Finding A Good Chiropractor
Samuel Homola, DC
Arch Fam Med. 1998;7:20-23.
Spinal manipulation provided by chiropractors is often beneficial in the treatment of some types of back pain. Since some chiropractors use spinal manipulation to treat visceral disease and back pain, medical practitioners may have to be cautious and selective in referring patients with back pain to chiropractors. This commentary will help family physicians determine when it might be appropriate to seek the services of a chiropractor in the treatment of back pain.
Spinal manipulation has undoubtedly been attempted from the time man rose to stand on 2 feet and had his first "back kink." Medical history indicates that manipulation and massage have been part of the ancient art of bonesetting from time immemorial.
The Greek physician Hippocrates (450 BC-375 BC), in his work On the Articulations, described a method of spinal manipulation as, "the most powerful of the mechanical means," in which a tractable patient is placed in a prone position so that a padded area of the spine could be rammed with a wooden beam guided by an overlying, slotted, wooden plank.
In the case of spinal curvature, Hippocrates recommended that the patient be placed face down on a bench that is "covered with robes, or any thing else which is soft, but does not yield much," and then stretch the patient longitudinally while pressure is applied to the hump of the curvature by both hands1 hand placed on top of the other.1
Bonesetting, as a method of relieving aches and pains, has been used by medical and laypersons alike, passed down through the centuries, largely by families of bonesetters.
"Crazy Sally Mapp," one of the most famous bonesetters, the daughter of a 17th-century bonesetter, toured London in the early part of the 18th century, "setting bones and curing disease" with bonesetting techniques handed down from one family to another.
Andrew Taylor Still, the "lightning bonesetter" who founded osteopathy, proclaimed in 1874: "I could twist a man one way and cure flux, fever, colds and the diseases of the climate; shake a child and stop scarlet fever, croup, and diphtheria; and cure whooping cough in three days by a wring of the child's neck."
BIRTH OF THE SUBLUXATION THEORY
With the development of osteopathy in 1874 and the appearance of chiropractic in 1895, spinal manipulation gave birth to a new theory. D. D. Palmer, the founder of chiropractic, a grocer, and a magnetic healer who healed by touch, announced his discovery that ". . . 95 percent of diseases are caused by displaced vertebrae; the remainder by luxations of other joints."2
While spinal manipulation used by medical practitioners was limited to treatment of mechanical problems, chiropractors promoted the use of spinal "adjustments" as a method of treating and preventing disease. Adjusting subluxations or misaligned vertebrae in the spine to relieve pinched nerves or to remove nerve interference, chiropractors claimed to have a cure for all types of disease and infection. Orthopedic specialists did not deny that vertebral subluxations caused pain, muscle spasm, loss of mobility, and other symptoms, but chiropractors claimed to be able to find subluxations in the spines of asymptomatic patientssubluxations not detectable by medical practitioners.
A number of studies have been done to indicate that spinal manipulation is effective in the treatment of mechanical-type back problems, but there are no definitive, scientific studies that indicate that vertebral misalignment is a cause of disease or infection.
At the present time, there have been no appropriately controlled studies that establish that spinal manipulation or any other form of somatic therapy represents a valid curative strategy for the treatment of any internal organic disease. Furthermore, current scientific knowledge also fails to support the existence of a plausible biological mechanism that could account for a casual segmentally or regionally related somato-visceral disease' relationship. On the other hand, it has now been firmly established that somatic dysfunction is notorious in its ability to create overt signs and symptoms that can mimic, or simulate (rather than cause), internal organ disease.3
Nansel and Szlazak concluded that there is not a single appropriately controlled study to indicate that dysfunction in structures of the spinal column could cause organic disease.
SPINAL MANIPULATION AND BACK PAIN
In 1991, RAND, a nonprofit research organization, published the first of a 4-part report on the effectiveness, complications, and indications for spinal manipulation for back pain.4 This multidisciplinary review of the literature on back pain supported the use of spinal manipulation as a treatment for patients with acute low back pain without symptoms of lower limb nerve-root involvement and other contraindicating signs. It was recommended that treatment be discontinued after 2 to 4 weeks in the absence of documented improvement. Support in the literature was less clear, insufficient, or conflicting for the use of spinal manipulation in treating subacute and chronic back pain, with or without neurologic findings or sciaticaindicating a great need for additional research.
Reporting similar findings, the Agency for Health Care Policy and Research of the US Department of Health and Human Services published a report that concluded that, in the absence of red flags, "Manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms."5
Despite accumulating evidence that spinal manipulation is an effective treatment for some types of back pain, the second most common reason expressed by patients for office visits to primary care physicians and the most common reason for office visits to orthopedic surgeons, neurosurgeons, and occupational medicine physicians,5 the chiropractic profession is resisting any effort to define chiropractors as back specialists.
Responding to a suggestion that chiropractic be defined as a specialty in the care of neuromusculoskeletal problems of mechanical origin, with emphasis on back care,6 the executive director of the Foundation for Chiropractic Education and Research (FCER) offered these comments:
It has long been the contention of FCER that to position chiropractors as "back doctors" would be disastrous for the future of the chiropractic profession and would only serve to limit the choice of treatments available to patients. Based on substantial anecdotal evidence supporting chiropractic intervention, FCER is funding research that investigates chiropractic treatment for the very ailments that Dr. Homola recommends that we back away from: colic, dysmenorrhea, and ear infection. It simply doesn't make good sense to deny the efficacy of chiropractic in these instances just because the preponderance of published data is on back pain.7
THE DEFINITION OF CHIROPRACTIC
The use of spinal manipulation for relief of back pain appears to have little to do with "chiropractic adjustments" used in the treatment of disease and infection. The chiropractic theory that vertebral subluxations or misalignments, or some other elusive problem in a spinal segment, can cause visceral disease cannot be explained in the binding subluxation that causes back pain. Based on the subluxation theory, chiropractic is defined more as a method of restoring and maintaining health than as a method of treating back pain.
In Florida, the practice of chiropractic is defined in this way:
"Practice of chiropractic" means a noncombative principle and practice consisting of the science of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulses between the brain, organs and tissue cells of the body, thereby causing disease, are adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse which produces normal function and consequent health.8
The president of Life Chiropractic College, one of the largest colleges training chiropractors, offers this definition of chiropractic:
Chiropractic is unique in that the goal of chiropractic is to correct spinal subluxation, normalize spinal biomechanics, remove neurological interference, and allow the body to heal itself using its own vital, vivifying, recuperative forces. We chiropractors areparadoxically, in a sensespecific spinal specialists yet, because of the nervous system, our care automatically produces global effects in diverse bodily systems.9
Some chiropractic colleges are more fundamental than others, with some teaching pure "subluxation-based" chiropractic and some broadening their treatment methods with more emphasis on neuromusculoskeletal problems. All seem to agree, however, that the primary purpose of chiropractic is to improve health by adjusting the spine and using other natural measures to stimulate the body's innate recuperative power by way of the nervous system.
In July 1996, the Association of Chiropractic Colleges, representing 16 North American chiropractic colleges, reached a consensus and issued these statements:
Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.
A subluxation is a complex of functional and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.10
REFERRAL TO A CHIROPRACTOR
At present, about 94% of all spinal manipulation in North America is performed by chiropractors.4 This figure might change, however, when manipulation becomes more available in departments of physical medicine. It was suggested that
Unless the chiropractic profession as a whole specializes in the physical treatment of back disorders . . . and earns reciprocity with other healing professions . . . there will be no justification for the existence of chiropractic when an adequate number of medical specialists and medical technicians make scientific manipulation available in a department of medical practice.2
This assumes, of course, that future research does not support use of the chiropractic adjustment as a viable alternative in the treatment of visceral disease.
In the meantime, orthopedic specialists, neurologists, family physicians, and other medical practitioners are often compelled to refer a patient to a chiropractor for manipulation when such treatment is indicated for back pain. Physicians might have difficulty, however, in selecting a chiropractor. Treatment methods may vary from one chiropractic office to another.
According to Job Analysis of Chiropractic, compiled by the National Board of Chiropractic Examiners in 1993, there are at least 19 different "adjustive techniques" being used by chiropractors. These techniques range from tapping "subluxated" vertebrae into place with a spring-loaded mallet to "applied kinesiology" muscle testing that is supposed to locate a diseased organ and the spinal segment responsible for the patient's problems. Proof of correction of vertebral misalignment when using such techniques, some of which do not make use of manual spinal manipulation, may consist of checking leg length and muscle strength.
Fortunately, most chiropractors use a form of manual spinal manipulation that is similar to that being used in physical medicine. It is the opinion of this author that a "good chiropractor" who can offer effective help in treating back problems would use hands-on spinal manipulation (along with physical therapy) in a practice limited to treatment of neuromusculoskeletal problems of mechanical origin. In addition, chiropractors who offer regular spinal adjustments in a preventive-maintenance program to maintain health and prevent disease may subject their patients to unnecessary manipulation and unnecessary risk, especially in the case of cervical manipulation.
APPROPRIATE CERVICAL MANIPULATION
A 1996 study by Coulter et al11 reported that cervical spine manipulation or mobilization may improve range of motion and provide short-term relief for subacute or chronic neck pain and muscle tension headaches. The report concluded that there is not sufficient data to support or refute the use of cervical spine manipulation or mobilization in the treatment of a variety of other conditions, such as cervical curvatures; migraine headache; shoulder, arm, and hand pain; cervical disc herniation; torticollis; infantile colic; and otitis media.
The rate of vertebrobasilar accidents and other complications that occur as a result of cervical spine manipulation was estimated to be 1.46 per 1000000 manipulations. This figure allowed for the possibility that published reports may represent about one tenth of the actual number of accidents.
While the risk of injury or stroke from cervical spine manipulation is low, this risk is unacceptable when cervical manipulation is routinely used as a preventive measure on asymptomatic patients or for conditions for which manipulation is not indicated.
According to the report by Coulter et al, 57.6% of reported indications for cervical manipulation was considered inappropriate, with 31.3% uncertain. Only 11.1% could be labeled appropriate. A panel of chiropractors and medical practitioners concluded that ". . . much additional scientific data about the efficacy of cervical spine manipulation are needed."11
AVOIDING UNNECESSARY MANIPULATION
Some chiropractors offer preventive-maintenance spinal adjustments that require regular treatments to realign the vertebrae of patients who simply want to stay healthy. Many of these patients believe they have vertebrae out of place, as suggested by the popping sound they hear and feel when their vertebrae are put back in place.
It is well known that you can pop a normal spinal joint by using manipulation that separates vertebral facets to produce cavitation. This sound is often proof enough to laypersons that their spinal joints are going in and out of place, causing some patients to believe that they have chronically misaligned vertebrae that might be surreptitiously damaging their health.
Properly performed spinal manipulation under proper indications should actually feel good. But some patients dutifully undergo painful improperly performed or inappropriate spinal manipulation because they believe that such treatment is preventing the development of disease by removing nerve interference or by boosting the body's immune system.
Because there is always some risk in the use of any kind of spinal manipulation, especially cervical spine manipulation, patients should be advised to get such treatment only when appropriate for selected neck and back problems. This appropriateness can often be determined by a family physician.
Although chiropractic is defined as a method of restoring and maintaining health, the average patient thinks of the chiropractor more as a "back doctor" than as a primary care physician and may not be inclined to seek spinal manipulation for health problems. According to a survey conducted by the American Chiropractic Association, 85.5% of chiropractic patients in a given period were treated for neuromusculoskeletal conditions. Only 11.3% were treated for viscerosomatic conditions,12 despite claims by many chiropractors that spinal adjustments can be used to improve health.
It has been estimated that only about 5% of the US population annually uses chiropractors.4 This low utilization might be due to the distrust generated by chiropractors who make unsubstantiated claims in the use of spinal adjustments as a treatment for disease and infection.
The question of the scope of chiropractic might ultimately be decided by managed care and by consumer savvy. Chiropractors might be forced into the role of specializing in the care of back problems, even though chiropractic colleges and chiropractic educators might be loath to train "back specialists."
DISCRETION IN SELECTION OF A CHIROPRACTOR
There is little doubt that spinal manipulative therapy can be beneficial in the treatment of certain types of neck and back trouble and related ailments such as loss of mobility and tension headache. And there is considerable scientific evidence to support such treatment.4-5,11
Regardless of what forthcoming research might reveal about the effect of spinal manipulation on infantile colic, ear infection, visceral disease, and other organic problems, chiropractors who do not have recourse to medical treatment methods might not be in a good position to treat disease or infection of any kind. Treatment of such conditions with spinal manipulative therapy could best be done by osteopathic physicians who can prescribe antibiotics or some other form of treatment when manipulation fails. As "drugless practitioners," chiropractors cannot prescribe medication for the pain of a severe back injury or for intolerable radicular pain caused by disc herniation or osteophyte formation, often forcing chiropractic patients to seek medical care for pain relief. Fortunately for chiropractic patients, there is some evidence to indicate that opiates might not be any more effective in relieving simple, uncomplicated back pain than safer analgesics, such as acetaminophen or aspirin or other nonsteroidal anti-inflammatory drugs.5
It is well known that spinal nerves supply musculoskeletal structures and do not have any controlling influence over visceral function, which is under the control of the autonomic nervous system. While a pinched spinal nerve can cause pain, weakness, numbness, and other symptoms in corresponding musculoskeletal structures, there is no evidence that it contributes to the development of organic disease.3
Every family physician who is concerned about the welfare of his or her patient should seek out a good chiropractor and establish rapport with that chiropractor to facilitate the cooperation and reciprocity needed to allow the combination of treatment methods that are best for the patient. Such cooperation might be essential (in the best interest of the patient) until manipulation becomes more readily available in medical facilities. If future research reveals unexpected findings that chiropractic adjustments are of some value in treating disease and infection, such treatment should be done only on referral by the appropriate medical specialist.
In the meantime, it might be necessary to take a managed-care approach and screen chiropractors before sending them patients with back pain, lest these patients be treated for something unrelated to neck or back trouble. There are increasing numbers of chiropractors who limit their practice to the treatment of neuromusculoskeletal problems of mechanical origin. Such chiropractors can often be found in "back clinics," hospital centers, and in other facilities where physicians from different fields have come together to form a back-care team.
Until the chiropractic profession is properly defined and specialized and its practitioners uniformly limited, it may be necessary to search for a good chiropractor who recognizes his or her limitations. When you do find such a chiropractor, he or she deserves your support. It would be helpful to encourage chiropractors who want to make the changes needed to fit chiropractic into this nation's health care system. Good chiropractors can provide welcome help in caring for back paina common, complicated problem that is often difficult to treat.
Accepted for publication February 7, 1997.
Reprints: Samuel Homola, DC, 609 N Cove Blvd, Panama City, FL 32401.
Dr Homola is in private practice in Panama City, Fla.
1. Hippocrates. Hippocratic Writings. Chicago, Ill: Encyclopedia Britannica; 1952:106-107.
2. Homola S. Bonesetting, Chiropractic, and Cultism. Panama City, Fla: Critique Books; 1963:97-114, 265-266.
3. Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative Physiol Ther. 1995;18:379-397.
4. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH. The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Santa Monica, Calif: RAND; 1991:3-4, 6-9.
5. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Rockville, Md: Agency for Health Care Policy and Research; 1994. AHCPR publication 95-0642.
6. Homola S. Chiropractic as a neuromusculoskeletal specialty. Chiropractic Tech. 1995;7:147-148.
7. Seater S. Letters to the Editor. Chiropractic Tech. 1996;8:93-94.
8. Fla Stat 460.403.
9. Williams S. The wonder of the wisdom within. Today's Chiropractic. 1996;25:6-11.
10. Association of Chiropractic Colleges. A position paper on chiropractic. J Manipulative Physiol Ther. 1997;19:633-637.
11. Coulter I, Hurwitz E, Adams A, et al. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica, Calif: RAND; 1996:18-43.
12. Goertz C. Summary of the 1995 ACA Annual Statistical Survey on Chiropractic Practice. J Am Chiropractic Assoc. 1996;33:35-41.
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Chiropractic: A Fantasy and Delusion
Lonergan and Homola
Arch Fam Med 1998;7:405-406.