Chiropractic: A Safe Treatment Option
Chiropractic services are some of the safest drug-free, noninvasive therapies available for the treatment of back pain, neck pain, joint pain of the arms or legs, headaches and other neuromusculoskeletal complaints. Although chiropractic has an excellent safety record, no health treatment is completely free of potential adverse effects. The risks associated with chiropractic, however, are very small.
Many patients feel immediate relief following chiropractic treatment, but some may experience mild soreness or aching (like that experienced after some forms of exercise), headaches and tiredness. Current literature shows that minor discomfort or soreness following spinal manipulation typically fades within 24 hours.1
In addition to being a safe form of treatment, spinal manipulation is incredibly effective, in some cases getting patients back on their feet faster than traditional medical care. A clinical comparative trial published by the Journal of the American Medical Association found that chiropractic care combined with usual medical care for low back pain provides greater pain relief and a greater reduction in disability than medical care alone.2 In addition, a study in the Annals of Internal Medicine found that spinal manipulative therapy and exercise are more effective at relieving neck pain than pain medication.3
Neck pain and some types of headaches are treated through precise cervical manipulation. Cervical manipulation, often called a neck adjustment or neck manipulation, works to improve joint mobility in the neck, restoring range of motion and reducing muscle spasm, which helps relieve pressure and tension. Patients typically notice a reduction in pain, soreness and stiffness, along with an improved ability to move the neck. Neck manipulation is a remarkably safe procedure. While some reports have associated high-velocity, upper-neck manipulation with a certain kind of stroke, or vertebral artery dissection, research suggests that patients are no more likely to suffer a stroke following a chiropractic neck treatment than they are after visiting their primary care medical doctor’s office. It was also concluded that vertebrobasilar artery (VBA) stroke is a very rare event, and that this type of arterial injury often takes place spontaneously or following everyday activities such as turning the head while driving, swimming or having a shampoo in a hair salon.4
Patients with this condition may experience neck pain and headache that leads them to seek professional care—often at the office of a doctor of chiropractic or medical doctor—but that care is not the cause of the injury. The best evidence indicates that the incidence of artery injuries associated with high-velocity, upper-neck manipulation is extremely rare – about 1 case in 5.85 million manipulations.5
To put this risk into perspective, if you drive more than a mile to get to your chiropractic appointment, you are at greater risk of serious injury from a car accident than from your chiropractic visit.
It is important for patients to understand the risks associated with some of the most common treatments for neck and back pain—prescription nonsteroidal anti-inflammatory drugs (NSAIDs) as well as prescription opioid pain medications—as these options may carry risks significantly greater than those of manipulation.
According to a study from the American Journal of Gastroenterology, approximately one-third of all hospitalizations and deaths related to gastrointestinal bleeding can be attributed to the use of aspirin or NSAID painkillers such as ibuprofen.6 In addition, as many as one in four people who receive prescription opioids long term for non-cancer pain in primary care settings struggle with addiction.7
Furthermore, surgery for conditions for which manipulation may also be used carries risks many times greater than those of chiropractic treatment. Even prolonged bed rest carries some risks, including muscle atrophy, cardiopulmonary deconditioning, bone mineral loss and thromoembolism.8
A comprehensive review of scientific evidence related to neck pain treatments found at least as much evidence supporting the safety and effectiveness of common chiropractic treatments, including manipulation, as for other treatments such as prescription and non-prescription drugs and surgery.9
If you are visiting your doctor of chiropractic for neck pain or headache, be very specific about your symptoms. This will help your doctor determine the safest and most effective treatment, even if it involves referral to another healthcare provider. If the issue of stroke concerns you, do not hesitate to discuss it with your doctor of chiropractic. Depending on your clinical condition, he or she can forego manipulation and can instead recommend joint mobilization, therapeutic exercise, soft-tissue techniques or other therapies.
The American Chiropractic Association believes that patients have the right to know about the health risks associated with any type of treatment, including chiropractic. Today, chiropractic researchers are involved in studying the benefits and risks of spinal adjustment in the treatment of neck and back pain through clinical trials, literature reviews and publishing papers reviewing the risks and complications of neck adjustment.
All available evidence demonstrates that chiropractic treatment holds an extremely small risk. The chiropractic profession takes the issue of stroke and the safety of patients very seriously and engages in training and postgraduate education courses to recognize risk factors in patients, and to continue rendering treatment in the most effective and responsible manner.
- Senstad O, et al. Frequency and characteristics of side effects of spinal manipulative therapy. Spine 1997 Feb15; 435-440.
- Goertz CM et al. Effect of usual medical care plus chiropractic care vs usual medical care alone on pain and disability among US service members with low back pain: A comparative effectiveness clinical trial. JAMA Network Open, 2018; 1(1): e180105. doi:10.1001/jamanetworkopen.2018.0105.
- Bronfort G, Evans R, Anderson A, Svendsen K, Bracha Y, Grimm R. Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial. Annals of Internal Medicine. 2012; 156(1):1-10.
- Cassidy D, et al. Risk of Vertebrobasilar Stroke and Chiropractic Care. Spine 2008; 33: S176–S183.
- Haldeman S, et al. Arterial dissection following cervical manipulation: a chiropractic experience. Can Med Assoc J 2001;165(7):905-06.
- Lanas A, et al. A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal anti-inflammatory drug use. Am J Gastroenterol 2005; 100:1685–1693.
- Boscarino JA. Risk factors for drug dependence among outpatients on opioid therapy in large US health-care system. Addiction. 2010 Oct;105(10):1776-82. doi: 10.1111/j.1360-0443.2010.03052.x. Epub 2010 Aug 16.
- Lauretti W. “The Comparative Safety of Chiropractic.” In Daniel Redwood, ed., Contemporary Chiropractic. New York: Churchill Livingstone, 1997, p.230-8.
- Hurwitz E, et al. Treatment of neck pain: noninvasive interventions. Spine 2008;33(4S):S123-S152
FROM: Complement Ther Clin Pract. 2019 (May); 35: 301–307 ~ FULL TEXT Christian Manansala, DC, MSc(c), Steven Passmore, DC, PhD, Katie Pohlman, DC, PhD(c), Audrey Toth, DC, Gerald Olin, BSc, DC, CDir Faculty of Kinesiology and Recreation Management, University of Manitoba, Canada.
BACKGROUND: The presence of spinal pain in young people has been established as a risk factor for spinal pain later in life. Recent clinical practice guidelines recommend spinal manipulation (SM), soft tissue therapy, acupuncture, and other modalities that are common treatments provided by chiropractors, as interventions for spine pain. Less is known specifically on the response to chiropractic management in young people with spinal pain. The purpose of this manuscript was to describe the impact, through pain measures, of a pragmatic course of chiropractic management in young people's spinal pain at a publicly funded healthcare facility for a low-income population. METHODS: The study utilized a retrospective analysis of prospectively collected quality assurance data attained from the Mount Carmel Clinic (MCC) chiropractic program database. Formal permission to conduct the analysis of the database was acquired from the officer of records at the MCC. The University of Manitoba's Health Research Ethics Board approved all procedures. RESULTS: Young people (defined as 10-24 years of age) demonstrated statistically and clinically significant improvement on the numeric rating scale (NRS) in all four spinal regions following chiropractic management.
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CONCLUSION: The findings of the present study provide evidence that a pragmatic course of chiropractic care, including SM, mobilization, soft tissue therapy, acupuncture, and other modalities within the chiropractic scope of practice are a viable conservative pain management treatment option for young people.
Evidence-based guidelines for the chiropractic treatment of adults with neck pain.
The purpose of this study was to develop evidence-based treatment recommendations for the treatment of nonspecific (mechanical) neck pain in adults.
Systematic literature searches of controlled clinical trials published through December 2011 relevant to chiropractic practice were conducted using the databases MEDLINE, EMBASE, EMCARE, Index to Chiropractic Literature, and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, weak, or conflicting) and to formulate treatment recommendations.
Forty-one randomized controlled trials meeting the inclusion criteria and scoring a low risk of bias were used to develop 11 treatment recommendations. Strong recommendations were made for the treatment of chronic neck pain with manipulation, manual therapy, and exercise in combination with other modalities. Strong recommendations were also made for the treatment of chronic neck pain with stretching, strengthening, and endurance exercises alone. Moderate recommendations were made for the treatment of acute neck pain with manipulation and mobilization in combination with other modalities. Moderate recommendations were made for the treatment of chronic neck pain with mobilization as well as massage in combination with other therapies. A weak recommendation was made for the treatment of acute neck pain with exercise alone and the treatment of chronic neck pain with manipulation alone. Thoracic manipulation and trigger point therapy could not be recommended for the treatment of acute neck pain. Transcutaneous nerve stimulation, thoracic manipulation, laser, and traction could not be recommended for the treatment of chronic neck pain.
Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.
© 2014. Published by National University of Health Sciences All rights reserved.
Complement Ther Med. 2019 Jun;44:61-67. doi: 10.1016/j.ctim.2019.02.012. Epub 2019 Mar 31.
Neck Pain and Chiropractic
Our neck, also called the cervical spine, begins at the base of the skull and contains seven small vertebrae. Incredibly, the cervical spine supports the full weight of your head, which is on average about 12 pounds. While the cervical spine can move your head in nearly every direction, this flexibility makes the neck very susceptible to pain and injury.
The neck’s susceptibility to injury is due in part to biomechanics. Activities and events that affect cervical biomechanics include extended sitting, repetitive movement, accidents, falls and blows to the body or head, normal aging, and everyday wear and tear. Neck pain can be very bothersome, and it can have a variety of causes.
Here are some of the most typical causes of neck pain:
- Injury and Accidents: A sudden forced movement of the head or neck in any direction and the resulting “rebound” in the opposite direction is known as whiplash. The sudden “whipping” motion injures the surrounding and supporting tissues of the neck and head. Muscles react by tightening and contracting, creating muscle fatigue, which can result in pain and stiffness. Severe whiplash can also be associated with injury to the intervertebral joints, discs, ligaments, muscles, and nerve roots. Car accidents are the most common cause of whiplash.
- Growing Older: Degenerative disorders such as osteoarthritis, spinal stenosis, and degenerative disc disease directly affect the spine.
- Osteoarthritis, a common joint disorder, causes progressive deterioration of cartilage. The body reacts by forming bone spurs that affect joint motion.
- Spinal stenosis causes the small nerve passageways in the vertebrae to narrow, compressing and trapping nerve roots. Stenosis may cause neck, shoulder, and arm pain, as well as numbness, when these nerves are unable to function normally.
- Degenerative disc disease can cause reduction in the elasticity and height of intervertebral discs. Over time, a disc may bulge or herniate, causing tingling, numbness, and pain that runs into the arm.
- Daily Life: Poor posture, obesity, and weak abdominal muscles often disrupt spinal balance, causing the neck to bend forward to compensate. Stress and emotional tension can cause muscles to tighten and contract, resulting in pain and stiffness. Postural stress can contribute to chronic neck pain with symptoms extending into the upper back and the arms.
Chiropractic Care of Neck Pain
During your visit, your doctor of chiropractic will perform exams to locate the source of your pain and will ask you questions about your current symptoms and remedies you may have already tried. For example:
- When did the pain start?
- What have you done for your neck pain?
- Does the pain radiate or travel to other parts of your body?
- Does anything reduce the pain or make it worse?
Your doctor of chiropractic will also do physical and neurological exams. In the physical exam, your doctor will observe your posture, range of motion, and physical condition, noting movement that causes pain. Your doctor will feel your spine, note its curvature and alignment, and feel for muscle spasm. A check of your shoulder area is also in order. During the neurological exam, your doctor will test your reflexes, muscle strength, other nerve changes, and pain spread.
In some instances, your chiropractor might order tests to help diagnose your condition. An x-ray can show narrowed disc space, fractures, bone spurs, or arthritis. A computerized axial tomography scan (a CT or CAT scan) or a magnetic resonance imaging test (an MRI) can show bulging discs and herniations. If nerve damage is suspected, your doctor may order a special test called electromyography (an EMG) to measure how quickly your nerves respond.
Doctors of chiropractic are conservative care doctors; their scope of practice does not include the use of drugs or surgery. If your chiropractor diagnoses a condition outside of this conservative scope, such as a neck fracture or an indication of an organic disease, he or she will refer you to the appropriate medical physician or specialist. He or she may also ask for permission to inform your family physician of the care you are receiving to ensure that your chiropractic care and medical care are properly coordinated.
A neck adjustment (also known as cervical manipulation) is a precise procedure applied to the joints of the neck, usually by hand. A neck adjustment works to improve the mobility of the spine and to restore range of motion; it can also increase movement of the adjoining muscles. Patients typically notice an improved ability to turn and tilt the head, and a reduction of pain, soreness, and stiffness.
Of course, your chiropractor will develop a program of care that may combine more than one type of treatment, depending on your personal needs. In addition to manipulation, the treatment plan may include mobilization, massage or rehabilitative exercises, or something else.
What Research Shows
A review of scientific literature found evidence that patients with chronic neck pain enrolled in clinical trials reported significant improvement following chiropractic spinal manipulation. As part of the literature review, published in the March/April 2007 issue of the Journal of Manipulative and Physiological Therapeutics, the researchers reviewed nine previously published trials and found “high-quality evidence” that patients with chronic neck pain showed significant pain-level improvements following spinal manipulation. No trial group was reported as having remained unchanged, and all groups showed positive changes up to 12 weeks post-treatment.
Another study, funded by the National Institutes of Health and published in the Annals of Internal Medicine in 2012, tested the effectiveness of different approaches for treating mechanical neck pain: 272 participants were divided into three groups that received either spinal manipulative therapy (SMT) from a doctor of chiropractic, pain medication (over-the-counter pain relievers, narcotics and muscle relaxants) or exercise recommendations. After 12 weeks, about 57 percent of those who met with chiropractors and 48 percent who exercised reported at least a 75 percent reduction in pain, compared to 33 percent of the people in the medication group. After one year, approximately 53 percent of the drug-free groups continued to report at least a 75 percent reduction in pain, compared to just 38 percent pain reduction among those who took medication.
Also in 2012, research published in the Spine journal analyzed the prevalence, patterns and predictors of chiropractic utilization in the U.S. general population. The researchers found that, "Back pain and neck pain were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being."
Cervical Manipulation Effects
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The effects of cervical joint manipulation on cervical lordosis, forward head posture, and cervical range of motion.
a. The authors compared general mobilization to “cervical posture manipulation based on passive motion analysis (MBPMA).”
b. They looked at 40 university students who had chronic cervical pain and divided them into two groups with one group receiving general mobilization and the other receiving MBPMA.
c. Both the general mobilization and the MBPMA group received three manipulations a week for four weeks.
d. The patients were X-rayed but the manipulations administered to the MBPMA group were based on passive motion analysis of the joints of the cervical spine.
e. The joints that were restricted were manipulated “while movement in the surrounding joints was prevented.”
f. They looked at cervical extension range of motion, ranges of flexion and extension motion, absolute rotation angle, anterior weight bearing and cervical flexion range of motion
g. “CER [Cervical Extension Range of Motion] and RFEM [Ranges of flexion and extension motion] were significantly higher in the MBPMA group than in the mobilization group after the experiment,” according to the researchers.
h. Overall changes in the MBPMA group were higher than the general mobilization group.
i. Absolute rotation angles (the cervical lordosis) and Forward Head Posture were both significantly more improved in the MBPMA group as opposed to the group that received a more generalized manipulation.
Manipulations based on locating restricted joints showed a greater increase in motion than general mobilization.
Although we might expect that care based on motion analysis would improve motion, it might not have turned out that way. It appears that directing the forces toward the restricted joints as opposed to a general manipulation does improve motion more. It reinforces the idea that quality care is more than just “pop and pray.” The direction of the forces does make a difference. Oh, if you don’t believe me see how well you do playing pool and directing the forces from your cue stick in random directions.
Reviewer: Roger Coleman, DC
Editor’s Comments: In terms of the lordosis, the MBPMA group showed an average correction of 5.2 degrees compared to the mobilization group which only improved 2.6 degrees…twice as much improvement.. While this obviously isn’t nearly what we would expect were we to add extension traction to the therapeutic mix, it’s still a sizeable difference. Correcting spines isn’t about home runs, it’s about base hits. It’s important to get whatever correction you can, where you can, in whatever way you can. This study gives us some insight on how we might possibly modify our manipulation/adjustment methods in order to improve our both our functional and structural care outcomes.
Editor: Mark R. Payne, DC
Reference: Gong W. The effects of cervical joint manipulation, based on passive motion analysis, on cervical lordosis, forward head posture, and cervical ROM in university students with abnormal posture of the cervical spine. J Phys Ther Sci. 2015 May;27(5):1609-11. doi: 10.1589/jpts.27.1609. Epub 2015 May 26.
Chiropractic manipulation in low back pain and sciatica: statistical data on the diagnosis, treatment and response of 576 consecutive cases.
A chiropractic multicenter observational pilot study to compile statistics on the examination procedures, diagnosis, types of treatments rendered, results of treatment, number of days of care, and number of treatments required to arrive at a 50% and a maximum clinical improvement was collected on 576 patients with low back and/or leg pain. The purpose was to determine the congenital and developmental changes in patients with low back and/or leg pain, the combinations of such anomalies, the accuracy of orthodox diagnostic tests in assessing low back pain, ergonomic factors affecting onset and, ultimately, the specific difficulty factors encountered in treating the various conditions seen in the average chiropractor's office. For all conditions treated, the average number of days to attain maximum improvement was 43 and the number of visits 19. It was concluded that this study provided useful data for assessment of routine chiropractic office based diagnosis and treatment of related conditions; however, further controlled studies are necessary for validation of specific parameters.
Back Pain Facts and Statistics
Although doctors of chiropractic treat more than just back pain, many patients initially visit a chiropractor looking for relief from this pervasive condition. In fact, about 31 million Americans experience low back pain at any given time.1
Interesting Facts about Back Pain
- Worldwide, back pain is the single leading cause of disability, preventing many people from engaging in work as well as other everyday activities.2
- Back pain is one of the most common reasons for missed work. One-half of all working Americans admit to having back pain symptoms each year.3
- Back pain accounts for more than 264 million lost work days in one year—that’s two work days for every full-time worker in the country.4
- Experts estimate that up to 80% of the population will experience back pain at some time in their lives.5
- Back pain can affect people of all ages, from adolescents to the elderly.5
- Back pain is the third most common reason for visits to the doctor’s office, behind skin disorders and osteoarthritis/joint disorders.6
- Most cases of back pain are mechanical or non-organic—meaning they are not caused by serious conditions, such as inflammatory arthritis, infection, fracture or cancer.7
- Most people with low back pain recover, however reoccurrence is common and for small percentage of people the condition will become chronic and disabling.7
- Worldwide, years lived with disability caused by low back pain have increased by 54% between 1990 and 2015.7
- Low-back pain costs Americans at least $50 billion in health care costs each year8—add in lost wages and decreased productivity and that figure easily rises to more than $100 billion.9
What Causes Back Pain?
The back is a complicated structure of bones, joints, ligaments and muscles. You can sprain ligaments, strain muscles, rupture disks, and irritate joints, all of which can lead to back pain. While sports injuries or accidents can cause back pain, sometimes the simplest of movements—for example, picking up a pencil from the floor— can have painful results. In addition, arthritis, poor posture, obesity, and psychological stress can cause or complicate back pain. Back pain can also directly result from disease of the internal organs, such as kidney stones, kidney infections, blood clots, or bone loss.
Research Supports Chiropractic Spinal Manipulation
With today's growing emphasis on quality care, clinical outcomes and cost effectiveness, spinal manipulation is receiving increased attention. The epidemic of prescription opioid overuse and abuse has also led to wider acknowledgment of the benefits of nondrug approaches to pain.
Spinal manipulation is a safe and effective nondrug spine pain treatment. It reduces pain (decreasing the need for medication in some cases), rapidly advances physical therapy, and requires very few passive forms of treatment, such as bed rest.10
A growing body of research supports spinal manipulation:
- After an extensive study of all available care for low back problems, the federal Agency for Health Care Policy and Research (now the Agency for Health Care Research and Quality) recommended that low back pain sufferers choose the most conservative care first. And it recommended spinal manipulation as the only safe and effective, drugless form of initial professional treatment for acute low back problems in adults.11
- A well-respected review of the evidence in the Annals of Internal Medicine pointed to chiropractic care as one of the major nondrug therapies considered effective for acute and chronic low back pain.12
- According to an article in the medical journal Spine, there is strong evidence that spinal manipulation for back pain is just as effective as a combination of medical care and exercise, and there is moderate evidence that it is just as effective as prescription NSAIDS combined with exercise. 13
- An article in the Journal of the American Medical Association suggested chiropractic care as an option for people suffering from low back pain--and noted that surgery is usually not needed and should only be tried if other therapies fail.14
- More recently, the results of a clinical trial published in JAMA Network Open showed that chiropractic care combined with usual medical care for low back pain provides greater pain relief and a greater reduction in disability than medical care alone. The study, which featured 750 active-duty members of the military, is one of the largest comparative effectiveness trials between usual medical care and chiropractic care ever conducted.15
Back Pain and the Opioid Epidemic
The opioid epidemic has led many respected health groups to reconsider the value of a conservative approach to low back pain (the most common condition for which opioids are prescribed). Most notably, the American College of Physicians (ACP), the largest medical-specialty society in the world, updated its low back pain treatment guideline in 2017 to support a conservative approach to care.
Published in the Annals of Internal Medicine and based on a review of randomized controlled trials and observational studies, the ACP guideline cites heat therapy, massage, acupuncture and spinal manipulation as noninvasive, nondrug options for low back pain treatment. The guideline further states that only when such treatments provide little or no relief should patients move on to medicines such as ibuprofen or muscle relaxants, which research indicates have limited pain-relief effects. According to ACP, prescription opioids should be a last resort for those suffering from low back pain, as the risk of addiction and overdose may outweigh the benefits.
Tips to Prevent Back Pain
There are several simple strategies that can help to prevent the onset of back pain. Among them:
- Maintain a healthy diet and weight.
- Remain active—under the supervision of your chiropractor.
- Avoid prolonged inactivity or bed rest.
- Warm up or stretch before exercising or physical activities, such as gardening.
- Maintain proper posture.
- Wear comfortable, low-heeled shoes.
- Sleep on a mattress of medium firmness to minimize any curve in your spine.
- When lifting an object, lift with your knees, keep the object close to your body, and do not twist.
- Quit smoking. Smoking impairs blood flow, resulting in oxygen and nutrient deprivation to spinal tissues.
- Work with your chiropractor to ensure that your workstation is ergonomically correct.
- Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. N Engl J Med 1994; 331: 69-116.
- Hoy D, March L, Brooks P, et al The global burden of low back pain: estimates from the Global Burden of Disease 2010 study Annals of the Rheumatic Diseases Published Online First: 24 March 2014. doi: 10.1136/annrheumdis-2013-204428
- Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98.
- The Hidden Impact of Musculoskeletal Disorders on Americans, United State Bone and Joint Initiative, 2018.
- Rubin Dl. Epidemiology and Risk Factors for Spine Pain. Neurol Clin. 2007; May;25(2):353-71.
- Sauver, JL et al. Why patients visit their doctors: Assessing the most prevalent conditions in a defined American population. Mayo Clinic Proceedings, Volume 88, Issue 1, 56–67.
- Hartvigsen J et al. Low Back Pain Series: What Low Back Pain Is and Why We Need to Pay Attention. Lancet, June 2018; Volume 391, Issue 10137; p2356-2367.
- In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville, MD.
- Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences [review]. J Bone Joint Surg Am. 2006;88(suppl 2): 21-24.
- Time to recognize value of chiropractic care? Science and patient satisfaction surveys cite usefulness of spinal manipulation. Orthopedics Today 2003 Feb; 23(2):14-15.
- Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No.14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December, 1994.
- Chou R, Hoyt Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann of Internal Med 2 Oct. 2007;147(7):492-504.
- Bronfort G, Haas M, Evans R, et al. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine. 2008;8(1)213-225.
- Goodman D, Burke A, Livingston E. Low Back Pain. JAMA. 2013; 309(16):1738.
- Goertz C et al. Effect of Usual Medical Care Plus Chiropractic Care vs. Usual Medical Care Alone on Pain and Disability Among U.S. Service Members With Low Back Pain: A Comparative Effectiveness Clinical Trial. JAMA Network Open
Chiropractic statistical survey of 100 consecutive low back pain patients.
One hundred consecutive patients with low back and/or lower extremity pain had the clinical data; including history, diagnosis, treatment and results of conservative manipulative therapy collected and tabulated on an IBM 370/138 computer at Indiana-Purdue University in Fort Wayne, Indiana utilizing the Statistical Package for the Social Sciences (SPSS) based on a standardized examination form. Various congenital, developmental and ergonomic factors in low back pain patients were collected and correlated for combinations of factors leading to back pain. Treatment methods and response to treatment as to time and patient visit numbers were determined. The frequency of congenital anomalies were found and those effecting or not effecting low back pain onset determined. Overall, 50% relief of low back and leg pain was obtained in 15.95 days and 10.8 visits average; maximum relief was found in 41.2 days, or 16.1 treatments.
Photomed Laser Surg. 2008 Apr;26(2):99-105. doi: 10.1089/pho.2007.2138.
Low-power laser treatment in patients with frozen shoulder: preliminary results.
In this study I sought to test the efficacy of low-power laser therapy (LLLT) in patients with frozen shoulder.
The use of low-level laser energy has been recommended for the management of a variety of musculoskeletal disorders.
MATERIALS AND METHODS:
Sixty-three patients with frozen shoulder were randomly assigned into one of two groups. In the active laser group (n = 31), patients were treated with a 810-nm Ga-Al-As laser with a continuous output of 60 mW applied to eight points on the shoulder for 30 sec each, for a total dose of 1.8 J per point and 14.4 J per session. In the placebo group (n = 32), patients received placebo laser treatment. During 8 wk of treatment, the patients in each group received 12 sessions of laser or placebo, two sessions per week (for weeks 1-4), and one session per week (for weeks 5-8).
Relative to the placebo group, the active laser group had: (1) a significant decrease in overall, night, and activity pain scores at the end of 4 wk and 8 wk of treatment, and at the end of 8 wk additional follow-up (16 wk post-randomization); (2) a significant decrease in shoulder pain and disability index (SPADI) scores and Croft shoulder disability questionnaire scores at those same intervals; (3) a significant decrease in disability of arm, shoulder, and hand questionnaire (DASH) scores at the end of 8 wk of treatment, and at 16 wk posttreatment; and (4) a significant decrease in health-assessment questionnaire (HAQ) scores at the end of 4 wk and 8 wk of treatment. There was some improvement in range of motion, but this did not reach statistical significance.
The results suggested that laser treatment was more effective in reducing pain and disability scores than placebo at the end of the treatment period, as well as at follow-up.
Back Pain Prevention & Treatment
Back pain is a fact of life for many people. Research shows that up to 80% of the population will experience back pain at some point during their lives.1 It is also the second most common reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.2
Sometimes back pain is sharp and intense, caused by a wrong move or an injury, and heals in a few days or weeks. Others experience back pain as a chronic condition, seriously altering their ability to work and enjoy time with family, friends and other leisure activities—leading to depression in some cases. A recent global survey of health conditions identified back pain as the single most disabling condition worldwide.3
Moreover, as lifestyles have become more sedentary and the rate of obesity has risen, back pain has become increasingly prevalent, even among young children.
Spinal health is an important factor in preventing back pain, as well as maintaining overall health and well-being. The American Chiropractic Association (ACA) encourages people to take steps to improve their spinal health and avoid injury.
Things such as better nutrition, exercise, ergonomic workspaces and proper lifting and movement techniques can go a long way in helping people to strengthen their spines and potentially avoid serious injury and chronic pain. When back pain hits, research shows that a conservative approach to treatment is the best option.
Conservative Treatment Options Supported by Research
Treatment for back pain has come a long way. It was once believed that taking pain medication and getting some rest and relaxation were the best course of treatment for a bout of low-back pain, but nowadays research supports first trying drug-free, conservative options for pain management while remaining as active as possible during recuperation.
The epidemic of prescription opioid overuse and abuse has also led many health groups to reconsider the value of a conservative approach to common conditions such as back pain. For example, the American College of Physicians (ACP), the largest medical-specialty society in the world, updated its back pain treatment guidelines4 to support a conservative approach to care.
In March 2016, the Centers for Disease Control and Prevention released updated guidelines for prescribing opioids that also promote the use of non-pharmacologic alternatives for the treatment of chronic pain. In 2015, the Joint Commission, the organization that accredits more than 20,000 health care systems in the U.S. (including every major hospital), recognized the value of non-drug approaches to pain management by adding chiropractic and acupuncture to its pain management standard.
Beyond the risks of overuse and addiction, prescription drugs that numb pain may also convince a patient that a musculoskeletal condition such as back pain is less severe than it is, or that it has healed. That misunderstanding can lead to over-exertion and a delay in the healing process or even to permanent injury.
With the steep costs associated with prescription drugs, chiropractic’s conservative approach makes economic sense as well. A 2012 study found that spinal manipulation for neck and back pain was cost-effective used either alone or combined with other therapies first.5
Another study based on Washington state workers found that 42.7 percent of people who visited a surgeon first for work-related back pain eventually had surgery, compared to only 1.5 percent of those who visited a chiropractor first.6
Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health.
Chiropractic services are used most often to treat conditions such as back pain, neck pain, pain in the joints of the arms or legs, and headaches. Chiropractors practice a hands-on, drug-free approach to health care that includes patient examination, diagnosis and treatment.
Widely known for their expertise in spinal manipulation, chiropractors are also trained to recommend therapeutic and rehabilitative exercises, and to provide nutritional, dietary and lifestyle counseling.
1. Rubin Dl. Epidemiology and Risk Factors for Spine Pain. Neurol Clin, 2007; May;25(2):353-71.
2. Hart LG, et al. Physician Office Visits for Low Back Pain: Frequency, Clinical Evaluation, and Treatment Patterns from a U.S. National Survey. Spine, 1995; 20:11–9.
3. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016 Oct 7; 388:1545–1602.Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med, 2017;166(7):514-530.
4. Machado GC, et al. Non-steroidal Anti-inflammatory Drugs for Spinal Pain: A Systematic Review and Meta-analysis. Annals of the Rheumatic Diseases. Published online first, Feb. 2, 2017; doi: 10.1136/annrheumdis-2016-210597
5. Keeney et al. 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.
In a Randomized controlled trial, 183 patients with neck pain were randomly allocated to manual therapy (spinal mobilization), physiotherapy (mainly exercise) or general practitioner care (counseling, education and drugs) in a 52-week study. The clinical outcomes measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care. Moreover, total costs of the manual therapy-treated patients were about one-third of the costs of physiotherapy or general practitioner care.
Korthals-de Bos et al (2003), British Medical Journal
National Guidelines: American Pain Society and the
American College of Physicians (2007) 
As has been true of low back pain guidelines worldwide, the 2007 guidelines prepared by a panel of the American Pain Society and American College of Physicians recognized spinal manipulation (over 90 percent of which is delivered by chiropractors)  as an effective procedure for both acute and chronic low back pain. This is consistent with the 1994 Guidelines on Acute Lower Back Pain in Adults  from the U.S. Agency for Healthcare Policy and Research (AHCPR). Both the APS-ACP guidelines and the earlier AHCPR guidelines were prepared by expert panels based on a full review of all existing research.
A 2011 systematic review  of the cost-effectiveness of treatments endorsed in the APS-ACP guidelines found that spinal manipulation was cost-effective for subacute and chronic low back pain, as were other methods usually within the chiropractor’s scope of practice (interdisciplinary rehabilitation, exercise, and acupuncture). For acute low back pain, this review found insufficient evidence for reaching a conclusion about the cost-effectiveness of spinal manipulation. It also found no evidence at all on the cost-effectiveness of medication for low back pain.
FROM: J Neuromusculoskeletal System 2002 (Fall); 10 (3): 98–103 Lisi, AJ., Dabrowski, Y
A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. An 8-year-old boy presented with a complaint of daily headache. The duration of symptoms was over 3 years. The patient met the diagnostic criteria for CEH. Awkward head position reproduced head pain, as did palpation of the upper cervical region. Decreased range of motion of the neck was evident, as well as abnormal tenderness and primarily of the right upper cervical region. A significant decrease in headache frequency as reported by the patient and parent was seen after the first treatment. After four treatments the headache frequency decreased to approximately one per month. The patient was followed for 2 months after termination of care and reported headache frequency of approximately two per month. There is evidence that spinal manipulation is effective in the treatment of CEH in adults. This appears to be the first published case of spinal manipulation for headache meeting the CEH diagnostic criteria in a child. Since headache in general is a common complaint in children, chiropractic treament of CEH in children may be an area warranting further investigation.
FROM: J Manipulative Physiol Ther 2001 (May); 24 (4): 300–304 ~ FULL TEXT Gregory J. Snow, DC Assistant Clinical Professor, Palmer College of Chiropractic West, 90 E. Tasman Drive, San Jose, CA 95134-1617 [email protected]
OBJECTIVE: To discuss the case of a patient with severe, multilevel central canal stenosis who was managed conservatively with flexion-distraction manipulation; to introduce a cautious approach to the application of treatment, which can reduce the risk of adverse effects and might make an apprehensive doctor more comfortable treating this condition; and to propose a theoretic mechanism for relief of symptoms through use of chiropractic manipulation. CLINICAL FEATURES: A 78-year-old man had low back pain and severe bilateral leg pains. Objective findings were minimal, yet magnetic resonance imaging demonstrated severe degenerative lumbar stenosis at L3-L4 and L4-L5 and to a lesser degree at L2–L3. INTERVENTION AND OUTCOME: Flexion-distraction manipulation of the lumbar spine was performed. Incremental increases in traction forces were applied as the patient responded positively to care. He experienced a decrease in the frequency and intensity of his leg symptoms and a resolution of his low back pain. These improvements were maintained at a 5–month follow-up visit. CONCLUSION: Successful management of symptoms either caused by or complicated by lumbar spinal stenosis is presented. Manipulation of the spine shows promise for relief of symptoms through improving spinal biomechanics. Further study in the form of a randomized clinical trial is warranted.
FROM: Arch Dis Child. 2012 (Aug); 97 (8): 730—732 Rodríguez-Oviedo P, Ruano-Ravina A, Pérez-Ríos M, García FB, Gómez-Fernández D, Fernández-Alonso A, Carreira-Núñez I, García-Pacios P, Turiso J. Department of Preventive Medicine and Public Health, School of Medicine, C/ San Francisco s/n, University of Santiago de Compostela, Santiago de Compostela CP 15782, La Coruña, Spain; [email protected]
OBJECTIVE: To investigate whether backpack weight is associated with back pain and back pathology in school children. DESIGN: Cross-sectional study. SETTING: Schools in Northern Galicia, Spain. PATIENTS: All children aged 12-17. INTERVENTIONS: Backpack weight along with body mass index, age and gender. MAIN OUTCOME MEASURES: Back pain and back pathology. RESULTS: 1403 school children were analysed. Of these, 61.4% had backpacks exceeding 10% of their body weight. Those carrying the heaviest backpacks had a 50% higher risk of back pain (OR 1.50 CI 95% 1.06 to 2.12) and a 42% higher risk of back pathology, although this last result was not statistically significant (OR 1.42 CI 95% 0.86 to 2.32). Girls presented a higher risk of back pain compared with boys. CONCLUSIONS: Carrying backpacks increases the risk of back pain and possibly the risk of back pathology. The prevalence of school children carrying heavy backpacks is extremely high. Preventive and educational activities should be implemented in this age group.
The Full-Text Article: INTRODUCTION: Back pain is currently a health problem of school children which can limit daily-life activities. Sedentary lifestyle is possibly the most important factor determining back pain among school children. According to the 2006 Spanish National Health Enquiry, 11.8% of students aged 10–15 classified themselves as sedentary.  Sedentarism along with lack of physical activity contributes to a lower muscular tonicity of the back. Some studies have shown that an individual with back pain in adolescence is more likely to develop low back pain in adult life or that heavy backpacks can cause neck, shoulders and back muscular problems, such as scoliosis. [2, 3] Experts recommend that school children should not carry loads exceeding 10% of their body weight.  The objective of this study is to analyse the infl uence of backpack weight on back pain and back pathologies.
DISCUSSION: Children carrying the heaviest backpacks have a higher risk of suffering from back pain and a higher risk of back pathology. Most school children carry backpacks exceeding the recommended weights. Many studies have found that backpacks alter posture and gait signifi cantly, produce modifi cations in the head–neck angle, shoulder asymmetry and even lumbar lordosis. These biomechanical alterations could induce the appearance of chronic pain and back pathologies in the long term. Between 20% and 45% of young people aged 14–18 have back pain for more than 15 days. A study performed in Northeast England in 2002 showed a low back pain prevalence of 24%, with girls posing a higher prevalence compared with boys.  Another study performed in Italy by Negrini and Negrini  found that 11-year-old children carried backpacks as heavy as 20% of their body weight, and also that 58.4% had experienced back pain more than once in their lifetime. Girls are more prone to experience back pain and back pathology than boys, although there are no differences on backpack weight by gender. Grimmer et al  observed that girls were more prone to have changes in the craniovertebral angle when carrying a backpack and this association became stronger with age. The cross-sectional design of the present study is a limitation, as it limits the causal inference of its findings. In this type of study, it is difficult to measure past events such as pain lasting more than 15 days. Other factors that have not been studied such as poor physical fitness, poor back posture, structural scoliosis and hypermobility cannot be excluded as the real cause of back pain. It is possible that backpacks were carried frequently with one strap instead of two with this fact acting jointly with weight in back pain incidence. The strength of this study is the sample size, which allows for precise estimations adjusted by sex, age, body mass index and sports activity. The results obtained have strong implications. Many children transport excessively loaded backpacks, an excess which would not be allowed for workers in employment. We strongly encourage the medical and educational community to start advising parents and school children about the risks posed by heavy school bags and the fact that this risk can be easily reduced.