Chiropractic

The "hands-on" joint manipulation known as chiropractic is considered particularly valuable for relief of acute (temporary) pain in the lower back. This type of pain usually subsides on its own within 3 months, but chiropractic treatment can often bring it to an end immediately.

In many cases, chiropractic can also ease pain--due to either a temporary condition or aggravation of a chronic problem--in areas such as the mid-back, neck, or joints. Additionally, it is sometimes used to relieve the pain of headaches, muscle spasms, and nerve inflammation. Its effectiveness for relief of sciatica (pain or numbness along the sciatic nerve, generally in the back, buttocks, hips, or adjacent parts) remains controversial.

After the common cold, low back pain is the most common reason for doctor visits. It's an especially frustrating problem because there's frequently no simple medical explanation for it--and therefore no easy cure. However, there's now mounting evidence that spinal manipulation can be a genuine source of relief. In 1994, the Agency for Health Care Policy and Research (AHCPR) released its Guidelines on Acute Low Back Problems in Adults. This report identified manipulation (defined as certain specific techniques used to re-align or re-adjust a joint) as the preferred method of treatment for relief of acute back pain. Traction, bed rest, corsets, or drug therapies were not recommended.

Similarly, a report from the RAND Corporation published in the prestigious Annals of Internal Medicine found manipulation effective for the relief of acute low back pain. (It was not, however, deemed as successful in the treatment of chronic or recurrent low back pain, sciatica, asthma, high blood pressure, or pain caused by neurological conditions.) Chiropractors, RAND pointed out, perform 94 percent of spinal manipulations (though not necessarily with the same techniques employed in the study).

To date, there's no scientific confirmation of chiropractic's effectiveness for anything other than low back pain. However, in a few years we should know more. In early 1998, the National Institutes of Health's Office of Alternative Medicine, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases awarded a research grant to support the first federally funded Center for Chiropractic Research.

Although the back is the primary focus of chiropractic, the manipulations can be applied to any muscle or joint in the body. Techniques vary among practitioners. Typically, after preparation and proper positioning, the chiropractor creates tension around the offending joint, then applies pressure to return it to its proper position. A popping sound is often heard--and sometimes felt--following this maneuver. The noise is similar to the one you hear when cracking your knuckles. It results from the sudden release of built-up pressure in the joint, and is generally painless. As the joint snaps into place, pain is relieved and proper function is restored. Other techniques you may encounter include soft tissue manipulation, trigger-point manipulation, or deep tissue massage.

On your first visit to a chiropractor, you'll probably be asked to complete a questionnaire about your personal and family medical history. Be sure to discuss any illnesses that run in the family. Although chiropractors are not prepared to diagnose the full gamut of disease, they are trained to perform physical examinations in much the same way as a general medical practitioner. For example, you may be given a blood test to rule out infection and a reflex test to rule out neurological problems. Your blood pressure, pulse, and respiration will also be measured.

Once these general readings have been taken, the examination will begin to zero in on your musculoskeletal system--the muscles and bones in your body--with particular attention to your spine. The chiropractor will also analyze your posture, and will probably perform some orthopedic tests as he examines your articulations (a chiropractic term for joints). These tests usually involve moving a particular limb in search of joints that are "fixated" (not moving) or moving with impaired range.

If the chiropractor identifies a fixated joint, he will then attempt to determine whether there is any risk involved to restoring normal movement to the joint and what other parts of the musculoskeletal system have been affected by the joint's dysfunction. It is common for a "healthy" joint to overcompensate by moving excessively when another joint is not working correctly. The healthy, hyperactive joint might be near the fixated joint or in an entirely different part of the musculoskeletal system. Overcompensation can result in new, incorrect structural configurations that cause discomfort or pain.

To rule out any conditions that would preclude treatment, chiropractors usually take an x-ray of the region causing your pain before beginning the manipulations. Some chiropractors also take x-rays to locate subluxations (partial dislocations). Most chiropractors have basic x-ray equipment on-site and all chiropractors are trained to read x-ray images. If a specialized view is required, you may be referred to a center that has advanced technology, such as magnetic resonance imaging (MRI) equipment, or other equipment that provides a comprehensive image.

About 90 percent of chiropractors use x-rays. However, full-spinal x-rays in search of subluxations are considered controversial by many practitioners, and constitute less than 17 percent of all x-rays performed by chiropractors, according to the American Chiropractic Association. Many practitioners, chiropractic and otherwise, believe that full-spinal x-rays yield little if any useful information, and thus expose patients to radiation needlessly.

The chiropractor will also examine your muscles to determine if they are balanced. Just as healthy joints compensate for injuries in other structures, muscles may also exhibit "compensated distortion." When one muscle or group of muscles is contracted, for example, those on the other side may be abnormally relaxed.

Once the chiropractor has all the information he needs, treatment will proceed. Therapeutic equipment common to virtually all chiropractors is a specialized table designed to conform to a patient's body. The table has mechanized parts that can be adjusted in accordance with the patient's size and the region of the body that requires treatment. For example, the surfaces where the face, pelvis, and other body structures lie will yield independently as the chiropractor applies controlled force to these areas during treatment.

According to the American Chiropractic Association, more than 90 percent of chiropractors use techniques common to physical therapy, especially in preparation for manipulation. Your practitioner may use a broad, pad-like vibrator to relax your back muscles. He may apply hot or cold compresses to increase circulation and relax painful muscle spasms, or use traction to ease pressure. Ultrasound is often used as a "micro massage" to stimulate circulation and remove fluid from the area around a damaged joint and nearby tissues.

Some chiropractors also recommend and teach relaxation techniques as a way to prevent future strain, and prescribe rehabilitative exercises as part of an extended treatment plan. Some also prescribe and sell dietary supplements and herbs, although such products fall outside the realm of chiropractic.

Treatment Time: The initial visit typically lasts at least 1 hour. Subsequent visits usually take between 10 and 30 minutes.

Treatment Duration: On average, a course of treatment involves 3 to 5 visits per week for 2 weeks. Several studies have noted that consumers using chiropractic care are more satisfied with treatment than patients who receive medical care. Chiropractors are perceived as spending more time face-to-face with the patient, although no studies have been done to verify this.

The primary goals of chiropractic therapy are relief of musculoskeletal pain and restoration of mobility. However, many consumers use (or misuse) chiropractors for a wide variety of unrelated ailments. In a 1993 survey of more than 5,000 chiropractors, musculoskeletal complaints did in fact dominate the list of conditions they treated, but respondents also reported "routinely" seeing patients with headaches, and "often" seeing patients with high blood pressure problems, allergies, or obesity. Seen less frequently were patients with nutritional disorders, menstrual irregularities, asthma, and diabetes.

Chiropractic has long drawn criticism from the medical world for its failure to provide valid proof of its effectiveness, and for the exaggerated claims of some practitioners, who have touted spinal adjustment as a cure for everything from chronic pain to sinus infections. Indeed, until 1980 the American Medical Association (AMA) labeled as unethical the referral of patients to chiropractors, only lifting the prohibition when challenged in a successful antitrust suit.

Lately, with growing proof of spinal manipulation's effectiveness for low back pain, chiropractic has gained new-found respectability. Collaboration between medical specialists and chiropractors is on the increase, and some managed care plans have begun covering chiropractic treatments. Still, critics say there is little evidence that chiropractic relieves anything other than acute back pain. Few reliable studies support chiropractic for the treatment of chronic musculoskeletal disorders, although some studies of chiropractic treatment for headache show promising results.

The version of chiropractic currently gaining medical favor is far different from the original discipline. Developed by Daniel David Palmer in Davenport, Iowa, in 1895, chiropractic started out as a natural healing method freighted with a variety of spiritual and metaphysical concepts. Palmer's theory suggested that an Innate Intelligence flows through the nervous system and can be obstructed by a "subluxation"--or misalignment--of one or more of the 24 joints in the vertebral column, thus interfering with the blood supply and the body's full expression of healthy functioning. Palmer believed that, because all parts of the body are connected through the nervous system, all diseases were caused by one or more subluxations. Thus, any disease could be cured by manipulating or realigning the vertebrae in order to allow the body to heal itself.

A significant misalignment of the vertebrae is rare--and, as in scoliosis, is usually quite noticeable. Conversely, many people have asymmetrical spines with slight imperfections in alignment, yet suffer no adverse effects on their health. Many contemporary chiropractors therefore have begun to discuss subluxation less in terms of misalignment and more in terms of loss of function, since even a joint in perfect alignment may fail to work properly and tend to cause pain.

Over the years, different branches of chiropractic developed that emphasized one or more principles of Palmer's original theories to greater or lesser degrees. Historically, chiropractors categorized themselves as "straights" or "mixers" to describe how closely they adhered to Palmer's philosophy. "Straights" were purists, using only manipulation and focusing exclusively on the spine; "mixers" supplemented manipulation with other forms of treatment, such as nutritional counseling and physiotherapy, and acknowledged that diseases were caused by problems other than subluxations. Chiropractic schools and professional associations developed along these lines.

Today, these distinctions are breaking down. According to a 1997 report from the Agency for Health Care Policy and Research, more than two-thirds of chiropractors use techniques other than manipulation, such as exercise, nutritional counseling, and physiotherapy, although 93 percent retain spinal adjustment as their primary approach to treatment.

Chiropractic is not recommended for disorders of other than musculoskeletal origin, and should be avoided for certain musculoskelatal problems as well. For instance, it is not recommended for osteoporosis, bone or joint infections, bone cancer, acute rheumatoid arthritis, and diseases of the spinal chord or bone marrow. It should also be avoided in an area that has been operated on, such as a spinal fusion, and near acute fractures and dislocations or healed fractures and dislocations with signs of ligament damage. Chiropractors do not treat fractures.

Scoliosis, a condition in which the spine curves to the side, is generally considered a target for chiropractic therapy. However, idiopathic scoliosis, which develops over time instead of being present at birth (congenital scoliosis), is not appropriate for treatment by a chiropractor.

Serious side effects from spinal manipulation appear to be rare. Strokes have been reported following manipulation of the neck, presumably as a result of damage to one of the arteries supplying blood to the brain. However, the incidence of adverse events from manipulation of the neck region is estimated to be 1 in 1 million procedures, according to the Agency for Health Care Policy and Research. Likewise, the Agency pegs the risk of a serious side effect from manipulation of the lower back at 1 case in 100 million manipulations.

Minor side effects of spinal manipulation have not been systematically analyzed. The adverse reactions reported by one study, such as headache, radiating discomfort, and fatigue following manipulation were not clearly shown to be a result of the treatment.

Choose a chiropractor as you would any other health care professional. Discuss your condition with him and clearly establish the type of treatment he plans to provide, its expected outcome, how long it will last, and how much it will cost. Ask about his training and treatment philosophy, bearing in mind that chiropractic is generally considered effective only for temporary back and joint pain. Find out whether the chiropractor is part of a team of health care providers, and see whether he will provide referrals if necessary. Be suspicious of a practitioner who attempts to sell you expensive nutritional supplements or devices that purport to improve your health.

There are approximately 50,000 chiropractors in the United States. They are licensed in every state and must pass an examination with the National Board of Chiropractic Examiners. Restrictions on the procedures they may perform vary from state to state. To be admitted to a managed care plan, they must often pass additional tests.

The 16 chiropractic colleges in the U.S. are accredited by the Council on Chiropractic Education, a federally recognized accrediting agency. Typical academic training and clinical internships include four years of training at an accredited institution after a minimum of two years of college; more than 2,000 study hours of biological and clinical sciences; more than 1,000 study hours of chiropractic sciences, including body mechanics, spinal analysis and adjustments, diagnostic imaging, and x-ray interpretation; internships in clinical radiology and interpretation; and at least 900 hours of clinical practice and patient care. Some chiropractors have additional postgraduate or continuing education in the fields of sports injuries, occupational health, orthopedics, or neurology.

In many cases, relief is immediate. If pain persists, allow some time for improvement to appear--2 weeks is generally sufficient in cases of acute low-back pain. If there's still no change, or if the condition becomes worse, stop the treatments and seek alternative therapy. Many chiropractors refer patients to specialists for further evaluation when a condition persists.

Despite chiropractic's original contention that all health problems stem from subluxation, your wisest course is to check with an M.D. if the problem isn't clearly related to the back or joints. Likewise, if a chiropractor discovers any dangerous problems that need immediate medical attention, he's likely to refer you to a medical specialist without delay. Tumors, fractures, or other suspicious findings viewed on an x-ray are common reasons for immediate referral.