Chiropractic

Chiropractor adjusting female patient

Terminology

The proper term for the profession is “chiropractic”, or occasionally “chiropractic medicine”, though some in the profession take umbrage at that term. It is decidedly not “chiropracty” or similar terms.

Chiropractic History

Chiropractic was “discovered” by D.D. Palmer, a magnetic healer (similar to Reiki therapy today), in 1895, during the era of “heroic medicine.”[i] This was a time when very harsh treatments, such as bloodletting, purging, leeches and powerful laxatives and other unproven treatments were part of “conventional” medicine of the day. The sicker the patient, the more extreme the treatment. Medical physicians of the day were typically self-taught or served short apprenticeships before hanging out their shingles. [ii]Magnetic healing and other medical treatments which may seem odd by today’s standards were common health care practices at the end of the 19th century. Palmer was largely self-taught but well-read and had a good grasp of anatomy and physiology for his time.

Harvey Lillard, a janitor who worked in Palmer’s building, explained to Palmer he had lost his hearing when he bent in an awkward position and felt a “pop” in his neck. Palmer reasoned the two events were related, and on examining Lillard, he found what felt to be a bone out of place in his neck, and using his hands manipulated it back into position. Surprisingly, Lillard’s hearing was restored and chiropractic was born.

Palmer’s understanding of the relationship of the spinal column and the nervous system led him to try spinal manipulation for other ailments, principally for what he termed “subluxations” in the spine, which he reasoned could produce effects on other types of conditions.

Remarkably he was successful in treating not only pain, but even other conditions like headache, stomach pain, epilepsy and other conditions.[iii] His success in helping patients led him to open a chiropractic school, and to eventually develop a philosophy and science which remain at odds with current mainstream medicine and which today might seem odd and unscientific, but which were largely well grounded on the knowledge available in his day.

Not surprisingly, medical physicians of the day were unimpressed, dismissed Palmer’s discovery, and he was even arrested and jailed at one point for practicing medicine without a license. Nevertheless, by 1913 the first law licensing doctors of chiropractic had passed, and by 1931, 39 states had licensing laws. Today chiropractic is licensed in all 50 states and many countries around the world.

There remains a dark period in the development of healthcare that organized medicine would rather forget due to the millions of patients adversely affected. In the early 70’s and 80’s the AMA and other co-conspirators engaged in an anti-competitive campaign to destroy chiropractic.[iv] In 1987, a federal judge in Chicago Illinois, Susan Getzandanner, found the AMA and others guilty of violating antitrust laws. During discovery and trial it was found that the AMA actually formed a “committee on quackery” whose sole purpose was to “contain and eliminate the chiropractic profession.”[v] They initiated several programs including a campaign to discredit the profession by calling chiropractors “quacks”. If you ever uttered those words you were likely the unwitting victim of the AMA’s campaign to destroy the reputation of chiropractic.

They also attempted to contain chiropractic by preventing MDs from even socializing or speaking to chiropractors, and by limited or preventing insurance coverage, including Medicare. But chiropractic prevailed primarily by consistently obtaining results even when medicine often failed to help the patient. Today, some doctors in the field still harbor those old anti-chiropractic sentiments, while many others now work collaboratively with chiropractors for the good of our mutual patients.

Chiropractic Philosophy

Chiropractic, which means “done with skill by hand” was one of several manipulation-based healing arts of the time (the principle other being Osteopathy.) Palmer developed a theory of why manipulating or “adjusting” the spine produced such amazing results. At the time, Vitalism was a popular concept of the day. Wikipedia defines vitalism as “ the belief that living organisms are fundamentally different from non-living entities because they contain some non-physical element or are governed by different principles than are inanimate things". Some equate this with the belief that the sum is greater than the parts, or that there is a “life force” inherent in all living things.

Vitalistic Theory

Palmer developed a philosophy that essentially held that a concept of “Universal Intelligence” or a force was present in all living things that was expressed through “innate intelligence”, or the natural, vitalistic wisdom of the body. Subluxations restricted the flow of “innate intelligence” in the body, resulting in dis-ease whenever those reductions in flow occurred and the cure was to remove the subluxations, allowing the body to return to a natural state of health which would “cure” the disease. So, according to the theory, all disease was due to a subluxation which reduced the ability of “Innate intelligence” to express itself fully.

In other words, the body is self-healing and self-regulating, needs no help in maintaining health so long as there is no interference with the flow of “Innate Intelligence.” Thus Palmer borrowed a long-standing and widely held belief in vitalistic theory and re-engineered it to set chiropractic apart from other health care professions of the day.

This theory was originally propounded in Palmer’s 1910 textbook and formed the foundational basis of chiropractic education and philosophy for decades, expanded and promoted by Palmer’s son Bartlett Joshua (B.J.) Palmer, who continued to promote the profession and philosophy.[vi]

Mixed Philosophy

Today, the majority of chiropractors in the US reject all or part of that philosophy, though some Doctors of Chiropractic (D.C.) still adhere to the premise. Some chiropractic colleges still teach it as a core element, but more and more are merely referring to it as part of the colorful history of the profession, and are turning to an “evidence-based” approach to understanding chiropractic’s role in the health care continuum. Remember, the roots of medicine were also grounded in equally questionable and disproven theories. As medicine grew, so did chiropractic.

Historically, and continuing today, D.C.’s who adhere strictly to much of the original Palmer philosophy are considered “straights,” or “principled”, and continue to believe in the primacy of the subluxation as a leading, if not THE leading cause of human disease. Their principle concern is the subluxation, and their primary tool is the adjustment. Unfortunately, this theoretical construct remains largely unsubstantiated and untested. [vii]

In the past, D.C’s who chose to incorporate other techniques and therapies into their practice and recognized other causes of disease were termed “mixers”. The term “subluxation” for many has been replaced by the more contemporary term “spinal dysfunction”[viii], meaning the spine is simply not functioning correctly. Emerging research continues to identify the importance of the spine and far-reaching effects of dysfunction of spinal joints, connective tissue, nerve tissue, and inflammation. The spine is a complex structure and today’s DCs recognize the importance of incorporating other treatments (ex. Nutrition, rehab, home-based exercises, laser therapy, etc.) and other providers into a treatment plan versus solely relying on a spinal adjustment to correct a subluxation.

Evidence-Based Chiropractic

Enter a new breed of chiropractor: the evidence-based D.C. Today there are more chiropractic colleges outside the U.S. than inside, and they no longer hew to the old philosophy. They are taught to evaluate effectiveness claims based on evidence-based care, meaning using the best available scientific evidene to inform practice approaches, and are taught to adhere to published chiropractic guidelines, such as those promoted on GGCPP.org. Those guidelines promote short and reasonable trials of care (6-12 visits) with further care depending on demonstrated improvement in pain and increased function. [ix] These doctors attempt to provide care that is grounded in the most recent scientific evidence of effectiveness, and adapt their approach based on patient response.

The Evidence for Chiropractic Care

Like all health care disciplines, chiropractic has been moving towards translating research into practical applications for clinical care based on the concept of “evidence-based care.” Such care consists of an interaction of 3 factors:

  1. Patient’s needs, values and preferences
  2. The skill, experience and clinical judgement of the provider
  3. The best available scientific evidence[x]

Good clinicians try to balance all three of these factors to provide care that is supported by science, makes sense to both the provider and patient, and takes the patient’s needs and wishes into account.

Early in the history of chiropractic there was little interest and fewer resources for conducting research. That began to change in the 1960’s and 1970’s, and today there is a robust chiropractic research community, funded in part by the Federal government, and extensive scientific literature regarding chiropractic care for many conditions, particularly neck pain, back pain and headaches, as well as many other conditions.

Back Pain Evidence:

  • One persuasive study showed manipulation was as effective as typical medical care for acute back pain. [xi]
  • Multiple medical societies, including the American College of Physicians, American Pain Academy,[xii] and most recently a review published in the Journal of the American Medical Association recommend spinal manipulation for low back pain. [xiii]
  • Chiropractic care has been shown in multiple studies to be more cost-effective than medical care[xiv]
  • A recent study showed that patients with a work related low back injury who see a surgeon first for care were much more likely to have surgery than those who saw a chiropractor first. 42.7% of patients who saw a surgeon first ended up with surgery, while only 1.5% of those who saw a chiropractor first ultimately had surgery. [xv]
  • The majority of clinical guidelines, which advise providers on which treatments have evidence of effectiveness recommend spinal manipulation for acute and chronic back pain.

Neck Pain Evidence:

  • A review of Randomized Controlled Trials (RCT’s), the “gold standard” for research recently published by the highly respected Cochrane Collaboration, found that manipulation for acute and subacute neck pain was more effective than typical combinations of pain medication, muscle relaxants and non-steroidal anti-inflammatory medication (NSAIDS). [xvi]
  • Other Cochrane reviews have looked at the effectiveness of patient education, whiplash treatments and traction for neck pain. They conclude that there is either little evidence to support the treatment, or simply not enough high quality research to pass judgement. [xvii],[xviii]
  • However, studies have also shown there is little evidence to support commonly used treatments for neck pain, like NSAIDs, and that surgery might provide some short-term benefits, but little or no real difference over time.[xix],[xx]
  • A recent extensive review of conservative treatments for neck pain and whiplash disorders concluded than “multi-modal” care, meaning multiple treatments such as manipulation, mobilization, soft tissue work, exercise, laser and other treatment was the most effective approach for neck pain conditions.[xxi]

Other Musculoskeletal Conditions:

Chiropractors treat most musculoskeletal conditions, besides neck pain, back pain and headaches, including jaw pain (TMJ), shoulder and elbow injuries, knee and hip problems, and foot problems including plantar fasciitis. There is fairly good research evidence for many of these conditions, but very little scientific literature one way or the other for other conditions. This does not mean it is not effective, but simply that there is not enough evidence to make a recommendation either way. Other conditions such as fibromyalgia and arthritis are also commonly treated by chiropractors, again with varying levels of scientific literature support.

An extensive study in 2010 reviewed the available literature at that time on manipulation and made the following conclusions:

“Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media [ear infection] and enuresis [bed wetting], and it is not effective for infantile colic and asthma when compared to sham manipulation.”[xxii]

CHIROPRACTIC EDUCATION

As of 2017, there were 17 chiropractic degree-granting programs in the U.S accredited by the government-recognized Council on Chiropractic Education (CCE), and a similar number of accredited programs around the world, including programs in Australia, the United Kingdom, Denmark, France, Canada, Japan, Malaysia, Spain, South Korea and others.8 In the United States, the degree granted is the Doctor of Chiropractic (D.C.) degree.

The D.C. curriculum is similar to the medical school program. [xxiii] Students seeking to enroll in chiropractic school must have at least a B average and have completed at least 3 years of college (though most students enter chiropractic school with a bachelor’s degree.) The chiropractic program is 4 academic years long, and the first two years include basic science courses including anatomy, physiology, embryology, biochemistry and biomechanics, among others. Later coursework teaches the student to evaluate and care for patients, including course work in diagnosis, neurophysiology and neurology, xray diagnosis, pathology, adjustive and physiotherapy techniques and philosophy, among others.8

Students must pass a series of National Board examinations in order to progress, and a final National Board examination which includes both written tests and practical demonstration the student has mastered the basic skills of diagnosis, xray evaluation, and clinical proficiency in treatment in order to obtain a license to practice chiropractic.

Chiropractic Licensure

D.C.’s are licensed in all 50 states, but since each state has its own licensing laws, different states have different scopes of practice which dictate what the D.C. is permitted to do. Some states have very “broad” scopes and include the use of certain medications and minor surgery, such as suturing. Others have very limited scopes permitting only manipulation of the spine. In all states D.C.’s are considered “primary portal of entry” doctors, meaning patients can seek care without any referral from an M.D. or other provider. In fact, D.C.’s are the second largest profession that serves as a primary portal of entry in the U.S., behind M.D.’s.

Chiropractic Practice

 D.C.’s are considered “primary portal of entry” providers, and are required by state law to evaluate and diagnose patients. Some D.C.’s stick to a more philosophical approach and limit their practice to the evaluation and treatment of subluxations, though they are still required to make appropriate diagnoses and refer patients out when the condition is not likely to benefit from chiropractic care. Most D.C.s practice a broader scope of practice, including physiotherapy treatments like exercise, laser and electrical stimulation treatments.

Despite the historical conflicts with organized medicine, D.C.’s today work collaboratively with medical doctors and other providers. Many D.C.’s both make and receive referrals to and from their medical colleagues, especially family practice, orthopedic, neurology and pain management physicians. Today, many D.C.’s work in integrated practices where the D.C. works in a medical practice.

Other examples of integrated practices include:

  • The Veterans Administration: D.C.s are on-staff providers at 50 VA centers around the country
  • Private hospitals
  • The Department of Defense (65 locations for active duty military personnel) including Walter Reed National Military Medical Center and Naval Medical Center San Diego
  • Large corporations such as Google, Qualcomm, Cisco and Stanford Health
  • Major professional sports teams, including all NFL teams

The Safety of Chiropractic

More than 110 years of experience has demonstrated that chiropractic care is remarkably safe. Addressing the issue of chiropractic’s safety begs the question: compared to what?

Most conditions treated by D.C’s, such as neck pain, back pain and headache are typically treated by medical doctors with drug therapy. Many people believe common over the counter medications, including acetaminophen (TylenolÒ) or ibuprofen (MotrinÒ) are very safe, since you can buy them almost anywhere. Here are some relevant facts you might consider:

  • The largest cause of drug overdoses in the U.S. is acetaminophen
  • The number one cause of liver failure in the U.S. is not alcohol, it’s TylenolÒ[xxiv]
  • The National Institute of Medicine concluded in 2010 that 16,500 people die in this country every year due to non-steroidal anti-inflammatory drugs (NSAIDs, like ibuprofen) taken for arthritis.[xxv] This is about how many people die of AIDS, and more than the deaths from multiple myeloma, asthma, cervical cancer, or Hodgkin’s disease.8
  • If you tallied up all the deaths from gastric bleeding due to NSAIDs, it would be the 15th leading cause of death in the U.S.
  • Muscle relaxants have many side effects, but only “fair” evidence they work for low back pain and even less for neck pain.

Opioids

The news today is filled with the problems caused by opioid addiction. According to the National Institute on Drug Abuse, 90 people die in the U.S. every day from opioid overdose, and 33,000 Americans died from it in 2015.[xxvi] The “economic burden” of opioid abuse is more than $78 billion dollars a year. On August 11, 2017, President Donald Trump declared the opioid crisis an “emergency.” Clearly there is a need for fewer, not more opioid prescriptions, and patients and providers should look to conservative measures, including chiropractic care, to alleviate pain first.

Injections and Surgery

 Most evidence-based guidelines say that spinal surgery should only be used in limited circumstances, and studies indicate that adverse effects occur in 10-24 percent of surgeries. Most recent guidelines suggest that conservative treatment approaches should be exhausted before surgery except in very specific circumstances. Nevertheless, the rate of spinal surgeries continues to increase 8

 Spinal injections, and in particular epidural injections are also being provided more frequently, despite the high cost, frequency of complications and lack of high quality studies demonstrating long-term benefit. Studies also show that epidural injections do not reduce the likelihood of future surgery.8

Chiropractic Risks

Chiropractic care is generally regarded as safe and effective, and a recommended alternative to drugs for musculoskeletal problems. All health care interventions can have side effects, and chiropractic is no exception. One study suggested that about 3 in 10 patients might experience a brief increase in localized pain or headache following manipulation.[xxvii]

Spinal manipulation for lumbar spine conditions appears to be remarkably safe, even for patients with lumbar disc herniation. One study suggested the risk of making the herniation worse or of causing a condition (cauda equine syndrome) which requires surgery from manipulation was one in 3.7 million cases.[xxviii]

A 2017 review of a large number of previous studies published in the Journal of the American Medical Association found that manipulation was effective for low back pain, and they also note there had been no reports of adverse events in the studies reviewed.13

Risks of Neck Manipulation

Perhaps no issue regarding spinal manipulation is more controversial than neck manipulation. There are individual case reports of patients suffering strokes after manipulation, often played up in the popular press, and some well-intentioned but often misinformed physicians will caution patients against undergoing neck manipulation.

Let’s review the facts:

An exceedingly rare condition called Vertebral Artery Dissection (VAD) can occur when there is damage to the inside of the vertebral artery, a major blood vessel in the neck that pumps blood to the brain. In dissection, part of the inside of the artery pulls away and results in restriction of blood flow. It is the leading cause of stroke in young and otherwise healthy people. It is most common in the 5th decade of life, and affects between 1 and 2 out of every 100,000 people.[xxix] The majority of these dissections are considered to be “spontaneous”, meaning there is no apparent event that caused it.

In order to understand what is responsible for specific conditions, it is important to understand the differences between causation and association. Wikipedia defines the terms as follows:

Causation: The act of causing. The act or agency by which an effect is produced. Cause and effect;

Association: The act of associating. The state of being associated; a connection to or an affiliation with something.  Any relationship between two measured quantities that renders them statistically dependent (but not necessarily causal or a correlation).A group of persons associated for a common purpose;

The point here is that there may be an association between two events, but one does not necessarily cause the other. For example, there may be an association with the dawn and the appearance of a newspaper on your porch, but dawn certainly does not cause the newspaper to appear, any more than the appearance of the newspaper causes the sun to rise. There is an association but no causation.

So what does that have to do with neck manipulation and stroke from vertebral artery dissection? We know that vertebral artery dissections are rare, and the association of neck manipulation and vertebral artery dissection rarer still. Chiropractors have been acutely aware of this association for decades, and are trained to look for warning signs or potential risk factors. Unfortunately there are no good tests to suggest who might be at risk.

The association extends not just to manipulation but also to everyday activities, such as getting one’s hair done at the parlor, backing up the car, coughing or even rapid head movements while listening to music.[xxx] In other words, trivial activities of daily living are associated with VAD.

Nevertheless, there have been case reports of patients suffering a VAD stroke after seeing a chiropractor. (There have also been reported cases where a patient had a VAD stroke while sitting in the waiting room before ever seeing the chiropractor!)

Herzog and colleagues tried to determine whether forces commonly used in cervical manipulation were strong enough to disrupt the artery wall, and concluded they were not, and in fact were not as forceful as those people experience during everyday activities, and less than forces exerted in simple range of motion tests. They concluded spinal manipulation did not appear to be a factor in VAD injury.[xxxi]

We do know that some people are at higher risk for VAD. These include patients with congenital connective tissue disorders, including Ehlers-Danlos syndrome, osteogenesis imperfecta and Marfan’s syndrome. There is a slightly increased risk for people with high blood pressure, history of smoking and use of birth control pills as well.

A very large (11 million people) study in Canada looked over a 9 year period at everyone who sustained a VAD related stroke and evaluated whether they had seen a D.C. or family physician in the two weeks before the stroke occurred. They found that there was a higher risk of stroke among the patients who saw their M.D. than their D.C., but ultimately concluded that while there was an association with the visit to either type of doctor, the stroke was not caused by the doctor, but was most likely already underway at the time of the visit. That is because the symptoms of a VAD are headache and neck pain, and patients with neck pain and headache go to their chiropractor or M.D.[xxxii]

Similarly a more recent review of the records of 39 million enrollees in a Medicare insurance plan were reviewed, and found no relationship between VAD and chiropractic care, although they did find an association between VAD and visits to their primary care physician. Again, the conclusion was that patients seeking care for their neck pain and headaches were already undergoing VAD before their stroke.[xxxiii]

A number of similar studies have come to the same conclusion: spinal manipulation is not likely the cause of vertebral artery injuries and subsequent strokes, and the association is more likely due to early symptoms of VAD which include severe headache and neck pain, which often prompts patients to visit their primary care physician or chiropractor.

So how rare are these events? A study 8,[xxxiv] by a major chiropractic malpractice carrier in Canada found that VAD will occur in 1 in 8 million chiropractic office visits, 1 in 5.85 million cervical adjustments, and once in nearly 50 chiropractic careers.

Early Symptoms and Red Flags for Stroke

Many cases of ultimate VAD with stroke begin with the sudden onset of severe headache (“worst ever”) and/or neck pain. The time between symptoms and onset of stroke can range from one day to two weeks. Presence of these other symptoms[xxxv], alone or in combination may warrant emergent referral.

  • Vertigo/dizziness
  • Numbness on one side of the face
  • Difficulty speaking
  • Difficulty swallowing
  • Nausea/vomiting
  • Unsteadiness
  • Double vision
  • Extremity numbness or tingling
  • Extremity weakness

In the presence of sudden onset severe headache or neck pain, with associated symptoms as noted above, it is safest to assume there may be an evolving VAD and impending stroke and to seek immediate medical attention until proven otherwise.

WHAT DO CHIROPRACTORS TREAT?

In addition to neck pain, low back pain and headache, most D.C.’s treat a wide variety of musculoskeletal conditions, and some treat other non-musculoskeletal conditions as well. Not every D.C. treats all these conditions, so it is a good idea to ask if your chiropractor has experience with the type of condition you have. Typical conditions seen in a chiropractic office include but are not limited to:

  • Neck pain, including whiplash
  • Low back pain, including sciatica, strains and disc herniation
  • Arthritis
  • Muscle strains
  • Shoulder injuries
  • Tennis elbow
  • Disc herniations
  • Arm or leg pain
  • Foot and ankle injuries
  • Plantar fasciitis
  • Fibromyalgia
  • Carpal tunnel syndrome
  • Wrist and hand injuries

WHAT TO EXPECT AT THE CHIROPRACTIC OFFICE

If you are in the market to see a chiropractor and have questions, most D.C.’s will be happy to provide a telephone or face to face “consultation” to see if they are a good fit, and likely to be able to help your condition. Most will provide this at no charge.

There are a wide variety of practice styles among chiropractors, but whether you are looking for a new D.C or have never been before, you should expect the new patient encounter to include certain common activities:

Intake Paperwork

Whether by tried and true pen and paper, or on the computer, the doctor will need to obtain certain demographic information as well as information about your history and complaints. This will also typically include acknowledgement of your privacy (HIPAA) rights, insurance information, and consent to treatment. Your doctor will typically want you to list prior medical conditions and any medications or supplements you currently take.

The History

The doctor will typically review your medical history with you and ask you about the condition or conditions which brought you to the office. He or she will want to know what caused the problem, how long you have had it, what makes it better or worse, and how it affects your ability to do things. They will usually ask about radiation of symptoms and other issues depending on the nature of the problem.

The Examination

The physical examination is largely dictated by the history. Don’t expect a leg exam if you present with headaches. Relevant body regions will be evaluated , typically using standard orthopedic, neurological or chiropractic tests. For example, a headache complaint would likely include examination of the neck, including range of motion testing, as well as palpation (feeling the tissues and joints) of the neck. Neurological testing of the reflexes, sensation in the hands and arms, and testing the strength of the arms and hands would also likely be performed. D.C.’s pay particular attention to tight muscles or spasm, and restrictions in joint movement, typical in subluxation or joint dysfunction.

Depending on you symptoms, he or she might perform more in-depth neurological tests, or listen to your heart or lungs with a stethoscope. They may look inside your ears, nose or mouth with an otoscope, in the same way your M.D. might, to evaluate for potential problems.

Other tests might be indicated as well. The doctor is also evaluating for “red flags,” or signs of a more serious condition that would warrant referral to a different doctor.

Red Flags

  • History of cancer
  • Unexplained fever
  • Unexplained weight loss, loss of appetite, anorexia
  • Unremitting pain not relieved by rest
  • Loss of bowel or bladder control, urinary changes
  • Sexual dysfunction
  • Progressive neurological deficit
  • Worsening pain despite treatment
  • Connective tissue disorders
  • Signs of potential stroke (dizziness, double vision, drop attacks, difficulty speaking or swallowing, weakness, gait problems, nausea and vomiting, facial numbness

(this list is not exhaustive)

Special Studies

In the past, most chiropractic patients received xrays. Not any longer. Research and current practice guidelines indicate that unless there is a red flag or history of significant trauma, a trial of chiropractic care is usually recommended before considering xrays.

Your chiropractor may also order other special studies, including MRI, computerized tomography (CT) scans, neurodiagnostic studies such as nerve conduction velocity and EMG tests to evaluate nerve and muscle function, or other special tests depending on your history, examination findings and response to previous care.

Consent to Treatment

Before undergoing care, you must provide your consent, and it should be informed. In most jurisdictions, is must be both verbal and written. This means your doctor should explain to you in terms you can understand what she believes is wrong, and what your treatment options are, including no care. She should explain the anticipated risks of treatment as well. You should be able to ask questions until you are satisfied you understand your options and potential risks before providing consent.

Treatment Plans

Current treatment guidelines9 for many conditions, such as low back pain, recommend trials of care including 6-12 visits, typically over a 2-4 week period with a re-evaluation after 6-12 visits to determine if progress is being made. If there has been little progress at that time, the doctor should try a different approach, order further tests, or refer you out to another provider.

Some doctors may recommend lengthy (and expensive) treatment programs including multiple visits, xrays and re-examinations, extending over several months, with a discount for pre-payment. While you may ultimately require extensive care, most D.C.’s believe it is impossible to predict that a patient will require an extended period of care up front. Shorter periods of care, or trials of care, allow time to demonstrate whether treatment is effective without encouraging unnecessary care and expense.

Undertreatment may be as serious an issue as overtreatment. Patients, particularly with longstanding problems, need to understand that treatment may be required for a reasonable period of time before benefits might be noted, particularly if they are continuing to perform the activities (poor posture, sitting at a computer all days, heavy lifting etc.) that brought on the condition in the first place. You doctor will provide you with a treatment plan, and it is important for the patient to cooperate with that plan. If you have questions about the plan, ask! If you were overweight and out of shape and decided to go to the gym to get in shape, you could not reasonably expect to be fit in 2-3 weeks, or if you only went once a week. Trying to change longstanding physical habits, including posture, overuse and joint dysfunction take time and repetition.

Chiropractic Manipulation

There are a variety of types of manipulation commonly used in chiropractic offices. The doctor will select the type based on the patient type (frail? Osteoporotic? Aged?) and his or her experience. Types of manipulation include:

Diversified (High Velocity Low Amplitude or HVLA): this is the most commonly used form of manipulation and includes a specific, high speed, but very shallow thrust, using parts of the vertebra as a lever. Typically this will result in “cavitation” or popping at the joint, which is really simply release of gas from within the joint. The treatment is aimed at restoring motion and relieving pain.

Diversified manipulation takes the joint just beyond the normal range of passive motion, and requires skill, experience and knowledge to perform safely and appropriately.

Activator and other instrument assisted techniques: these techniques use a spring-loaded instrument or other device to deliver a gentle and precise amount of force directed at a restricted joint.

Soft Tissue Techniques: rely on palpating or feeling for problems in the muscles or connective tissues and using a variety of manual techniques to break up scar tissue and mobilize or free up restricted tissues, muscle spasms or trigger points (localized, very irritable segments of a muscle that can refer pain to other areas and affect how the muscle works.)

Drop Table: this procedure uses a specially designed table with a spring-loaded section below the patient which is set to the patient’s weight. The mechanism is cocked, and the doctor provides a thrust through the relevant body part which causes the table to “drop” about an inch, allowing the force of the thrust to pass through the body and be absorbed by the table. This allows for a gentler and well controlled force.

Flexion-Distraction technique is frequently used for conditions such as herniated discs: It relieves on a motorized or manually assisted portion of the lower part of the table which allows for an up and down or side to side motion to pump the lower back and increase motion in that area.

Other techniques: there are dozens of other chiropractic techniques. Some D.C.’s rely exclusively on one technique, while others use a variety of them depending on their experience and the patient’s presentation. Many techniques use little to no force and are extremely gentle.

Other Treatments:

While manipulation is the primary treatment modality used by most D.C.’s it is by no means the only tool in their toolbox. Chiropractors use a wide variety of other treatment approaches with their patients including:

  • Lifestyle and wellness advice
  • Exercises, stretches and rehabilitation protocols
  • Ergonomic evaluation and advice
  • Electrical muscle stimulation to relax muscles
  • TENS, interferential and other electrical modalities to reduce pain
  • Low level laser therapy to enhance healing
  • Traction
  • Counseling
  • Nutrition
  • Massage therapy
  • Acupuncture

There is also a growing trend for collaborative care with other providers, including M.D.s as well as acupuncturists. As noted, some D.C.s work in multidisciplinary practices, while others work collaboratively and trade referrals with their medical colleagues.

Chiropractic Specialties

Some D.C.’s specialize in certain patient types. Examples include pediatrics, women’s health issues, sports injuries, nutrition, work injuries or auto accidents, or neurological conditions.

Other D.C.’s complete additional academic post-graduate programs leading to Board Certification in specialties such as chiropractic orthopedics, neurology, internal medicine, and radiology to name a few. Most require a 300 hour program and successful completion of a specialty board written and practical examination.

How to Find a Good Chiropractor

Finding the right chiropractic doctor for you should be like finding any other heathcare provider. You want a provider who is a good fit for you and your own health philosophy and goals. Here are some tips for finding the right D.C. for you.

  • Ask around: ask your primary care physician (assuming he has no anti-chiropractic bias) or other healthcare providers such as orthopedists or physical therapists for a recommendation.
  • Ask family and friends (although the right one for them may not be the right one for you.)
  • Check social media websites such as Yelp and Google+ for reviews
  • Interview prospective doctors: most D.C.’s will be happy to provide a free telephone or in person “meet and greet” consultation to see if you are a good fit.
  • Ask about their length of time in practice and experience with your health complaint
  • Ask about their techniques: do you want a more forceful style of adjusting or do you prefer the gentlest possible manipulation? Does the D.C. always use only one style of manipulation, or do they have multiple techniques they can draw from?
  • Do they have additional training or certification, such as Board certification in neurology, orthopedics, pediatrics or other specialties? The lack of such additional credentials doesn’t mean the doctor isn’t a great provider, but further certification implies an additional level of expertise.
  • Do they work with the broader health care community, and both make and receive referrals from other physicians? If necessary, whom do they refer out to for consultations, co-management or to take over care? Will they provide reports to your primary care physician or other provider if requested?
  • Is their license in good standing? You can research this online, typically at the State Board of Chiropractic Examiners website. Help What Hurts checks this for all the doctors listed on our directory.
  • What is the typical wait time in the office?
  • Are they on your health plan or an all cash practice where you would be expected to bill your own insurance?
  • Do they offer discounts for low income patients, those without insurance or time of service discounts if you pay cash?
  • What it their typical treatment plan? National guidelines recommend 2-6 week trials of care, typically at 2-3 times a week, followed by a reexamination to determine progress towards meeting goals. Some D.C.s will recommend lengthy (3, 6 or 12 month) plans, paid up front after only a brief initial evaluation. Most reputable D.C.s understand that there is no way to know in advance if that much care will be necessary. If a prospective D.C. says he requires you to commit to a year of care up front, look elsewhere.
  • What is their policy on xrays? Some chiropractic techniques require xrays on all patients to determine where to manipulate (though there is little scientific evidence to support this.) Most chiropractors will xray if there are red flags, or if the patient is not responding to the plan of care. Do they have xray on site, or refer out for xrays? If they feel an xray is necessary, they should explain why and how it will impact treatment choices.
  • Do they provide nutritional or other supports? Don’t feel pressured to purchase them simply because the doctor recommends them. Ask how and why it will benefit you, and whether they can be purchased elsewhere.
  • Beware long term (lifetime) care plans. Many patients have chronic recurrent issues, with periodic flareups, and may benefit from periodic supportive treatment. Many spinal conditions are chronic and cannot necessarily be cured, but rather managed, and some studies[xxxvi] have shown the patient with chronic conditions who receive periodic care do better than those who don’t. Patients with no symptoms do not likely need ongoing treatment to “prevent” further problems.
  • What will it cost? Is there a free consultation? How much is the initial exam? Routine treatments, including additional services (therapy, exercise, massage?) Seeking the lowest price provider in your area may be counterproductive, since typically you get what you pay for. Doctors with more experience and busier practices my well deserve higher fees. Typically if you needed surgery, you wouldn’t necessarily go to the cheapest surgeon. Most people want the best. Remember, you pay for value. Fees for care should be within the “usual and customary” range in your area.

[i] http://www.utoledo.edu/library/canaday/exhibits/quackery/quack2.html

[ii] Cassedy JH. Medicine in America: A Short History. Baltimore, MD. Johns Hopkins University Press; 1991.

[iii] https://sciencebasedmedicine.org/chiropractic-a-brief-overview-part-i

[iv]  Agocs S. Chiropractic’s Fight for Survival. AMA Journal of Ethics. June 2011, Volume 13, Number 6: 384-388.

[v] http://www.nytimes.com/1987/08/29/us/us-judge-finds-medical-group-conspired-against-chiropractors.html

[vi] https://www.acatoday.org/About/History-of-Chiropractic

[vii] Subluxation: dogma or science? Keating J, Charlton K, Grod J, Perle S, Sikorski D, Winterstein J. Chiropractic & Osteopathy200513:17

[viii] Hawk C. The Praeger Handbook of Chiropractic Health Care.Santa Barabara CA: ABC-CLIO; 2017.

[ix] https://ccgpp.org

[x] Johnson C. Highlights of the basic components of evience-based practice. J Manipulative and Physiol Ther. 2008; 31(2):91-92.

[xi] Bishop PB, Quon JA, Fisher CG, Dvorak MF. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Spine J. 2010; 10 (2):1055-1064.

[xii] Chou R, Qaseem A, Snow V, et al. 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.

[xiii] Paige MN, Miake-Lye IM, Booth MS, et al.Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460

[xiv] Van TUlder MW. Michaleff ZA, Lin CW, Maher CG. Spinal manipulation epidemiology; systematic review of cost effectiveness studies. J Electromyogr Kinesiol. 2012;22(5): 655-662.

[xv] Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KCG, Franklin GM. Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State. Spine. 2013;38(11):953-964. doi:10.1097/BRS.0b013e3182814ed5.

[xvi] Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilization for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Sys Rev. 2015;9: CD004249.

[xvii] Verhage AP, Scholten-Peeter GC, vanWijngaarden S, et al. Conservative treatment for whiplash. Cochrane Database Sys Rev. 2017;2: CD003338

[xviii] Gross A, Forget M, St George K, et al. Mechanical traction for neck pain with or without radiculopathy or myelopathy. Cochrane Database Sys Rev. 2012;3: CD005106

[xix] Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: non-invasive 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.

[xx] Nikolaidis I, Fouyas IP, Sandercock PAG, Statham PF. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Sys Rev. 2010;1: CD001466.

[xxi] Bussières, André E. et al The Treatment of Neck Pain–Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. Journ Manip Phys Ther.39(8);523-564.

[xxii] Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy. 2010;18:3. doi:10.1186/1746-1340-18-3.

[xxiii] Coulter I, Adams A, CoganP, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Altern Ther Health Med. 1998;4(5):6464-75.

[xxiv] Fontana RJ. Acute Liver Failure including Acetaminophen Overdose. The Medical clinics of North America. 2008;92(4):761-794. doi:10.1016/j.mcna.2008.03.005.

[xxv] Wolfe MM, Lichtenstein DR, Singh G. Gatrointestinal toxicity of non-steroidal anti-inflammatory drugs. N Engl J Med. 2007;147(7):478-491.

[xxvi] https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis

[xxvii] Hurwitz EL1Morgenstern HVassilaki MChiang LM. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study. J Manipulative Physiol Ther. 2004 Jan;27(1):16-25.

[xxviii] Oliphant D..Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):197-210.

[xxix] Park K-W, Park J-S, Hwang S-C, Im S-B, Shin W-H, Kim B-T. Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations. Journal of Korean Neurosurgical Society. 2008;44(3):109-115

[xxx] Haneline MT, Rosner AL. The etiology of cervical artery dissection. Journal of Chiropractic Medicine. 2007;6(3):110-120. doi:10.1016/j.jcme.2007.04.007.

[xxxi] Herzog W1Leonard TRSymons BTang CWuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012 Oct;22(5):740-6.

[xxxii] 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. European Spine Journal. 2008;17(Suppl 1):176-183.

[xxxiii][xxxiii] Kosloff TMElton DTao JBannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap. 2015 Jun 16;23:19

[xxxiv] Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ: Canadian Medical Association Journal. 2001;165(7):905-906.8,

[xxxv] Saeed A. B., Shuaib A., Al-Sulaiti G., Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Canadian Journal of Neurological Sciences. 2000;27(4):292–296

[xxxvi]
Senna, M K, Machaly, S A. Does Maintained Spinal Manipulation Therapy for Chronic
Non-specific Low Back Pain Result in Better Long Term Outcome?
Spine (Phila Pa 1976) 2011 (Aug 15);   36 (18):   1427–1437