Chiropractic treatment techniques

Chiropractors primarily use manipulation ("adjustment") of the spine as a treatment. Such treatments trace back to ancient China, Greece and Egypt.[1] It gained popularity in the late 19th century, with the development of osteopathic and chiropractic medicine in North America.[2]

Spinal manipulation (SMT) became more popular in the 1980s.[3] It includes manipulation and massage to "adjust" the spine and related tissues,[4] and is a primary basis of chiropractic.[5] Systematic reviews have not found evidence that chiropractic manipulation is effective for any medical condition, with the possible exception of treatment for back pain.[6] The safety of manipulation, particularly on the cervical spine has been debated.[7] Adverse results, including death, are rare, with very low mortality rates.[8][9] Chiropractors may use exercise and other treatments and advice.[5]

Interventions

Skilled, specific hands-on techniques, including manipulation and mobilization, are used to diagnose and treat soft tissues and joint structures, to reduce pain and to increase range of motion and general health.[10]

The approach is generally conservative, and treatment may include:

Chiropractors may also use exercise and other conservative treatments and advice.[5]

Manual and manipulative therapy

Lumbar, cervical and thoracic chiropractic spinal manipulation

The Chinese used such therapy more than 3000 years ago. Hippocrates also used such techniques[1] as did the ancient Egyptians and other cultures.

In the late 19th century in North America, therapies including osteopathy and chiropractic became popular.[2] Spinal manipulation gained mainstream recognition during the 1980s.[3]

In this system, hands are used to manipulate, massage or otherwise influence the spine and related tissues.[4] It is the most common and primary intervention used in chiropractic care.[5]

Effectiveness

Neuromusculoskeletal disorders

Treatment is usually for neck or low back pain and related disorders.[11]

For acute low back pain, low quality evidence has suggested no difference between real and sham spine manipulation,[12] and moderate quality evidence has suggested no difference between spine manipulation and other commonly used treatments, such as medication and physical therapy.[12][13][14]

National guidelines vary; some recommend the therapy for those who do not improve with other treatment.[15] It may be effective for lumbar disc herniation with radiculopathy,[16][17] as effective as mobilization for neck pain,[18] some forms of headache,[19][20][21] and some extremity joint conditions.[22][23] A 2011 Cochrane review found strong evidence that suggests there is no clinically meaningful difference between spinal manipulation therapy and other treatments for reducing pain and improving function for chronic low back pain.[24] A 2008 review found that with the possible exception of back pain, chiropractic manipulation has not been shown to be effective for any medical condition.[6][25]

Non-musculoskeletal disorders

The use of spinal manipulation for non-musculoskeletal is controversial. It has not been shown to be effective for asthma, headache, hypertension, or dysmenorrhea.[14] There is no scientific data that supports the use of SMT for idiopathic adolescent scoliosis.[26][27]

Cost-effectiveness

Spinal manipulation is generally regarded as cost-effective treatment of musculoskeletal conditions when used alone or in combination with other treatment approaches.[28] Evidence supports the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain whereas the results for acute low back pain were inconsistent.[29]

Safety

All treatments need a thorough medical history, diagnosis and plan of management. Chiropractors, must rule out contraindications to any treatments, including adverse events.

Relative contraindications, such as osteoporosis are conditions where increased risk is acceptable in some situations and where mobilization and soft-tissue techniques may be treatments of choice. Most contraindications apply to the manipulation of the affected region.[30]

While safety has been debated,[7] and serious injuries and deaths can occur and may be under-reported,[8] these are generally rare and spinal manipulation is relatively safe[12] when employed skillfully and appropriately.[9]

Adverse events are believed to be under-reported [31] and appear to be more common following high velocity/ low amplitude manipulation than mobilization.[32] Mild, frequent and temporary adverse events occur in SMT which include temporary increase in pain, tenderness and stiffness.[7] These effects generally are reduced within 24–48 hours [33] Serious injuries and fatal consequences, especially to SM in the upper cervical region, can occur.[34] but are regarded as rare when spinal manipulation is employed skillfully and appropriately.[30]

The relationship to stroke has been debated. Stroke is statistically associated with both general practitioner and chiropractic services in persons under 45 years of age, and these associations may be related to preexisting conditions.[35][36][37] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy and vertebrobasilar artery stroke.[38] A 2012 review found that there is not enough evidence to support a strong association or no association between cervical manipulation and stroke.[39] A 2008 review found chiropractic are more commonly associated with serious related adverse effects than other professionals following manipulation and concluded that the risk of death from manipulations to the neck outweighs the benefits.[8]

Techniques

According to the American Chiropractic Association the most frequently used techniques by chiropractors are Diversified technique 95.9%, Extremity manipulating/adjusting 95.5%, Activator Methods 62.8%, Gonstead technique 58.5%, Cox Flexion/Distraction 58.0%, Thompson 55.9%, Sacro Occipital Technique [SOT] 41.3%, Applied Kinesiology 43.2%, NIMMO/Receptor Tonus 40.0%, Cranial 37.3%, Manipulative/Adjustive Instruments 34.5%, Palmer upper cervical [HIO] 28.8%, Logan Basic 28.7%, Meric 19.9%, and Pierce-Stillwagon 17.1%.[40] There are about 200 chiropractic technique, but there is a mostly overlap between them, and many techniques involve slight changes of other techniques.[41]

Diversified technique

Like many chiropractic and osteopathic manipulative techniques, Diversified technique is characterized by a high-velocity, low-amplitude thrust.[42] It is considered the most generic chiropractic manipulative technique and is differentiated from other techniques in that its objective is to restore proper movement and alignment of spine and joint dysfunction.[42]

Atlas Orthogonal technique

Atlas Orthogonal Technique is an upper cervical chiropractic treatment technique created by Roy Sweat, DC.[43] It is a technique which uses a percussion instrument in attempts to adjust what is perceived to be a subluxation of the atlas vertebra, the top vertebra in the cervical spine. It is based on the teachings of B. J. Palmer, who advocated the Hole-In-One version of spinal adjustment. It is primarily used by straight chiropractors. Referring to the origins of upper cervical techniques, Dan Murphy, DC, DABCO, wrote: "Over the past 100 years, the practice of chiropractic has branched into dozens of specialty techniques. However, historically, for a third of this time, from the 1930s into the 1960s, the predominant practice of chiropractic involved primarily the upper cervical spine."[44]

Activator methods

Activator V Chiropractic Adjusting Instrument

The Activator Method Chiropractic Technique (AMCT) is a chiropractic treatment method and device created by Arlan Fuhr as an alternative to manual manipulation of the spine or extremity joints. The device is categorized as a mechanical force manual assisted (MFMA) instrument which is generally regarded as a softer chiropractic treatment technique.

The activator is a small handheld spring-loaded instrument which delivers a small impulse to the spine. It was found to give off no more than 0.3 J of kinetic energy in a 3-millisecond pulse. The aim is to produce enough force to move the vertebrae but not enough to cause injury.[45]

The AMCT involves having the patient lie in a prone position and comparing the functional leg lengths. Often one leg will seem to be shorter than the other. The chiropractor then carries out a series of muscle tests such as having the patient move their arms in a certain position in order to activate the muscles attached to specific vertebrae. If the leg lengths are not the same, that is taken as a sign that the problem is located at that vertebra. The chiropractor treats problems found in this way moving progressively along the spine in the direction from the feet towards the head.[45]

Although prone "functional leg length" is a widely used chiropractic tool, it is not a recognized anthropometric technique, since legs are often of unequal length, and measurements in the prone position are not entirely valid estimates of standing X-ray differences.[46] Measurements in the standing position are far more reliable.[47] Another confounding factor is that simply moving the two legs held together and leaning them imperceptibly to one side or the other produces different results.[48] Fuhr claims that properly trained doctors show good interexaminer reliability.[45]

In 2003, the National Board of Chiropractic Examiners found that 69.9% of chiropractors used the technique, and 23.9% of patients received it.[49] The majority of U.S. chiropractic schools and some schools in other countries teach the AMCT method, and an estimated 45,000 chiropractors worldwide use AMCT or some part of the technique.[45]

There have been a number of studies of AMCT, including case reports, clinical studies and randomized controlled trials, but there are still unanswered questions. A few studies suggest that the activator may be as effective as manual adjustment in treatment of back pain.[45]

Graston technique

Graston Technique (GT) is a trademarked therapeutic method for diagnosing and treating disorders of the skeletal muscles and related connective tissue. The method employs a collection of six stainless steel tools of particular shape and size, which are used by practitioners to rub [50] patients' muscles in order to detect and resolve adhesions in the muscles and tendons.[51] Practitioners must be licensed by the parent corporation (Graston Technique, LLC.) in order to use the Graston Technique trademark or the patented instruments.[52]

Several examples of Graston treatment have been used in contact sports where scars and contusions are common.[53] However, the Graston Technique has not been rigorously scientifically tested and its evidence basis and assumptions are considered questionable at best. There are no high quality clinical trials that validate the efficacy of the Graston Techniques.[54]

Koren Specific technique

Koren Specific Technique (KST) is a technique developed by Tedd Koren.[55] While the technique is associated with chiropractic techniques, Koren has variously described it as an "analysis protocol" or "healthcare protocol".[55] KST may use their hands, or they may use an electric device known as an "ArthroStim" for assessment and adjustments.[56] KST can use different postures.[57] The insurers NHS Leeds West CCG,[58] North Dakota Department of Human Services,[59] Aetna,[56] and Oklahoma State University[60] cover other chiropractic techniques but exclude KST from coverage because they consider it to be "experimental and investigational."[56] Aetna's policy states there is a lack of efficacy regarding this method.[56]

Gonstead technique

The Gonstead technique is chiropractic method that had been developed by Clarence Gonstead since 1923.[61] The technique focuses on hands-on adjustment and is claimed to expand "standard diversified technique" by implementing additional instrumentation including X-rays, Gonstead Radiographic Parallel, a measuring device, and the development of Nervo-Scope,[62] an ineffective and pseudoscientific device said to detect nerve imbalance based on skin temperature.[63] The technique gained popularity in the 1960s.[64] About 28.9% of patients have been treated with the Gonstead technique.[65]

References

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  37. ↑ Cassidy, JD; Boyle, E; Côté, P; He, Y; Hogg-Johnson, S; Silver, FL; Bondy, SJ (15 Feb 2008). "Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.". Spine 33 (4 Suppl): S176–83. doi:10.1097/BRS.0b013e3181644600. PMID 18204390.
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  40. ↑ "Chiropractic Techniques" (PDF). American Chiropractic Association. August 2003. Archived from the original (PDF) on April 6, 2008.
  41. ↑ "Chiropractic in Canada". Canadian Chiropractic Association.
  42. 1 2 Technique Systems in Chiropractic - Cooperstein & Gleberzon
  43. ↑ Atlas orthogonal chiropractic program, Roy W. Sweat, DC
  44. ↑ Eriksen K. Upper Cervical Subluxation Complex. A review of the chiropractic and medical literature. LWW, 2004; p. vii
  45. 1 2 3 4 5 Fuhr, Arlan W.; J. Michael Menke (February 2005). "Status of Activator Methods Chiropractic Technique, Theory, and Practice". Journal of Manipulative and Physiological Therapeutics 28 (2): e1–e20. doi:10.1016/j.jmpt.2005.01.001. PMID 15800504. Retrieved 2008-08-18.
  46. ↑ D W Rhodes, E R Mansfield, P A Bishop, J F Smith. The validity of the prone leg check as an estimate of standing leg length inequality measured by X-ray. J Manipulative Physiol Ther. ;18 (6):343-6
  47. ↑ E Hanada, R L Kirby, M Mitchell, J M Swuste. Measuring leg-length discrepancy by the "iliac crest palpation and book correction" method: reliability and validity. Arch Phys Med Rehabil. 2001 Jul ;82 (7):938-42
  48. ↑ Keeping Your Spine In Line, Adjusting the Joints, and Video, Alan Alda, PBS, Scientific American Frontiers. Video discusses Activator and leg length
  49. ↑ Christensen MG, Kollasch MW (2005). "Professional functions and treatment procedures" (PDF). Job Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners. pp. 121–38. ISBN 1-884457-05-3. Retrieved 2008-08-25.
  50. ↑ Zachary Lewis (2012). "Graston Technique gives muscles a sharp workout: Stretching Out".
  51. ↑ About the Graston Technique, retrieved 2008-10-11
  52. ↑ US 5231977, Graston, "Tools and method for performing soft tissue massage", issued 3 August 1993
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  55. 1 2 Editorial Board (29 January 2009). "Koren Specific Technique Not Chiropractic? WFC Alleges "Serious Professional Misconduct"". Dynamic Chiropractic. Retrieved 29 March 2016.
  56. 1 2 3 4 "Chiropractic Services - Policy". Aetna. Retrieved 29 March 2016.
  57. ↑ "Lake Mills Family Chiropractic practices new method". AlbertLeaTribune. October 15, 2009.
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  63. ↑ "The Nervo-Scope". www.quackwatch.org. Retrieved 2016-05-02.
  64. ↑ "Technique Summary: Gonstead Technique". ChiroACCESS. 2010-02-08. Retrieved 2015-07-01.
  65. ↑ Cooperstein, Robert (2003). "Gonstead Chiropractic Technique (GCT)". Journal of Chiropractic Medicine 2 (1): 16–24. doi:10.1016/S0899-3467(07)60069-X. ISSN 1556-3707. PMID 19674591.
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