Chiropractic in the 21st Century: An Overview for Primary Care Physicians
Chiropractic in the 21st Century: An Overview for Primary Care Physicians
Author: Paul E. Dougherty, DC, Associate Professor, New York Chiropractic College, Departments of Clinics and Research; Adjunct Assistant Professor of Orthopedics, University of Rochester School of Medicine and Dentistry; Part-time Staff Chiropractor, Canadaigua Veteran's Affairs Medical Center, Rochester, NY.
Peer Reviewer: Mark Jeffries, DO, FACOFP, Medical Director, Indian Ripple Family Health Center, Kettering Health Network, Beavercreek, OH.
For many years, chiropractic medicine often has been viewed with skepticism and even ridicule by organized medicine. Yet, we have all had patients who praise their chiropractor for taking care of symptoms for which we have only pills and physical therapy to offer. This issue summarizes the history of chiropractic medicine, including the increasing recognition by third-party payers and the Department of Defense and U.S. Department of Veterans Affairs. Characteristics of typical chiropractic patients are described as well as therapeutic approaches used by today's chiropractic practitioners. This issue should serve as a reference for primary care physicians to help provide guidelines for the appropriate referrals to chiropractors and the services they can collaboratively provide for our patients.
The Editor
Case Study. A 40-year-old woman presents to a primary care office with a chief complaint of lower back and neck pain. The patient states that she was doing yard work that entailed a lot of bending, twisting, and lifting approximately two months ago. She reports that the morning after the work she awoke with lower back and neck pain. She initially treated the problem by taking hot showers and using over-the-counter nonsteroidal anti-inflammatory medications. She also tried doing some stretching at home with only transient relief of her pain. She reports that she has persistent pain in the right lumbosacral region and pain that radiates into the right buttocks. She is also having persistent neck pain but no radiation into the upper extremities. She reports that her pain is worse with prolonged sitting and standing. She also reports that slight trunk flexion, such as brushing her teeth, is provocative for the lower back pain. She reports that her neck pain is worst when she is driving the car. She denies any headaches associated with her neck pain. Her past medical history is significant only for mild gastroesophageal reflux. Her past surgical history includes a tonsillectomy and adenoidectomy as a child and a cesarean section 10 years ago. Her past musculoskeletal history includes a history of a motor vehicle accident five years ago that resulted in some mild neck and lower back pain that resolved within one month, but otherwise no significant musculoskeletal trauma. Her current medications are Prilosec for reflux and over-the-counter ibuprofen (400 mg bid). Her social history reveals she is married with two children and currently works as a graphic designer. She is a non-smoker and is a "social" drinker.
The physical examination reveals tenderness over the lumbosacral region and pain on lumbar extension. She exhibits some tenderness over her lumbar erector spinae musculature to palpation. She shows no positive neural tension tests. Her neurologic examination shows reflexes of the upper and lower extremity to be 2+ bilateral and symmetric; sensory and motor examinations of the upper and lower extremity are within normal limits. You obtain plain film radiographs that reveal mild degenerative changes in the cervical spine and lumbar spine, but no other significant osseous or soft-tissue abnormalities. At this point, you finish the evaluation with the patient and it is time to decide on what treatment you want to offer to this woman. Now is the time that you breathe a sigh of frustration, as there is no definitive answer for this patient.
For the primary care physician who wants to practice evidence-based medicine there are many choices for the care of this patient. The most recent guideline from the American College of Physicians recommends that for patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits. For acute low back pain, spinal manipulation is recommended. For chronic or subacute low back pain, the recommended treatments include intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, and progressive relaxation.1 For neck pain, the U.S. Bone and Joint Decade's Task Force on Neck Pain found that, "A number of nonsurgical treatments appeared to be more beneficial than usual care, sham, or alternative interventions but none of the active treatments were clearly superior to any other in the short or long term. Educational videos, mobilization, manual therapy, exercises, low-level laser therapy, and perhaps acupuncture appeared to have some benefit. For whiplash associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function and returning to work as soon as possible were relatively more effective than interventions that did not have such a focus."2
The challenge for busy primary care physicians is how to choose the best option for their patients. Many patients come to their physicians with a plethora of information harvested from the Internet and they want the physician to be familiar with all of the available treatment options ranging from acupuncture to spinal fusion. While the physicians' training has well equipped them for addressing the "traditional" medical options for back pain, their education may not have informed them about some recommended options such as Complementary and Alternative Medicine (CAM) therapies. One of these options is chiropractic. The above-mentioned guidelines state that spinal manipulation is considered a treatment modality "with proven benefits." In the United States today, chiropractors perform the vast majority of spinal manipulation for back pain.4 It is therefore a reasonable option for a primary care provider to refer a patient to a chiropractor. The dilemma that faces most primary care providers today, however, is that they have little to no knowledge about chiropractic or chiropractors from their medical training.5 The purpose of this manuscript is to provide the primary care physician with an overview of the chiropractic profession, the conditions that may be appropriate for referral, the evidence base supporting the treatment modalities utilized by chiropractors, and guidelines on finding a high-quality chiropractor.
What is Chiropractic?
The chiropractic profession originated with Daniel David Palmer in Davenport, Iowa in 1895. Palmer established the first chiropractic school in 1896. Palmer utilized a form of spinal manipulation initially to treat a patient who was suffering from deafness. After the patient underwent a spinal manipulative technique, his hearing purportedly returned. This profound outcome from a manipulation to the spine led Palmer to pursue further study in developing a new profession that he named "chiropractic." The term chiropractic means, "Practice done with hands." In the subsequent years to Palmer's original "adjustment" or manipulation of the spine, numerous schools of chiropractic were established. By 1925, some historic references state that there were as many as 82 schools in existence at the same time in the United States. However, by 1969 the number of schools had decreased to 11. It is thought that the number of schools decreased due to increased standards of accreditation and licensure requirements.6 The chiropractic profession has continued to mature through the years. There are currently 18 chiropractic colleges in the United States and 15 throughout the rest of the world. Today chiropractic is the most commonly utilized non-allopathic treatment modality.7 It has steadily increased in acceptance and use by the public. There has also been increased acceptance by third-party payers, with most major medical insurance companies paying for chiropractic services. Chiropractic services have also recently been included in Department of Defense and Veteran's Affairs clinics throughout the United States. These trends of increased utilization and acceptance by government-sponsored clinics and third-party payers indicate that chiropractic is no longer the "marginal" or "deviant" profession that it previously was considered.8
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Another area that indicates a maturation of the chiropractic profession is in the area of federally funded and published research. The published data on the efficacy of chiropractic treatment was very sparse throughout most of the first century of the profession's existence. However, in the last 20 years there has been a substantial increase in the amount of federal funding for chiropractic research and a significant increase in the number of randomized controlled trials that have investigated the main treatment modality of chiropractic, spinal manipulation. Meeker and Haldeman reported that as of 2002 there were 73 randomized clinical trials of broadly defined spinal manipulation procedure in the English language.4 Since 2002 there have been several other randomized controlled trials published and there are also multiple randomized clinical trials that are ongoing worldwide.
Chiropractic Education. In the United States, all but one of the 18 chiropractic colleges is privately funded. In other countries such as Australia, South Africa, Denmark, Canada, and Great Britain, chiropractic colleges are part of established government-sponsored universities and colleges. The Council on Chiropractic Education, an agency certified by the U.S. Department of Education, accredits most chiropractic colleges in the United States. Each college requires at least four academic years of professional education prior to students being qualified to sit for licensure examinations. A minimum of 90 units of prescribed college level courses, mostly in sciences, is required prior to admission to a chiropractic college. The classroom and clinical hours for chiropractic students equal about 4820, with 30% spent in basic sciences and 70% in clinical sciences. Chiropractic curricula focus on biomechanics, musculoskeletal function, and manual treatments. There is less emphasis on pharmacology and surgery in chiropractic than in medical school.9,10 There is an increasing emphasis on public health issues in chiropractic programs, focusing on issues such as fall prevention and nutritional programs. All chiropractic colleges maintain teaching clinics, either on campus or at remote locations.
Currently nine chiropractic colleges in the United States have academic affiliations with 13 Veteran's Administration (VA) hospitals. These VA clinics allow chiropractic students to have a variety of clinical experiences with a complex patient base and allow for training of chiropractic students in an integrated clinical setting.11 The New York Chiropractic College has a teaching clinic in a long-term care facility in Rochester, NY. This is a first-of-its-kind teaching clinic that has allowed for an increase in the emphasis on geriatric issues, which will be increasingly important in the next 10-20 years.12,13 These integrated training opportunities are invaluable assets to the chiropractic profession as it continues to mature in today's healthcare environment. There are also at least three chiropractic colleges that are members of federally funded Geriatric Education Centers (GEC) in the United States. Specialty training is available for chiropractors in 2-3 year residency programs in radiology, orthopedics, neurology, sports, rehabilitation, and pediatrics. Each of these specialties has a board competency examination, which confers "diplomate" or "certified" status. The vast majority of states require passage of examinations by the National Board of Chiropractic Examiners in the areas of basic science, clinical science, and clinical competency prior to granting a license to practice in a given state. Most states also require annual proof of continuing education credits for ongoing license renewal.
Characteristics of Chiropractic Patients
In 1990, it was reported that about 34% of the population utilized non-allopathic care, or complementary and alternative medicine (CAM). By 1997, that number had increased to 42%, and this number remained stable from 1997 to 2002.14 Chiropractors are the most common CAM providers utilized by patients in the United States. In 2002, it was estimated that approximately 15 million Americans sought chiropractic care. The demographic profile of chiropractic patients is that they are typically white, with an average age of 42 years, a slight predominance of females (62%), and most are married. Approximately one-third of the patients have a college degree and earn in excess of $30,000 (in 2002). The majority of patients have not had previous care for the problem for which they were seeing the chiropractor; however, if they had seen someone else, it was typically a medical care provider.
People seek out chiropractic care for a variety of reasons; however, the most common reasons for people to seek chiropractic care are for neck and back pain. In the 2002 report, Coulter, et al., reported that greater than 40% of the patients sought chiropractic care for back injury or a similar problem. An additional 24% reported their condition related to their neck. In total, more than 70% of patients named a problem with their back or neck as the reason that they were seeking chiropractic care. Concerning the level of disability, the authors reported that compared with the disability and quality-of-life scores of previous studies, the chiropractic patients were very similar to patients seeking medical or surgical care.15 Chiropractic continues to integrate into managed care and is currently almost a universal benefit under managed care plans. This increased integration is at least partially due to patient preferences. Some of the reasons that patients choose chiropractic are high satisfaction with chiropractic care, the strength of the patient-provider relationship, and the "art of medicine" practiced by chiropractors. Another reason for the popularity of chiropractic is the recommendation by national and international guidelines for the treatment of back and neck pain that spinal manipulation is a viable treatment option for both these conditions.16
What Treatment Methods Do Chiropractors Utilize?
The most commonly used treatment modality by chiropractors is spinal manipulation. Spinal manipulation is a technique utilized for centuries. Spinal manipulation is thought to act on a "manipulable lesion" (or a functional spinal unit that has altered movement, typically hypomobile). This lesion is thought to respond to specific forces and movements in such a way that the internal mechanical stresses that generate symptoms are reduced when appropriate forces are delivered to the joint.17 Although spinal manipulation is the most commonly used technique among chiropractors (92%), chiropractors typically use other systems or techniques. The most popular additional or alternative techniques include flexion distraction (39%), Nimmo-tonus (37%), Gonstead technique (36%), and activator (35%). Each of these techniques represents an alternative method of improving joint function and/or decreasing muscular tightness. For example, James Cox, DC, developed flexion distraction technique, which uses a specialized table to create a traction force of the spine combined with slight flexion. Nimmo-tonus technique is a soft-tissue technique that focuses on the reduction of "trigger points" in muscles by creating direct pressure over the area of tenderness. Gonstead technique is another form of spinal manipulation that claims to provide a much more specific and focused force on the spine using x-ray markings to help determine the direction of force. Activator is an instrument-assisted technique that allows the practitioner to deliver a more focused force on the spine with a small spring-loaded device.
Chiropractors also use a wide range of non-manipulative treatment methods. The most commonly used method is patient education, utilized by 95% of chiropractors. Other treatments include exercise (92%), ice therapy (78%), massage (77%), electrical therapy (71%), physical therapy (70%), ultrasound (67%), heat therapy (66%), and acupressure (61%).17 Some chiropractors and other practitioners have also recently started using spinal decompression machines. Although there is limited evidence for these devices, a recent report stated, "There is little evidence for or against this form of traction, which is aggressively promoted in the United States health-care market (eg, VAX-D, DRX9000)."19 Although this list of alternative treatments offered by chiropractors is by no means exhaustive, it allows one to see that spinal manipulation is not the only treatment available for the chiropractic patient.
The approach used by the typical chiropractor for clinical diagnosis is similar to that of all health disciplines. The chiropractor is trained to obtain a thorough history of the patient's current complaint as well as the past medical history to assess the role of any co-morbidity in the patient's presenting complaint. The chiropractor then physically examines the patient utilizing standard orthopedic and neurologic examinations. The National Board of Chiropractic Examiners' survey reports that the vast majority of chiropractors felt that this was "extremely important" and that a failure to perform this was a significant risk to the patient.17 The physical examination typically focuses on the musculoskeletal system. This examination routinely involves some assessment of the patient's range of motion and also putting the patient through some maneuvers to determine what area of the musculoskeletal system is painful and what forces seem to make the patient feel better or worse (directional preference). The chiropractor also performs a neurologic assessment of the reflexes, myotomes, and dermatomes. The chiropractor then determines whether the patient is likely to benefit from chiropractic services. In most cases, the patient will then undergo a therapeutic trial of care. After a reasonable trial of care (guidelines suggest 4-6 weeks, during which time the patient is undergoing constant reassessment), the chiropractor will determine if there is a need for a change in the care or if there is a need for further testing or referral to another specialty.20 The goal of care is to move the patient from a passive care model to an active care model. The chiropractor typically gives the patient home exercises to perform and encourages the patient to remain or become active. Some patients find that they do well with regular chiropractic treatments, such as coming in once per month for care. This ongoing care may fall into one of two categories, either maintenance care or supportive care. Maintenance care is a poorly defined concept in the chiropractic literature. The main idea, however, is that it is designed to maintain health in someone who has had an episode of pain. There is currently no convincing evidence that ongoing care will "maintain health."21 One study did show that patients who had previously experienced an episode of back pain experienced fewer exacerbations of pain over the subsequent nine months if they had once per month treatment than those who did not have treatment once per month.22
Supportive care is defined as "treatment/care for patients having reached maximum therapeutic benefit, in which periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains and would otherwise progressively deteriorate."20 The theory behind this type of care is that patients may require periodic treatments to prevent them from getting worse. Again, there is little objective evidence for the role of this type of care; however, this type of care is more often reimbursed through insurance companies than maintenance care. The main differentiation between the two is that supportive care requires the documentation of the worsening of a condition if the treatment is withdrawn.
What Is the Evidence Base for These Treatments?
When a primary care physician is deciding whether to refer a patient for a specific type of specialty care, there is an increasing emphasis on whether or not the type of care is evidence based. A universal dilemma for all healthcare providers is that in the area of back pain there are so many options for treatment. Even with the numerous options, though, no one treatment has been proven superior to any other.
Currently, more than 60 pharmaceutical products are being offered to patients with back pain. There are 32 different manual therapies; this is only a partial list as there are well over 100 named techniques in chiropractic, physical therapy, osteopathy, and massage therapy. There are 20 different exercise programs, even after excluding all of the different machines and products that are widely promoted in the media. There are 26 different passive physical modalities, and numerous variants exist for each of these approaches. There are nine educational and psychological therapies, which is by no means an exhaustive list. There are 20 different injections therapies, which themselves have numerous subtypes according to practitioner preference. There are a number of procedures commonly included under the umbrella of minimally invasive interventions promoted as alternatives to surgery. There are also more traditional and newer surgical approaches. There is an extensive list of lifestyle products sold for back pain, including braces, beds, chairs, and ergonomic aides. Finally, there is a constantly changing variety of complementary and alternative medical approaches to back pain, used by a large and apparently growing number of patients.23 This extensive list of therapeutic options makes it continually more difficult for the primary care provider to decide which options are best for their patients.
The purpose of this section is to aid the primary care provider in understanding the evidence for the most commonly utilized treatment methods of chiropractors. As was previously mentioned, the most commonly utilized treatment methods are spinal manipulative technique, flexion distraction therapy (FDT), instrument assisted manipulation (IAM), and soft-tissue techniques.
Spinal manipulative technique consists of the application of a high velocity, low-amplitude thrust to the spine with the practitioner's hand to distract spinal zygapophyseal joints slightly beyond their passive range of joint motion into the paraphysiologic space. There are many specific high velocity, low-amplitude techniques available to practitioners of spinal manipulative technique that are modifiable according to patient need. This type of spinal manipulative technique has also been termed short-lever spinal manipulative technique because the thrust is applied directly to the spine. The exact mechanism by which spinal manipulation improves pain and function is not known. The theorized mechanism of spinal manipulation is through stimulation of joint mechanoreceptors.24 This stimulation of joint receptors causes a suppression of the excitability of the alpha motor neurons and an increase in the excitability of the lateral corticospinal tract.25,26 It is thought that these central reactions cause a decrease in local sensitivity over the motor unit and a decrease in the tightness of the paravertebral musculature.27,28 There has also been recent work suggesting that the manipulative force may also affect inflammatory changes at the dorsal root ganglion.29
Although the exact mechanism of spinal manipulation remains somewhat elusive (similar to many other treatments), this treatment has been shown to have definite clinical effects that are greater than placebo.30,31 Currently there are systematic reviews of the literature concerning spinal manipulation for lower back pain, neck pain, and headaches. Most of these reviews find that spinal manipulation is beneficial for spinal pain and headaches; however, the data state that it performs similarly to other currently available treatments for spine pain.32 Traction therapy is defined as, "any method of separating the lumbar vertebrae with the primary force directed along the inferior-superior axis of the spine, in an attempt to treat spinal pain."33 The use of traction or distraction therapy has also been reviewed for neck pain and lower back pain. The most recent manuscript addressing the use of traction therapy for chronic lower back pain states, "The preponderance of evidence indicates that sustained traction is ineffective for LBP with or without leg pain and that there is little data to support that intermittent traction is significantly different than sustained traction."19 Regarding neck pain, the most recent review found "inconclusive evidence" for continuous and intermittent traction.33
Instrument-assisted manipulation is defined as manipulation performed utilizing a spring-loaded, handheld device designed to deliver a focused force to a structure. Instrument-assisted manipulation has been studied, but to date there are no systematic reviews of the literature addressing the few trials that have been conducted. The two small trials conducted did find favorable comparable results with this type of manipulation compared with high velocity spinal manipulation, but these were very small trials and cannot be considered as conclusive evidence either for or against instrument-assisted manipulation.34,35 There is also a review of the literature addressing spinal manipulation for non-musculoskeletal conditions. The most recent review found that, "evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia." The authors point out, however, that there is a need for more research in this area and also a need for high quality randomized controlled trials to further investigate these areas.36
Safety of Chiropractic Treatment
Spinal manipulative therapy has been shown to be safe in the general population.37 The most valid studies suggest that about half of all patients will experience adverse events after spinal manipulative therapy. These events are usually mild and transient.38 The most common of these adverse events from spinal manipulative therapy is soreness that is similar to that of vigorously exercising or an intramuscular injection. No reliable data currently exist about the incidence of serious adverse events associated with spinal manipulation.38 Although most work done in this area has concentrated on the lumbar spine, a recent published study found that, "Although minor side effects following cervical spine manipulation were relatively common, the risk of serious adverse event, immediately or up to 7 days after treatment, was low to very low."39 Some recent work performed has attempted to identify predictors of adverse events associated with spinal manipulation; however there are no definitive data that specifically predict who might experience an adverse event associated with spinal manipulation.40,41 There are three areas typically discussed in relationship to adverse events associated with spinal manipulation: risk of disc injury, risk of vertebral arterial dissection, and risk of fracture (particularly in older adults).
Risk of Disc Injury with Spinal Manipulation. The role of spinal manipulative therapy in the treatment of symptomatic lumbar disc disease, specifically herniated disc and internal disc disruption, is considered somewhat controversial. Some sources state that this treatment should be considered safe, effective, and indicated, while other sources state that it is dangerous, ineffective, and contraindicated.42,43 Some of this controversy centers on the lack of specificity in the diagnosis of whether a disc herniation is the exact source of pain. Safety concerns center on the risk of spinal manipulative therapy triggering or worsening a herniation and/or causing acute cauda equina syndrome. Malpractice claims data from a major U.S. carrier show that "disc problems" are the leading reason for malpractice claims made against chiropractors, accounting for approximately 27% of all claims from 1991 to 1995, and 26% of claims from 2001 to 2003.42
Despite this controversy, it appears that patients with disc pathology seek manipulative treatment. Although an accurate estimate of the numbers of such patients is lacking, utilization studies of chiropractic and osteopathic patients suggest that 3% to 4.5% of all cases may include an unspecified disc problem, and 6.1% of cases with LBP may represent symptomatic lumbar disc disruption. In a survey of U.S. chiropractors, 70% reported managing intervertebral disk syndrome, and 76% reported managing radiculopathy. One published manuscript reported on 80 patients who were "surgical candidates" secondary to disc pathology who underwent spinal manipulative therapy without any serious adverse events.44 Recent multidisciplinary clinical guidelines from the North American Spine Society include manual therapy and manipulation as options in the nonoperative care of lumbar herniated disc. Two reviews of the literature have been performed concerning the risk of significant adverse events from spinal manipulation in patients with disc pathology. Both of these reviews found that there is insufficient data to make definitive conclusions.42,43
The risk of significant adverse event post spinal manipulation is estimated at somewhere between 1 in 3.7 million to 1 in 100,000,000. This estimate calculates to risk in less than 2% of patients. When one compares this number to the complication rates of other commonly utilized treatments for symptomatic lumbar disc disease such as non-steroidal anti-inflammatory drugs (NSAIDs) and spinal surgery, spinal manipulation appears to be a relatively safe option. NSAIDs are very commonly used, and adverse events occur in 25% of patients, with significant complications occurring in 1% to 4% per year. The major side effects include gastrointestinal (GI) ulceration and bleeding, hepatorenal dysfunction, organ failure, and skin reactions.45 Large long-term studies investigating spinal surgery report rates of repeat surgical intervention after lumbar discectomy to be approximately 12%.46 Epidemiologic studies of lumbar surgery, in general, have also found high rates of reoperation (9.5%). The any-complication rate associated with spine surgery is estimated to be 3.7% or more, including 1.5% mortality.46 Given the fact that no study to date has shown superiority of any one of these treatments over another, one may suggest spinal manipulation be considered a safe option in relation to other treatment options for spinal conditions, specifically disc pathology.
Risk of Vertebral Artery Dissection. Multiple case reports published have purported a relationship between cervical spinal manipulation and vertebral artery dissection and stroke. The most common theory is that cervical extension and/or rotation causes damage to the vertebral artery, specifically an intimal tear resulting in a dissection leading to occlusion of the vertebral artery. Other activities have also been linked to vertebral artery dissection, such as shoulder checking when driving, cervical rotation with bow hunting, working overhead, coughing, and sneezing.47 Most vertebral and carotid dissections, however, are spontaneous. Spontaneous dissection is the most common type of stroke in those younger than 45 years of age.48 There remains a controversy over the exact etiology of these types of spontaneous stroke. In a recent review article, the authors report that the exact etiology of these spontaneous dissections remains elusive.49 There have been some weak data to support a relationship to homocysteine, but there remains a need for further research in this area.
The true incidence of vertebral artery dissection is unknown, since many cases are asymptomatic or the dissection produces only mild symptoms. The most recent and comprehensive population-based study, however, found that there was an equally high risk of a patient suffering a vertebral artery dissection after seeing a primary care physician as after seeing a chiropractor. The authors concluded, "Vertebrobasilar artery (VBA) stroke is a very rare event in the population. The reported increased risk of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke."50 Currently in our institution, we are training our students to look for a new onset of a new/unique headache. If a patient presents with these symptoms, it is recommended that the patient immediately be sent for either neurologic evaluation or imaging, specifically magnetic resonance angiography (MRA).
Osteoporosis. Even though spinal manipulative therapy is a commonly used treatment for older adult patients with chronic lower back pain,51,52 issues of safety must be taken into consideration given the reduced strength, endurance, and tissue capacity associated with aging and disease.53 Two of the commonly listed relative contraindications to spinal manipulative therapy are osteopenia and osteoporosis.54 Loss of bone density is common in the elderly and, therefore, must be considered by anyone using spinal manipulation in the elderly population. In regards to osteopenia and osteoporosis, Triano states, "only under the most severe losses of bone mass is spinal manipulation contraindicated."55,56 It has been demonstrated, however, that the clinician can alter their force through positional variation.56 In our own work at Monroe Community Hospital, we have demonstrated that spinal manipulation could be performed safely in osteoporotic older adults.57-59 It is imperative that the chiropractor use care and be familiar with special issues associated with manipulation in the older adult.
How to Find a Good Chiropractor
In giving presentations to different groups of primary care physicians, the response of most groups is very positive to the data presented regarding chiropractic. However, the most common question that I am asked is, "How do I find a good chiropractor?" Unfortunately, the answer to this question is not simple and straightforward. In the United States today there remains a great amount of variation among chiropractors. These variations include different types of technique and differences in how they approach different clinical presentations. Currently there is no definitive way to delineate one type of chiropractor from another by just looking at his or her ad or qualifications. There are however, some helpful things that a primary care physician may want to consider regarding patient selection for referral to a chiropractor and also selection of a chiropractor.
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Who Should Be Referred for Chiropractic Care?
There has been recent work attempting to identify specific patient characteristics that are predictive of positive response to certain interventions.60 In the case of manual therapies offered by chiropractors, there has been work in attempting to predict responsiveness to spinal manipulation, specific exercises (flexion and extension), stabilization exercises, and traction therapy. The results of this recent work are presented in Table 2. Although a primary care physician may not evaluate all of these predictive factors, particularly the specific orthopedic tests, there are some important principles to consider about patients prior to referral for manual therapies. These principles include first defining if the patient has a "mechanical pain syndrome," which is the most common type of pain that will respond to manual therapy. This type of pain is simply defined as pain that can be made either worse or better in different functional positions.
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Another very important factor to consider is the psychosocial overlay in patients who suffer with chronic pain. The previous work in this area has found that patients with high "fear avoidance belief" behavior, as measured by the Fear Avoidance Beliefs Questionnaire (FABQ), do poorly with mechanical treatment.60 The FABQ is a commonly used measure of pain-related fear for patients with low back pain. The FABQ measures fear avoidance beliefs, which are theorized to be a quantification of an individual's fear of pain and beliefs about the need to change behaviors to avoid low back pain. A high score on this questionnaire would indicate that the patient has more fear about his or her pain. This has been shown to correlate with poor prognosis in acute and chronic lower back pain.60 Concerning relative and absolute contraindications for manual therapies, the overarching principle is, "Can this patient's underlying pathophysiology be made worse with some type of manual therapy?" An absolute contraindication is defined as any circumstance that renders a form of treatment or clinical intervention inappropriate because it places the patient at undue risk. A relative contraindication is defined as any circumstance that may place the patient at undue risk unless the treatment approach is modified. In the case of spinal manipulation, examples of absolute contraindications include acute fracture, unstable joint, and acute inflammatory arthropathy. Relative contraindications for spinal manipulative therapy include severe osteoporosis, poorly controlled anti-coagulation, and abdominal aortic aneurysm of greater than 3.5 cm.20 When deciding on referral to a chiropractor it is also important to consider the patient's expectations and life experience. There are recent data that indicate that a patient's expectations going into a specific type of care can influence the effectiveness of that care.61 Therefore, it is important to discuss this choice with the patient to assess the patient's impression of chiropractic, and whether he or she is willing to try it.
Another consideration in referring a patient to a chiropractor is the type of technique that the chiropractor utilizes. Some chiropractors perform spinal manipulation with their hands (as previously discussed this is high velocity low amplitude manipulation), while others use techniques involving specialized instruments or tables (as previously discussed flexion distraction or instrument assisted manipulation). Additionally, some chiropractors use more force, while others have a lighter touch. This is a very individual preference by both the chiropractor and the patient. Some patients prefer the immediate feeling of relief offered by high velocity low amplitude manipulation, while others may be more hesitant about this and may request a low-force technique (such as flexion distraction/traction or instrument assisted manipulation).
Some specific questions a primary care physician may want to ask a chiropractor are:
Which techniques does the chiropractor use and why?
Good chiropractors will be willing to take the time to speak to primary care providers and will be willing to share the types of techniques they utilize and the rationale behind them. They should also be willing to share the current evidence base for the techniques utilized. In this case, if it is a technique that you are unfamiliar with, you may want to ask if the technique is done with the hands, with an instrument, or with a specialized table. A primary care physician may even want to take the time to set up a meeting or go to the chiropractor's office and observe the equipment and the techniques used. Since very few medicine residencies offer these types of experiences, it would be very helpful to observe what a chiropractor does in the office.
What is a typical treatment plan for patients?
Something to be hesitant about in a chiropractor is if he/she claims to be the only one with a "special new technique" that no other chiropractor can use. In addition, if the chiropractor claims to be able to "cure" various conditions such as diabetes, cancer, or some other long-term, chronic condition, another choice may be appropriate. Similarly, a long-term treatment plan such as 3 times/week adjustments for 6-12 months, 2 times/week for another 6-12 months, and 1 time/week for 6-12 or more months is a strong warning sign of unrealistic forecasting. Another concern would be if a practitioner asks for a large sum of money up front for care.
Chiropractic Case Management. Depending on the nature and extent of the specific back problem, a few visits to the chiropractor should help the patient feel noticeably better. Within one to four weeks, the pain for non-complex musculoskeletal conditions such as acute neck or lower back pain should typically be reduced by 40-80%, and the frequency of visits should decrease as the patient's pain and function improve. If symptoms are not improving in that timeframe, either there is another mechanical problem that has been overlooked such as repeated ergonomic stress that reproduces the pain, or there is a complicating condition that may need further diagnostic evaluation or may benefit from some other form of treatment.
Patient-centered, conscientious chiropractors will make every effort to give their patients relief as quickly as possible with as few treatments as necessary, and also give advice on how to avoid future problems by evaluating lifestyle ergonomics, implementing an exercise approach, and reducing care to an as-needed plan. In general, in the absence of progressive worsening of a condition in spite of care, a common treatment plan is 3 times/week for 2-4 weeks with constant reevaluation throughout treatment to monitor if the patient is responding to care. If the patient is improving, a tapering of treatment frequency is appropriate while introducing a self-help, home-based exercise program and/or ergonomic modifications to activities of daily living. If the patient is not getting relief after the first 4-6 weeks, depending on the specific case, the good chiropractor will recommend an alteration in the treatment plan including diagnostic imaging, laboratory testing, advanced imaging, or referral to another practitioner. It is important to note that in most states a chiropractor is licensed to order diagnostic imaging (including advanced imaging) and laboratory tests. Good chiropractors will utilize testing in a judicious but appropriate manner.
Many chiropractors have excellent relationships with other spine specialists in their community (or even practice in the same facility with them). Chiropractors routinely refer patients to injectionists and spinal surgeons. There is also a society dedicated to the collaborative relationships between neurosurgeons and chiropractors (http://www.spinephysicians.org). Other questions that one might consider asking include: What services does the chiropractor offer? Some chiropractors offer additional services such as massage therapy, exercise instruction, rehabilitation and strength training, and nutritional counseling. If a chiropractor is offering nutritional counseling, it is important to be sure that he/she is not selling large numbers of supplements to every person without evaluating the specific needs of the patient. It is advisable to avoid practitioners who tend to find the same thing wrong with every patient and treat every patient identically.
Chiropractic Education and Qualifications. Chiropractors are licensed to practice in their state, and need to have completed the national board examinations. Check to see if there have been any disciplinary actions against the chiropractor. This information is available from each state's Chiropractic Board of Examiners, which can usually be found on the state's web site.
Conclusion
Chiropractic as a profession is maturing and progressively integrating into the mainstream of medicine. With the growth and integration of chiropractic, it is important that the primary care physician have a working understanding of what chiropractic is and what specific types of patients should be referred to a chiropractor. This article has given a brief overview of the history of chiropractic. It has reviewed the indications and contraindications for referral to a chiropractor. As the chiropractic profession continues its evolution, it will be imperative that the primary care physician and chiropractor communicate on a regular basis and work together for the good of patients.
References
1. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147: 478-491.
2. Guzman J, Haldeman S, Carroll LJ, et al; Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. Spine 2008;33(4 Suppl):S199-213.
3. Frenkel M, Ben-Arye E, Hermoni D. An approach to educating family practice residents and family physicians about complementary and alternative medicine. Complement Ther Med 2004;12(2-3):118-125.
4. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136:216-227.
5. Brokaw JJ, Tunnicliff G, Raess BU, et al. The teaching of complementary and alternative medicine in U.S. medical schools: A survey of course directors. Acad Med 2002;77: 876-881.
6. Keating JC. Several pathways in the evolution of chiropractic manipulation. J Manipulative and Physiol Ther 2003;26: 300-321.
7. Barnes PM, Powell-Griner E, McFann K, et al. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004;(343):1-19.
8. Coulter ID. Sociological studies of the role of the chiropractor: An exercise in ideological hegemony? J Manipulative Physiol Ther 1991;14:51-58.
9. Homola S. Chiropractic: History and overview of theories and methods. Clin Orthop Relat Res 2006;444:236-242.
10. DeVocht JW. History and overview of theories and methods of chiropractic: A counterpoint. Clin Orthop Relat Res 2006; 444:243-249.
11. Dunn AS. Department of defense chiropractic internships: A survey of internship participants and nonparticipants. J Chiropr Educ 2006;20:115-122.
12. Dougherty PE, Katz P. Complementary and alternative care in a long-term setting. Annals of Long Term Care: Clinical Care and Aging 2005;13:48-54.
13. Dougherty PE, Killinger L. Role of chiropractic in a long-term care setting. Long-Term Care Interface 2005;6:33-38.
14. Tindle HA, Davis RB, Phillips RS, et al. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med 2005;11:42-49.
15. Coulter ID, Hurwitz EL, Adams AH, et al. Patients using chiropractors in North America: Who are they, and why are they in chiropractic care? Spine 2002;27:291-296; discussion 297-298.
16. Sharma R, Haas M, Stano M. Patient attitudes, insurance, and other determinants of self-referral to medical and chiropractic physicians. Am J Public Health 2003;93:2111-117.
17. Triano JJ. Biomechanics of spinal manipulative therapy. Spine J 2001;1:121-130.
18. National Board of Chiropractic Examiners: Job analysis of chiropractic 2005. http://www.nbce.org/publication/job-analysis.html
19. Gay RE, Brault JS. Evidence-informed management of chronic low back pain with traction therapy. Spine J 2008; 8:234-242.
20. Haldeman S, Chapman-Smith D, Petersen DM, eds. Guidelines for Chiropractic Quality Assurance and Practice Parameters, 2nd edition. Boston: Jones & Barlett Publishers; 2004.
21. Leboeuf-Yde C, Hestbæk L. Maintenance care in chiropractic - what do we know? Chiropr Osteopat 2008;16:3.
22. Descarreaux M, Blouin J-S, Drolet M, et al. Efficacy of preventive spinal manipulation for chronic low back pain and related disabilities: A preliminary study. J Manipulative Physiol Ther 2004;27:509-514.
23. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J 2008;8:1-7.
24. Pickar JG, Sung PS, Kang YM, et al. Response of lumbar paraspinal muscles spindles is greater to spinal manipulative loading compared with slower loading under length control. Spine J 2007;7:583-95.
25. Dishman JD, Greco DS, Burke JR. Motor-evoked potentials recorded from lumbar erector spinae muscles: A study of corticospinal excitability changes associated with spinal manipulation. J Manipulative Physiol Ther 2008;31:258-70.
26. Dishman JD, Dougherty PE, Burke JR. Evaluation of the effect of postural perturbation on motoneuronal activity following various methods of lumbar spinal manipulation. Spine J 2005;5:650-659
27. Ruiz-Sáez M, Fernández-de-las-Peñas C, Blanco CR, et al. Changes in pressure pain sensitivity in latent myofascial trigger points in the upper trapezius muscle after a cervical spine manipulation in pain-free subjects. J Manipulative Physiol Ther 2007;30:578-583.
28. Pickar J. Neurophysiological effects of spinal manipulation. Spine J 2002;2:357-371.
29. Song XJ, Gan Q, Cao JL, et al. Spinal manipulation reduces pain and hyperalgesia after lumbar intervertebral foramen inflammation in the rat. J Manipulative Physiol Ther 2006; 29:5-13.
30. Hurwitz EL, Carragee EJ, van der Velde G, et al; Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: Noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33(4 Suppl):S123-152.
31. Bronfort G, Haas M, Evans R, et al. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J 2008;8:213-225.
32. Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev 2004;(1):CD000447.
33. Graham N, Gross AR, Goldsmith C; the Cervical Overview Group. Mechanical traction for mechanical neck disorders: A systematic review. J Rehabil Med 2006;38:145-152.
34. Gemmell HA, Jacobson BH. The immediate effect of Activator vs Meric adjustment on acute low back pain: A randomized controlled trial. J Manipulative Physiol Ther 1995;18: 453-456.
35. Wood TG, Colloca CJ, Matthews R. A pilot randomized clinical trial on the relative effect of instrumental (MFMA) versus manual (HVLA) manipulation in the treatment of cervical spine dysfunction. J Manipulative Physiol Ther 2001;24: 260-271.
36. Hawk C, Khorsan R, Lisi AJ, et al. Chiropractic care for nonmusculoskeletal conditions: A systematic review with implications for whole systems research. J Altern Complement Med 2007;13:491-512.
37. Senstad O, Leboeuf-yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy. Spine 1997;22:435-441
38. Ernst E. Prospective investigations into the safety of spinal manipulation. J Pain Symptom Manage 2001;21:238-242.
39. Thiel HW, Bolton JE, Docherty S, et al. Safety of chiropractic manipulation of the cervical spine: A prospective national survey. Spine 2007;32:2375-2378.
40. Thiel HW, Bolton JE. Predictors for immediate and global responses to chiropractic manipulation of the cervical spine. J Manipulative Physiol Ther 2008;31:172-183.
41. Cagnie B, Vinck E, Beernaert A, et al. How common are side effects of spinal manipulation and can these side effects be predicted? Man Ther 2004;9:151-156.
42. Lisi AJ, Holmes EJ, Ammendolia C. High-velocity low-amplitude spinal manipulation for symptomatic lumbar disk disease: A systematic review of the literature. J Manipulative Physiol Ther 2005;28:429-442.
43. Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: A systematic review and risk assessment. J Manipulative Physiol Ther 2004;27:197-210.
44. Dougherty P, Bajwa S, Burke J, et al. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: A retrospective case series. J Manipulative Physiol Ther 2004;27:449-456.
45. Gurwitz JH, Fields TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003;289:1107-1116.
46. Wera GD, Dean CL, Ahn UM, et al. Reherniation and failure after lumbar discectomy: A comparison of fragment excision alone versus subtotal discectomy. J Spinal Disord Tech 2008; 21:316-319.
47. Santos-Franco JA, Zenteno M, Lee A. Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options. Neurosurg Rev 2008; 31:131-140.
48. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001;344:898-906.
49. Rubinstein SM, Peerdeman SM, van Tulder MW, et al. A systematic review of the risk factors for cervical artery dissection. Stroke 2005;36:1575-15780.
50. Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Spine 2008;33(4 Suppl):S176-S183.
51. Foster DF, Phillips RS, Hamel MB, et al. Alternative medicine use in older Americans. J Am Geriatr Soc 2000;48: 1560-1565.
52. Astin JA, Pelletier KR, Marie A, et al. Complementary and alternative medicine use among elderly persons: one-year analysis of a Blue Shield Medicare supplement. J Gerontol Biol Sci Med Sci 2000;55:M4-9.
53. Dougherty PE, Killinger L. Role of chiropractic in a long-term care setting. Long-Term Care Interface 2005;6:33-38.
54. Triano JJ. Managing geriatric spine patients. In: Bougie L, Morgenthal P, eds. The Aging Body. McGraw-Hill Companies, Inc.; 2001.
55. Hessel B, Herzog W, Conway P, et al. Experimental measurement of the force exerted during spinal manipulation using the Thompson Technique. J Manipulative Physiol Ther 1990; 8:448-453.
56. Triano JJ,Schultz AB. Loads transmitted during lumbosacral SMT. Spine 1997;22:1955-1964.
57. Dougherty PE, Burke JM, Owens H. Physiologic effects of thoracic manipulation on long-term care patients with chronic obstructive pulmonary disease: A case series report. Platform presentation World Federation of Chiropractic Sydney Australia, 2005.
58. Dishman JD, Katz P. Establishment of chiropractic services in a geriatric inpatient rehabilitation hospital: A pilot of one model of integration. J Chiro Edu 2003;17:6-7.
59. Dougherty PE, Lawrence D. Chiropractic management of musculoskeletal pain in the multiple sclerosis patient. Clinical Chiropractic 2005;8:57-65.
60. Hebert J, Koppenhaver S, Fritz J, et al. Clinical prediction for success of interventions for managing low back pain. Clin Sports Med 2008;27:463-479, ix-x.
61. Myers SS, Phillips RS, Davis RB, et al. Patient expectations as predictors of outcome in patients with acute low back pain. J Gen Intern Med 2008;23:148-153.
For many years, chiropractic medicine often has been viewed with skepticism and even ridicule by organized medicine. Yet, we have all had patients who praise their chiropractor for taking care of symptoms for which we have only pills and physical therapy to offer.Subscribe Now for Access
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