Effectiveness of Chiropractic Manual Therapy

Evidence-Based Practice Skills

Although all 4 institutions have followed different approaches to implementation, the overall strategies share some common principles. (a) Course work should incorporate journal club formats, checklist reviews of current studies, and student construction of critical appraised topics. (b) Informational literacy assignments should span all 4 years, be relevant, and relate to other course content. (c) The language and concepts of evidence-based practice must permeate all diagnosis and management courses and, where feasible, basic science courses as well. (d) Focused and ongoing training must target a large proportion of classroom and clinical faculty across the entire school curriculum. (e) Application of these skills must be patient based and become part of the clinic culture as opposed to an endeavor segregated to a journal club activity.

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Effectiveness of Manual Therapies

The goal of evidence-based practice is to incorporate the best-quality evidence into the clinical decision-making process to provide timely, appropriate care.11,12 The results of randomized controlled trials (RCTs) on manual therapies have been published in more than 200 peer-reviewed articles, and many of these have been synthesized in systematic reviews and evidence-based guidelines.13

Below we present a brief evidence synthesis based predominantly on the United Kingdom Evidence Report by Bronfort et al,13 currently the most comprehensive review of the evidence for the efficacy of manual therapies.14 The report was commissioned by the UK General Chiropractic Council in response to media concerns about scope of practice and claims of effectiveness in advertising. The report summarized the scientific evidence regarding the effectiveness of manual treatment as a therapeutic option of the management of 26 musculoskeletal and nonmusculoskeletal conditions. The authors based their conclusions on the results of systematic reviews of randomized controlled trials, widely accepted evidence-based guidelines, and randomized controlled trials not yet included in the former.

Low Back Pain

Spinal manipulation is an effective care option for acute, subacute, and chronic low back pain. Massage was also found to be effective for chronic low back pain.13 Notably, these finding were based, in part, on the clinical practice guidelines developed for the American Pain Society and the American College of Physicians. Chou et al15,16 recommended these treatments in addition to medical care. The most recent meta-analysis was supportive in finding clinically meaningful differences in aggregate between manipulation and other treatment alternatives.17 A 2010 Cochrane review suggested that there is moderate evidence that exercise can prevent recurrences of back pain, although there was conflicting evidence as to its effectiveness as a primary treatment.18 Based on fewer studies than on exercise or manipulation, a Cochrane systematic review found benefit of massage for patients with subacute and chronic nonspecific low back pain, especially when combined with exercise and education.19 Research on most conservative treatments for low back pain, including drug therapy, have reported only modest benefits.20 It remains to be seen whether this is due to the limited effectiveness of the interventions or the heterogeneity of patient populations. Research continues in an attempt to identify potential responder and nonresponder subgroups currently under the generic label of nonspecific low back pain. Potentially better results can also be linked to combination therapies and interdisciplinary approaches.

Neck Pain

Spinal manipulation was found to be effective for acute and subacute neck pain. Effectiveness was also found for acute whiplash when spinal manipulation is combined with exercise. Spinal manipulation was shown to be effective for chronic neck pain when combined with exercise.13 However, a new study suggests the efficacy of spinal manipulation alone in patients with associated cervicogenic headache.21Massage is also effective for chronic neck pain. An influential systematic review on this topic was conducted by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain.22

Mid Back Pain

The evidence to date is inconclusive in a favorable direction for the use of thoracic spinal manipulation for mid back pain. This is because there has been only 1 small placebo-controlled trial to date. On the other hand, thoracic spinal manipulation has been shown to be efficacious for the care of neck pain.13 The trends in the data thus suggest spinal manipulation for mid back pain is a promising therapy requiring further trials.

Headaches

Spinal manipulation is an effective option for migraine and cervicogenic headaches. The evidence was found inconclusive for tension-type headaches.13 There is little information available on other types of headache. A Cochrane systematic review by Bronfort et al is notable.23

Extremity Conditions

Manipulation of extremity joints is used for a variety of conditions. However, there are fewer trials than for back pain, neck pain, and headaches. Effectiveness was found for shoulder girdle pain, adhesive capsulitis, lateral epicondylitis, hip and knee osteoarthritis, patellofemoral pain syndrome, and plantar fasciitis. Inconclusive evidence in a favorable direction was observed for rotator cuff pain, shoulder pain, carpal tunnel syndrome, ankle sprains, Morton’s neuroma, hallux limitus, and hallux abductor valgus. The only definitive negative finding was for ankle fracture rehabilitation, while several other forms of post surgical rehabilitation had inconclusive evidence leaning in the negative direction.13

Nonmusculoskeletal Conditions

There was positive evidence for spinal manipulation for only 1 nonmusculoskeletal condition, cervicogenic dizziness. The evidence for the effectiveness of spinal manipulation was negative for asthma and dysmenorrhea; the addition of spinal manipulation to diet was also ineffective for hypertension. Evidence was inconclusive for pneumonia, stage 1 hypertension, pre-menstrual syndrome, nocturnal enuresis, and otitis media.13

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Safety

Manual therapies including spinal manipulation are generally safe. Side effects tend to be benign: minor and self-limiting with short duration (eg, mild postmanipulation soreness).24–26 Severe complications have been associated with spinal manipulation but are extremely rare.25 For example, cauda equina syndrome can be as rare as 1 in 100 million following lumbar manipulations.27 Cassidy et al28 reviewed approximately 100 million person-years of records to evaluate stroke risk associated with cervical spinal manipulation and medical care. The authors concluded that the risk was extremely small and there was no excess risk from chiropractic care compared with medical care for neck pain and headaches. They hypothesized that the equivalent risk for chiropractic and medical care suggests that a stroke prodrome can lead to care seeking for these conditions. It is unlikely that manipulation of the neck is causally related to stroke.

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Other Interventions

Other interventions commonly employed by the chiropractic profession have a similar evidenced-based foundation. A 2010 Cochrane review suggested that there is moderate evidence that exercise can help prevent recurrences of back pain, although there was conflicting evidence as to its effectiveness as a primary treatment.18 Based on fewer studies than on exercise or manipulation, a Cochrane systematic review found benefit of massage for patients with subacute and chronic nonspecific low back pain, especially when combined with exercise and education.19

Research on most conservative treatments for low back pain, including drug therapy, have reported only modest benefits.20 It remains to be seen whether this is due to the limited effectiveness of the interventions or the heterogeneity of patient populations. Research continues in an attempt to identify potential responder and nonresponder subgroups currently under the generic label of nonspecific low back pain. Potentially better results can also be linked to combination therapies and interdisciplinary approaches.

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Conclusion

Evidence-based practice has made significant inroads into the chiropractic profession by expanding clinical research into interventions commonly employed by chiropractors and by graduating more Evidence-based practice savvy practitioners. The most common conditions treated by chiropractors are back pain, neck pain, and headaches.9 The best available evidence supports manipulative therapy as a reasonable option for many of these complaints. Manipulative therapy also holds potential value for the treatment of a variety of extremity conditions. Chiropractic practice is far broader than spinal manipulation alone, typically including other evidenced-based interventions such as massage, exercise therapy, and activity modification advice. Chiropractic education, with the help of federal grants and partners in established medical schools, is aggressively addressing the need to create more Evidence-based practice savvy graduates. These efforts will hopefully lead to improved patient outcomes and offer a common language and perspective to facilitate greater interprofessional cooperation.

Surprise: Chiropractors Can Treat These 5 Conditions

Read on if you're stressed, have a migraine or struggle with flexibility.

By David Starr, Contributor Nov. 30, 2015, at 7:00 a.m.

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Surprise: Chiropractors Can Treat These 5 Conditions

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Chiropractors are trained as neuromusculoskeletal specialists, and one of the main focuses of chiropractic care is the positive impact it can have on a person's nervous system. (ISTOCKPHOTO)

YOU MIGHT THINK chiropractors are only able to help with back aches, stiff necks, slipped discs and whiplash injuries. If so, you're not alone – but you're missing out.

Chiropractic care – which is based on the understanding that, given the opportunity, the mind and body can heal itself – can treat many issues that might surprise you.

Here's a look at the top five most surprising conditions a chiropractor can treat:

1. Migraines and tension headaches

Nine out of 10 Americans suffer from headaches. Some are occasional. Some are persistent. Some are dull and nagging, while others cause debilitating pain and nausea. Taking a painkiller and hoping your headache goes away is one option. But there's a better one.

Research shows that spinal manipulation – the primary form of care provided by chiropractic doctors – is an effective way to treat tension headaches and headaches that begin in the neck.

In a clinical trial conducted at Macquarie University, 72 percent of migraine sufferers experienced either "substantial" or "noticeable" improvement after a period of chiropractic treatment.

In fact, most headaches are related to muscle tension in the neck, which is an increasingly common condition among Americans who spend hours in the same position or posture (such as in front of a computer or television), leading to joint irritation and tension in the upper back and scalp that cause headaches.

What Can a Doctor of Chiropractic Do?

• Perform spinal manipulation or chiropractic adjustments to improve spinal function and alleviate stress on your system.
• Provide nutritional advice, recommending a change in diet or the addition of vitamins.
• Offer advice on posture, ergonomics, exercises and relaxation techniques.

2. Stress and anxiety

We perceive stress from three basic sources: our environment, our body and our emotions.

Environmental stress includes noise, weather, physical threats, time pressures and performance standards. Body stress includes disease processes, organ malfunction, poor nutrition, poor sleepand physical injury. And emotional stress is more difficult to define, but it encompasses our reactions, in both thought and emotion, to environmental and physical stressors.

Jobs today are increasingly complex as the business world becomes more and more competitive. Physical stresses such as sound, air and water pollution have also grown worse over the last century – especially in the United States – and so have emotional and psychological stresses caused by an increasing awareness of troubles and tragedies around the globe, brought to our attention every hour by the Internet and its 24/7 news cycle.

Many illnesses are caused or worsened by stress, which activates our "fight or flight" reaction. This systemic reaction affects almost every part of the body, as the hypothalamus in the brain stimulates the sympathetic nervous system, which causes an increase in heart rate, blood volume and blood pressure, redirecting blood away from our digestive system and extremities.

When prolonged, the long-term effects of this state can be disastrous to good health and cause high blood pressure, muscle tissue damage, diabetes, infertility, damage to the immune system and slowed healing from disease and injury.

Chiropractors work primarily with the spine – the root of the nervous system through which nerve impulses travel between the brain and the rest of the body – and can help the body manage and process this stress in a healthier way.

What Can a Doctor of Chiropractic Do?

• Chiropractors can release muscle tension, one effect of chronic stress that leads to nerve irritation and creates uneven pressures on the body's bony structures, which can cause the spinal column to become misaligned. This, in turn, helps the body return to a more balanced, relaxed state.
• Chiropractic adjustments can reduce spinal nerve irritation and improve blood circulation, which can help signal the brain to turn off the "fight or flight" response and begin the healing process.
• A doctor of chiropractic can suggest nutritional supplements, like B complex vitamins, to help the body cope with stress.
• A chiropractor can also recommend relaxation techniques and discuss posture and environmental changes to help you recover from chronic stress.

3. Fibromyalgia

Fibromyalgia is a chronic disorder involving widespread pain and sensitivity throughout the entire musculoskeletal system. To be diagnosed with FM, a patient typically has a minimum of 11 out of 18 specific tender points on the body. In addition to pain, patients also report long-term fatigue and/or disturbed sleep and mood. Other disorders commonly associated with FM include irritable bowel syndrome, TMJ pain and dysfunction, psychological conditions and some autoimmune diseases.

Fibromyalgia is a widespread condition that affects about 2 percent of the United States, and medical science has yet to discover the cause of this condition.

Since those with FM often experience an altered mood, like depression, many experts focus on the psychological aspect of the disease. Others feel that FM is more physiological and has its origins in physical trauma or chronic postural alterations. Still others suggest that FM is a central nervous system disorder rooted in neurochemical imbalances, since those with FM are hypersensitive to even the slightest stimuli and often have a pain response to normally non-painful pressure or activity. Since all information from the outside world is collected and analyzed by the nervous system, it's logical to assume that if a person with FM is sensitive to a stimulus that others are not, there may be something wrong with this system.

It's often difficult for patients to find solutions for all of their symptoms, but recent studies show that chiropractic adjustments combined with a soft tissue technique called ischemic compression can help FM patients.

In one study, 60 percent of the subjects treated by a chiropractor experienced a significant improvement: reduced pain, improved sleep and decreased fatigue.

What Can a Doctor of Chiropractic Do?

• Chiropractors are trained as neuromusculoskeletal specialists, and one of the main focuses of chiropractic care is the positive impact it can have on a person's nervous system. Therefore, chiropractic adjustments can improve a FM patient's nervous system, which gives them a better chance for recovery.
• Chiropractic care can treat pressure points, back pain, neck pain, shoulder pain, headaches and pain from musculoskeletal injuries.
• Chiropractors can also reduce a patient's overall pain through spinal adjustments that increase the mobility between spinal vertebrae, which have become restricted, locked or slightly out of proper position, thereby increasing cervical and lumbar range of motion.

4. Weak immune systems
The nervous system, endocrine system and immune system are inextricably linked. Together they share tiny messenger molecules that mediate communication between them, creating optimal responses for the body to adapt and heal appropriately.

Until recently, one of these messenger molecules, IL-2, was thought of as an immune system molecule. But recent studies have clearly shown its presence and activity in the nervous system, leading researchers to believe that neural dysfunctions due to spinal misalignments are stressful to the body and can cause abnormal changes that lead to a poorly coordinated immune response.

Subluxation is the term for misalignments of the spine that cause compression and irritation of nerve pathways, affecting the body's organs. Subluxations are an example of physical nerve stress that affects neuronal control. According to researchers, such stressful conditions lead to altered measures of immune function and an increased susceptibility to a variety of diseases.

It's important to note here how the endocrine system also impacts the immune system by producing cortisol in the adrenal glands – endocrine glands that are directly connected to the nervous system through the sympathetic nervous system – a stress hormone that inhibits the immune system.

If the sympathetic nervous system is too "switched on" due to stress and subluxation, it can increase the adrenal glands' synthesis of cortisol, in turn affecting the immune system.

What Can a Doctor of Chiropractic Do?

• Chiropractic care is the only way to detect and eliminate subluxation, and chiropractic adjustments have been shown to reduce the stress on the nervous system, thereby boosting the coordinated responses of the nervous and immune systems.
• One research group found that when an adjustment was applied to a subluxated area, the white blood cell count collected rose significantly.
• Another study measured the effects of six months of regular chiropractic care on the immune system function of HIV patients. At the end of six months of care, the patients who had received regular adjustments showed a 48 percent increase in the number of CD4+ T cells, whereas patients who had not been adjusted showed an 8 percent decrease in CD4+ T cells.

5. Flexibility

When we're younger, it's easy to take our extensive range of motion and flexibility for granted. As we age, a number of health conditions – and the cumulative effects of wear and tear – can affect our ability to move the way we used to.

But a decrease in range of motion and flexibility can result in a downward spiral of disability.

For example, an injury or degenerative condition that causes pain, swelling and stiffness, may limit our flexibility and range of motion. When this happens, we may avoid activities that involve the affected body parts, either consciously or unconsciously.

This then becomes a classic case of "use it or lose it." Without regular exercise, the muscles and joints stiffen, adhesions and scar tissue can form, and mobility may be further reduced. Eventually, a person can become completely incapacitated, and ordinary tasks such as picking up something off the floor or tying your shoes can become extremely challenging or painful.

Regular chiropractic can help increase both range of motion and flexibility.

A study performed by researchers at the Phillip Chiropractic Research Centre of RMIT University in Melbourne, Australia, and published in the Journal of Manipulative and Physiological Therapeutics found that chiropractic adjustments increased range of motion in the 105 patients who participated in the study. There were three phases of this study, in which each of the participants was given no adjustments, fake adjustments or true adjustments. In each phase, the patients who were given the true adjustments showed a significant improvement in range of motion, which was not the case for the other two groups.

What Can a Doctor of Chiropractic Do?

• A chiropractor uses spinal adjustments and manipulations to other parts of the body to realign the bones and joints so as to reduce pain, restore range of motion and improve flexibility, balance and coordination.
• Your chiropractor can also recommend specific exercises that can be done at home to increase your strength and flexibility so that you're able to maintain and build upon the gains from your chiropractic adjustments.
• Regular chiropractic care can reduce or eliminate the source of your back and joint pain, allowing you to resume your normal activities and to remain more flexible into your golden years.

Dr. David L. Starr is the founder of Starr Physical Therapy, Chiropractic and Acupuncture in New York City, where he has successfully practiced chiropractic for the past 18 years. A native New Yorker, Starr graduated from Life College in Atlanta, Georgia and donated his skills to Flying Doctors of American in the Dominican Republic before returning to New York City and establishing a successful, multidisciplinary office in Union Square.

You may not always be able to avoid stressful...

You may not always be able to avoid stressful situations, especially during the holidays, but you can help manage your body's reaction to stress with regular chiropractic care.​

You may not always be able to avoid stressful...

You may not always be able to avoid stressful situations, especially during the holidays, but you can help manage your body's reaction to stress with regular chiropractic care.​

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