Jeffrey Reed D.C.  

Chiropractic manipulation

The term "adjustment" refers to the specific manipulation chiropractors apply  to vertebrae that have abnormal movement patterns or fail to function normally. The objective of the chiropractic treatment is to reduce the subluxation, which results in an increased range of motion, reduced nerve irritability and improved function.

The adjustment made by the chiropractor consists of a high velocity, short lever arm thrust applied to a vertebra, which is often accompanied by an audible release of gas (joint cavitation). The audible sound is caused by the release of oxygen, nitrogen, and carbon dioxide, which releases joint pressure (cavitation) (23). The sensation is usually relieving, though minor discomfort has been reported (that usually lasts for only a short time duration) if the surrounding muscles are in spasm or the patient tenses up during the chiropractic procedure.

There are times when joint cavitation or cracking does not occur and this is often due to either significant muscle splinting or the patient may not be adequately relaxed during the chiropractic procedure. At times like this, it is sometimes best for the chiropractor to apply ice, have the patient rest, or do electrical stimulationand massage prior to attempting spinal manipulation.

Positive effects of a chiropractic adjustment from a chiropractor
Objective effects of a chiropractic adjustment have been investigated and reported. More specifically, a single chiropractic adjustment produces both sensory and motor effects as well as sympathetic nervous system effects.

The sensory and motor effects of a chiropractic manipulation include:

• increased joint ROM in all 3 planes and reduction of pain (24, 25)
• increased skin pain tolerance level (26)
• increased paraspinal muscle pressure pain tolerance (27)
• reduced muscle electrical activity and tension (28)

Sympathetic nervous system effects of a chiropractic manipulation include:

• increased blood flow and distal skin temperature (fingertips) (29)
• blood pressure reduction (30, 31)

Blood chemistry changes after a chiropractic manipulation include:

• increased secretion of melatonin (32)
• increased plasma beta endorphin levels (33)
• elevation of Substance P and enhanced neutrophil respiratory burst (34)
• pupillary diameter changes (35).

There are many different techniques a chiropractor can choose from and there is a certain skill level and "art" involved with high velocity, low amplitude adjustment or manipulation. It is perhaps more important for the chiropractor to determine when not to apply the adjustment, which is the reason for the extensive academic load placed on the chiropractic student (4 years of college plus 4 years at a chiropractic college).

The number of chiropractic treatments required for the particular patient varies significantly due to the degree of the injury, the biovariability between patients, and co-morbid risk factors of chronicity (anxiety, depression, poor coping strategies, financial distress, low educational attainment, and others) (36, 37). For example, the chiropractic treatment plan of a grade 1, lumbar sprain/strain rarely demands greater than 4-6 weeks to manage in an uncomplicated case with no co-morbid factors.

Chiropractic "Only Proven Effective Treatment" for Chronic Whiplash

Study Says 74% of Chronic Whiplash Patients Improved with Chiropractic

A new study published in the Journal of Orthopaedic Medicine¹ not only points out the superiority of chiropractic care for chronic whiplash patients, but also examines which chronic whiplash patients respond best to chiropractic care. The authors begin the paper by explaining that:

"Conventional treatment of patients with whiplash symptoms is disappointing.

"A retrospective study by Woodward et al., demonstrated that chiropractic treatment benefited 26 of 28 patients suffering from chronic whiplash syndrome."²

The question was not whether chiropractic was beneficial for acute whiplash patients, but to determine "which patients with chronic whiplash will benefit from chiropractic treatment."
The authors interviewed "100 consecutive chiropractic referrals for chronic whiplash symptoms," seven of which were "lost to follow up." They were able to divide the remaining 93 patients into three symptom groups:

Group 1: patients with "neck pain radiating in a 'coat hanger' distribution, associated with restricted range of neck movement but with no neurological deficit";

Group 2: patients with "neurological symptoms, signs or both in association with neck pain and a restricted range of neck movement";

Group 3: patients who described "severe neck pain but all of whom has a full range of motion and no neurological symptoms or signs distributed over specific myotomes or dermatomes." These patients also "described an unusual complex of symptoms," including "blackouts, visual disturbances, nausea, vomiting and chest pain, along with a nondermatomal distribution of pain."

The patients underwent an average of 19.3 adjustments over the course of 4.1 months (mean). The patients were then surveyed and their improvement reported as follows:

Group 1

24% - Asymptomatic
24% - Improved by Two Symptom Grades
24% - Improved by One Symptom Grade
28% - No Improvement

Group 2

38% - Asymptomatic

13% - Improved by One Symptom Grade
6% - No Improvement

Group 3

0% - Asymptomatic

In their discussion, the authors made these observations:

"Woodward, et al.,² found improvement in chronic symptoms in 26 of 28 patients (93%) following chiropractic treatment. Our results confirm the efficacy of chiropractic, with 69 of our 93 patients (74%) improving following treatment.

"Our study suggests that such a group of nonresponders does exist, represented by group 3. The defining characteristics of patients in this group were the full range of neck movement in association with neck pain, bizarre symptoms, female sex and ongoing litigation. The mean age of the group at 29.5 (16-43) was lower than that of the other two groups (mean 36.8, range 18-65).

"The results from this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms. However, our identification of a group of patients who fail to respond to such treatment, highlights the need for a careful history and physical examination before commencing treatment."

References

1. Khan S, Cook J, Gargan M, Bannister G. A symptomatic classification of whiplash injury and the implications for treatment. Journal of Orthopaedic Medicine 1999;21(1):22-25.

2. Woodward MN, Cook JCH, Gargan MF, Bannister GC. Chiropractic treatment of chronic whiplash injuries. Injury 1996;27:643-645.

Chiropractic treatments for back pain

Introduction to chiropractic care
Spinal manipulation (like that used by chiropractors in chiropractic medicine) is not a new or recent concept. Records show that manipulation of the spine can be traced back to the time of Hippocrates (1, 2).

Since the inception of chiropractic medicine in 1895, chiropractors have held as a primary tenet that biomechanical and structural derangement of the spine can affect the nervous system. Because the nervous system is so intimately related to the spine from an anatomical standpoint, identifying and restoring spinal structural integrity through chiropractic treatments can improve the health of the individual by reducing pressure on sensitive neurological tissue. This tenet continues to be the emphasis that many chiropractors embrace and chiropractic patients seek.

The research status of chiropractic medicine, or manipulative therapy, was reviewed in a 1975 NINCDS (National Institute of Neurological and Communicative Disease and Stroke) conference held in Bethesda, Maryland that included experts from many of the disciplines that utilize manipulation (3). Dr. Joseph Janse, DC, who was president of the National College of Chiropractic at the time, was the spokesperson for chiropractic medicine.

Chiropractic treatment for lower back pain
In his presentation, Dr. Janse reviewed the literature from the time of the founding of chiropractic in 1895 to the 1975 conference date. From that review, various chiropractic hypotheses were identified and research recommendations were drafted in order to dispel the myths and/or to support the tenets of the chiropractic hypotheses. Much of the chiropractic research conducted to the 1975 date supports the proposed hypotheses while others continue to be investigated.

It is important to note that doctors of chiropractic do not utilize drugs or surgery in their practice. However, there are times when a chiropractor  will recommend that the patient consult another practitioner if these or other methods of treatment are indicated.

This article will restrict its focus to the chiropractic treatment of lower back pain, which is included in the biomechanical hypothesis and carries perhaps the greatest level of research evidence for chiropractic care.

There appears to be firm literature support for chiropractic treatment of lower back pain. Many of the published guidelines recommend spinal manipulation to be included in the treatment plan early in the care of lower back pain (4-12).

It is difficult to discuss the relationship of chiropractic medicine to the treatment of lower back pain without addressing the history and concepts behind the chiropractic profession. Therefore, one of the goals of this article is to introduce to the reader some of the concepts of chiropractic and address the issues surrounding a typical chiropractic visit.

Chiropractors

When accidents, falls, tension, over-exertion or other injuring mechanisms occur, the inability of the spine to compensate can result in minor displacements or derangement of one or more vertebrae, causing irritation to spinal nerve roots directly by pressure or indirectly through reflexes. This type of injury may call for consultation with a chiropractor. The treatment concept of chiropractic manipulative therapy is to re-establish normal spinal mobility, which in turn alleviates the irritation to the spinal nerve and/or re-establishes altered reflexes (13).

Chiropractic examination information
All health care providers, including chiropractors, use a standard procedure of examination to diagnose a patient’s condition in order to arrive at a plan of treatment. Chiropractors use many of the same time-honored methods used throughout the various health care professions, including:

• Consultation

• Case history

• Physical examination

• Laboratory analysis

• X-ray studies

Therefore, the patient usually perceives very little difference comparing an initial chiropractic and medical consultation. However, the chiropractor’s examination of the spine to evaluate structure and function and the treatment focus on the spine separates chiropractic from other health care disciplines.