7 Things You Should Know
Seven things you should know about chiropractors and chiropractic treatment...
In December of 1994, the Agency for Health Care Policy and Research published guidelines for the management of acute adult low back pain. Spinal manipulation, the treatment that has become synonymous with the chiropractic profession, was a recommended front line treatment. Despite this publication, and over forty randomized control trials that support spinal manipulation as an effective treatment for low back pain, the referral patterns of most medical physicians has not changed to include chiropractic care. Also, numerous papers support the efficacy of chiropractic treatment for other musculoskeletal disorders such as whiplash, neck pain and headaches.
What has prevented the use of spinal manipulation and utilization of chiropractic services from logically increasing?
The answer may be found in the profession that delivers this service. To the medical profession, there are simply too many unanswered questions about chiropractors and chiropractic treatment. Perhaps the following will clarify some of your questions. _________________________________________________________________
1. Which patients should I consider for chiropractic care?
- The outcomes for Chiropractic treatment are optimal for patients with acute/subacute mechanical/myofascial cervical, thoracic or lumbosacral spinal pain.
- Diagnostic classifications include whiplash, stable radiculopathy, lumbar stenosis, facet syndrome, costotransverse capsulitis, sacroiliac joint pain, spinal strain/sprain, non-specific spinal pain, discogenic low back pain, myofascial pain syndromes and cervical headaches.
- Patients with cervical or lumbar intervertebral disc herniations commonly respond positively to chiropractic management. Treatments are likely to include forms of traction (e.g., flexion-distraction), Mackenzie (extension) therapy and other positional release techniques.
- Our patients with repetitive strain injuries, carpal tunnel syndrome, thoracic outlet syndrome, temporomandibular joint pain and other musculoskeletal disorders also appreciate excellent outcomes.
2. How much care is necessary for a patient to improve with chiropractic treatment?
- Patients with spine pain commonly appreciate functional improvement and pain relief within a few treatment sessions, while others require more extensive care. It is not uncommon for immediate relief following the first treatment. The acute, uncomplicated spine pain patient should appreciate significant relief within 2-4 weeks of care. Chronic or complicated acute patients may require four to five weeks of treatment before a cumulative symptom response is appreciated.
- Patients with chronic or permanent conditions may be treated under a —disease management— model. Once the patient has reached a point of maximum therapeutic benefit in a comprehensive treatment program, manipulation and adjunctive therapies may be provided on a periodic basis to maintain functional and symptom gains. Our goal is to encourage independence from treatment.
3. Is chiropractic manipulation safe?
When the correct manipulation technique is paired with the appropriately selected patient, spinal manipulation is a very safe procedure. There are relative and absolute contraindications to spinal manipulation that have been identified in the physical medicine literature. The most common side effect experienced by patients receiving spinal manipulation is short-term soreness in the area of the treatment; commonly 1in 5.
The most concerning potential complications from spinal manipulation are cauda equina syndrome (CES) and vertebral basilar artery injury (VBAI). The likelihood of these complications is approximately 1: 4.5 million (VBAI) to 1: 100 million (CES).
- A history of spinal surgery, osteoporosis, healed fracture, disc herniation without significant or progressive neurologic deficit, scoliosis, chronic arthopathies, degenerative changes, some acute injuries and joint instability are not absolute contraindications to treatment.
- Absolute contraindications: severe or progressive neurologic deficit, infections or malignancies, acute bone demineralization, acute fracture/dislocation and acute arthropathies.
- A contraindication to spinal manipulation in one region of the spine rarely precludes treatment in another region. If techniques cannot be modified to accommodate the patient's condition, manipulation is withheld.
4. How does manipulation work?
- Spinal manipulation has shown to result in an immediate post treatment increase in range of motion, decreased adjacent soft tissue tenderness, improved function and decreased pain.
- Although the exact mechanism is not clear, current models that explain the treatment benefits appreciated following spinal manipulative therapy (SMT) include: motion segment unbuckling, meniscoid inclusion release, intra-articular adhesion / fringe release, stimulation of joint mechanoreceptors and/or relaxation of hypertonic muscle. Centrally mediated reflexes are being investigated.
5. Why is there such variation in treatment among chiropractors?
The chiropractic profession is philosophically divided into two primary groups;
- those who adhere to many of the traditional chiropractic theories that promote lifelong care, and
- those who work on an integrated, evidence based care model.
Philosophically based chiropractors advocate that spinal manipulation (referred to an —adjustment—) improves health through reducing sub-clinical neurologic impairment by correcting intervertebral joint dysfunction (referred to as a 'subluxation'). Theoretically, spinal adjustments are directed at restoring neural homeostasis, rather than administered to treat a clinical disorder. Also, regular adjustments are administered as a means of preventive healthcare. Most of these chiropractors do not seek a clinical diagnosis other than 'subluxation', and do not exercise standard examination and treatment procedures.
Evidence based chiropractors commonly work on a physical medicine model to diagnose and treat their patients. Spinal manipulation is one component of the management strategy, which also draws from those therapies that are shared with physical therapists and physiatrists. These chiropractic physicians administer therapeutic treatment modalities such as ultrasound, electrical muscle stimulation, hot/cold therapies and instruct their patients in rehabilitative exercises, stretches, lifestyle changes and proper diet. Many evidence based chiropractors work cooperatively within hospitals and integrated care centers.
6. With all of the variation in chiropractic, how does one identify a qualified chiropractor?
The Journal of Family Practice (1992) published the following guidelines to consider when selecting a chiropractor:
- Treats mainly musculoskeletal disorders
- Does not radiograph every patient
- Willing to be clinically observed
- Positive feedback from patients
- Communicates with the referring physician
- Administers reasonable treatment programs
- Does not charge a global, up front fee
7. How well educated are chiropractors?
Candidates for entry into most chiropractic colleges are required to complete a four-year undergraduate program. Ten trimesters of chiropractic college training (four years) must be completed to graduate. The first eight trimesters are primarily didactic training. Courses include human anatomy and dissection, branches of physiology, pharmacology, diagnostic imaging, nutrition, rehabilitation, spinal manipulation and medical patient management strategies. The ninth and tenth trimesters are completed through an internship under the direction of a licensed chiropractor. Upon graduation, most chiropractors enter private practice after successfully passing national and state board examinations.
Residency programs after chiropractic training are optional and include specialties in Orthopedics, Diagnostic Imaging, Clinical Studies, Rehabilitation and Research. A multitude of post-graduate lectures are also offered.