000,000, can cause devastating stroke.

Myofascial pain syndrome (fibromyalgia)

Another condition that chiropractors probably recognize and treat is shoulder, neck and possibly lower back pain due to fibromyalgia in which extremely tense "knotted' small balls of muscle can be felt in the neck and shoulders. Although a muscle sprain or injury can exacerbate this condition it is not caused by injury or sprain. The pain of fibromyalgia can be intermittent or occur on a daily basis.

These "tender points' are extremely tender and painful to rub. Sometimes manipulation of a tender point causes pain to shoot elsewhere in the body- it is now called a trigger point.

Although the cause is unknown current thinking is that focal areas of hypoxia (lack of oxygen) occur in the muscles. This may cause changes in the muscle spindle fibers causing them to be more irritable. Persons with this condition often demonstrate a decreased amount of time in deep sleep (stage 4) that appears to be important for muscular well being.

Standard medications that work well for muscle sprains and overuse injuries, such as acetaminophen (Tylenol ™) or antiinflammatory medications such as aspirin and ibuprofen (Motrin™, Advil™), are not as effective for this condition. Patients prescribed narcotic containing medications and muscle relaxants do get fairly good pain relief but are at greatly increased risk of becoming dependent on these medications if used for more than 2-3 weeks on a continuous basis.

Long term treatment for tender and trigger points includes improved sleep hygiene, more physical exercise, treatment of underlying anxiety or depression, and possible use of certain sedating low dose antidepressants.

Immediate relief can often be achieved by gently massage, vibration therapy, acupuncture, acupressure or injection of a small amount of anesthetic and anti-inflammatory steroid into the trigger points. Chiropractors can use manipulation but not injection or medications.


Conditions chiropractic can't help

Aside from placebo effect chiropractic therapy has never been shown to treat any condition other than musculoskeletal problems. Several recent studies, conducted jointly with MD's and DC's, investigated if chiropractic treatment, in addition to traditional therapies, could improve asthma control in children and reduce tension headaches in adults. Neither study showed any added benefit from chiropractic manipulation.


Test and procedures to avoid

Chiropractic care should be focused on a specific musculoskeletal condition. Periodic "maintenance" adjustments in persons without specific musculoskeletal symptoms do nothing to improve health and are a waste of money. A healthy back does not require treatment to stay healthy.

Those with insurance who do not "have to worry" about the cost should consider a few things:

  1. Unnecessary treatment (chiropractic or otherwise) indirectly increases overall healthcare costs to everyone with insurance.

  2. Secondly, persons in the habit of very routine "maintenance manipulations" can be lulled into complacency and avoid routine visits with their physician to check such things as blood pressure, cholesterol , breast, prostate, and diabetes screening.

  3. One study has shown that for persons with health insurance the frequency of chiropractic treatment is very sensitive to the amount of CO-pay required with higher CO-pays resulting in much less frequent chiropractic visits.

Secondly, chiropractors are limited in their scope of practice. Although they are not trained to perform or interpret many tests used by physicians this does not stop some from using gadgets that are claimed to either treat or diagnose "spinal" or other alleged health problems. Examples include testing body fluids (urine/ blood) or analyzing hair for certain "deficiencies" with machines that have no place or relevance in modern medicine. Such devices and tests are simply money makers and have no useful purpose in patient care. Performing diagnostic tests that physicians perform would be likely result in chiropractors being legally held to a similar standard of care in the interpretation of test results. Patients with abnormal test results would need to be referred to physicians for further evaluation.

 

Useless (for the patient) gadgets and tests
Activator methods Spinal analysis machine
Applied kinesiology Surface Electromyography (SEMG)
Bioenergetic Synchronization technique (B.E.S.T.) Toftness device (thermography)
Biologic Terrain Assessment Ultrasound (spinal)
Contact reflex analysis X rays (inappropriate usage)
Contour analysis  
 

Visit "Quackery" to learn more about other useless treatments

Warning - leave my neck alone!

"Manipulation of the cervical spine" (MCS) is used in the treatment of people with neck pain and muscle-tension headache. This procedure, performed by chiropractors, physical therapists, and some physicians, involves using a sudden forceful thrust after the neck has been turned about as far as it can stretch. This is different than "Mobilization of the cervical spine" which involves low-velocity (nonthrust) passive motion that can be stopped by the patient. The speed of the technique (not necessarily the amount of force), therefore, differentiates manipulation from mobilization. [9]

MCS has been associated with fractures of cervical vertebra, stroke due to dissection of the vertebral artery that runs along the cervical vertebra, and spinal cord hematomas resulting in paralysis.  Although not extremely common the incidence of such injuries may be as high as 1 in 500 to 1 in 1000 MCS procedures [9]. Mobilization of the cervical spine has not been associated with these injuries.

Stoke due to vertebral artery dissection has been well described in riding rollercoaster type rides as well.

Although it is believed that most persons are not at risk for this type of injury there is currently no way of screening or predicting who should avoid such at risk activities, whether it be MCS or whipping and winding amusement park rides.


Lack of scientific research supporting chiropractic theory

No studies have shown that "subluxations" (misalignment) of spinal vertebrae cause disease by interfering with the flow of "nerve energy" from the brain to the body's tissue cells. Further, subluxations in the chiropractic sense can not even be agreed on by different chiropractors when asked to independently identify subluxations in a blinded fashion (unaware of other chiropractors conclusions).

It must be said that there are members of the chiropractic profession that are receptive to objective scientific study on whether or not chiropractic care improves certain medical conditions. Although studies thus far have not shown chiropractic care to be beneficial for conditions other than certain musculoskeletal problems [8], this openness is encouraging. All legitimate disciplines of medicine and science must be willing to accept new information that has been objectively demonstrated even if it conflicts with currently established "dogma".


Appropriate chiropractic practice

Choosing a chiropractor can be difficult because, according to several large surveys the many of chiropractors are involved in unscientific practices . If you decide to consult one, start with a telephone interview in which you explore the chiropractor's attitudes and practice methods [2].

Good signs

  • Practice limited to conservative treatment of back pain and other musculoskeletal problems.

  • Recommendation from your medical doctor.

  • Membership in the National Association for Chiropractic Medicine or the Canadian Academy of Manipulative Therapists (CAMT); however, the number of chiropractors who belong to these groups is small. CAMT's "orthopractic guidelines" describe a science-based approach to manipulative therapy.

  • In addition to manual manipulation or stretching of tight muscles or joints, science-based chiropractors commonly use heat or ice packs, ultrasound treatment (not diagnosis), and other modalities similar to those of physical therapists. They may also recommend a home exercise program.

  • For most conditions that chiropractic care can help, significant improvement should occur within a few visits.

    Avoid Chiropractors

  • advertising about "danger signals indicating the need for chiropractic care
  • making claims about curing diseases
  • trying to get patients to sign contracts for lengthy treatment, promote regular "preventive" adjustments
  • using scare tactics
  • disparaging scientific medical treatment or preventive measures such as immunization or fluoridation
  • who claim to diagnose or treat "subluxations," or who have literature promoting "nerve interference" as an underlying cause of disease
  • who suggest that chiropractic might help nearly every type of health problem
  • routinely performing or ordering x-ray examinations of all patients, particularly full spine X rays.
  • Avoid chiropractors who "prescribe" dietary supplements, homeopathic products, or herbal products for the treatment of disease or who sell any of these products in their offices. For dietary advice, the best sources are physicians and registered dietitians.
  • who offer any of the listed "Useless (for the patient) gadgets and tests". In addition other dubious tests and/ or procedures include:
    • body fat analysis
    • computerized "nutrient deficiency" testing
    • computerized range-of-motion analysis
    • cytotoxic testing, electrodermal testing
    • Functional Intracellular Analysis (FIA)
    • herbal crystallization analysis
    • blood cell analysis (also called nutritional blood analysis or Hemaview)
    • testing with a Nervo-Scope
    • Nutrabalance, NUTRI-SPEC
    • pendulum divination
    • reflexology
    • saliva testing

This list is by no means inclusive. The viewer is directed to quackwatch for a comprehensive review of dubious chiropractic (and medical) devices and procedures.


Conclusion

We believe that chiropractic care may play a limited role for certain persons with musculoskeletal problems [1] but it should not be a substitute for regular visits to your doctor and should not diagnose and "treat" medical problems other than straight forward musculoskeletal conditions.

Before seeking chiropractic care :

1. Persons with true medical problems must be under the care of a physician- hopefully a competent and caring one. Have the problem evaluated by a medical doctor first.

2. Have underlying serious illnesses ruled out before deciding that the problem is musculoskeletal. Heart disease, cancer, kidney disease, and other serious problems that need prompt medical care may manifest themselves as back pain and dysfunction. Don't allow an overzealous, inadequately trained chiropractor to keep you from prompt diagnosis and care. [10]

3. Chiropractic care should not involve repeated preventative manipulations or other treatments nor the "prescribing" of medicinal supplements.

4. If you have not experienced significant relief within three weeks, discontinue SMT (spinal manipulation therapy). Do not submit to long-term care. Education about how to prevent back problems by safe lifting techniques, proper exercise, and ergogenics (analyzing and redesigning the workplace to avoid injuries) is valuable. [10]

5. No practitioner, chiropractic or otherwise should use any of the devices or techniques listed under "Useless (for the patient) gadgets and tests"

6. If the chiropractor recommends X-rays, have them done by a radiologist.



Where to find more information

1. Annals of Internal Medicine Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America Annals of Internal Medicine, 1 July 1998. 129:9-17. @http://www.acponline.org/journals/annals/01jul98/chiro.htm

2. Barrett S., M.D.Tips on Choosing a Chiropractor @ http://www.quackwatch.com/01QuackeryRelatedTopics/chirochoose.html

3. Crelin ES. Anatomy of the Newborn: An Atlas. Philadelphia: Lea and Febiger, 1969.

4. Crelin ES,Ph.D. "A Scientific Test of Chiropractic's Subluxation Theory -The first experimental study of the basis of the theory demonstrates that it is erroneous." @http://www.chirobase.org/02Research/crelin.html

5. Crelin ES 1973. Functional Anatomy of the Newborn. New Haven, Conn.: Yale University Press, 1973.

6. Former Students Sue Cleveland Chiropractic College @ http://www.chirobase.org

7. National Association for Chiropractic Medicine @ http://www.chiromed.org

8. N Engl J Med 1998 Oct 8;339(15):1013-20 "A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma." Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaughnessy D, Walker C, Goldsmith CH, Duku E, Sears MR

9. Physical Therapy Volume 79 · Number 1 · January 1999 "Professional Perspective- Manipulation of the Cervical Spine: Risks and Benefits" Richard P Di Fabio 

10. Why Chiropractic Is Controversial (1990) William T. Jarvis, Ph.D. @ http://www.chirobase.org

 

Quackwatch (http://www.quackwatch.org) and Chirobase (http://www.chirobase.org) are two sites providing comprehensive information about medical quackery and various aspects, both positive and negative, about chiropractic.

 


Doctors Corner INternet Group, Inc. 1997-2005

 

Created: July 18, 2000

Modified: March 14, 2005