Principal Proposed Uses
Chiropractic is one of the most widely used health services today. It has gained increasing acceptance as a treatment for back and neck pain, and it is covered by many health insurance plans. Millions of people would report that chiropractic spinal manipulation has brought them relief. Nonetheless, at present the research record for its effectiveness is inconclusive at best.
History of Chiropractic
Daniel David Palmer founded chiropractic in 1895, after an experience in which he apparently believed he cured a man’s deafness by manipulating his back. He opened the Palmer School of Chiropractic and began teaching spinal manipulation. This college still exists today, with a fully accredited program.
One of Palmer’s first students was his son, Bartlett Joshua (B.J.) Palmer. It was B.J. Palmer who truly popularized the technique. Later, Willard Carver, an Oklahoma City lawyer, opened a competing school. He believed that chiropractic physicians needed to offer other methods of treatment in addition to spinal manipulation. This opened a schism in the chiropractic world that still exists today. Followers of Palmer and his methods focus only on spinal adjustments, an approach called "straight" chiropractic. Those who, like Carver, use various approaches to healing are called "mixers." Mixers may use vitamins, herbs, and any other treatment methods they find useful (and are allowed to practice by law).
Medical treatments in the 19th and early 20th centuries were not based on scientific evidence of effectiveness, and chiropractic treatment was no exception. It became a widespread technique long before there was any real evidence that it worked. Chiropractic schools utilized all of their profits and resources to further develop programs for training people in chiropractic techniques—not for verifying the theory and practice of chiropractic. However, in the 1970s, proper scientific research into chiropractic began to draw interest. In 1977, the Foundation for Chiropractic Education and Research (FCER) established a program to train chiropractic researchers. Since then, efforts have been made to fund scientific trials testing the effectiveness of chiropractic techniques and to establish a scientific foundation for the practice.
Forms of Spinal Manipulation
There are many different chiropractic techniques in use today, some with proprietary names such as the Gonstead and Maitland techniques. In general, most involve rapid (high-velocity) short (low-amplitude) thrusts. Manipulation may be purely manual or mechanically assisted. For example, some chiropractors use an "activator"—a small metal tool that applies a force directly to one vertebra.
In addition, some chiropractors use a related therapy called spinal mobilization. This method involves gentle, extended movements (low-velocity, high-amplitude), rather than the “back-cracking” of classic chiropractic spinal manipulation.
How Does Chiropractic Spinal Manipulation Work?
Since its origin, chiropractic theory has based itself on “subluxations,” or vertebrae that have shifted position in the spine. These subluxations are said to impede nerve outflow and cause disease in various organs. A chiropractic treatment is supposed to "put back in" these "popped out" vertebrae; for this reason, it is called an “adjustment.”
However, no real evidence has ever been presented showing that a given chiropractic treatment alters the position of any vertebrae. In addition, there is as yet no real evidence that impairment of nerve outflow is a major contributor to common illnesses, or that spinal manipulation changes nerve outflow in such a way as to affect organ function.
What Is Chiropractic Used For?
Chiropractic spinal manipulation is widely used for the treatment of back pain, neck pain, and headaches, whether acute or chronic. It is also frequently tried for pain in other areas, such as the shoulders, knees, and jaw, as well as for breech birth positioning of a baby, infantile colic, frequent colds, and many other conditions.
Some chiropractic physicians promote “comprehensive chiropractic care” as a means of staying healthy. This approach may include diet, exercise, and supplements, along with regular chiropractic manipulation.
What Is the Scientific Evidence for Chiropractic Spinal Manipulation?
Chiropractic spinal manipulation has been evaluated scientifically to determine its efficacy, as well as its costs comparative to other forms of health care. However, the evidence is not compelling in either case.
Although there is some evidence that chiropractic spinal manipulation may be helpful for various medical purposes, in general the evidence is not strong. There are several reasons for this, but one is fundamental: Even with the best of intentions, it is difficult to properly ascertain the effectiveness of a hands-on therapy like chiropractic.
Only one form of study can truly prove that a treatment is effective: the double-blind, placebo-controlled trial. (For more information on why such studies are so crucial, see Why Does This Database Rely on Double-blind Studies? ) However, it isn’t easy to fit chiropractic into a study design of this type. Consider the obstacles: What could researchers use for placebo chiropractic treatment? And how could they make sure that both participants and practitioners would be kept in the dark regarding who was receiving real chiropractic manipulation and who was receiving fake manipulation?
Because of these problems, all studies of chiropractic manipulation fall short of optimum design. Many have compared chiropractic treatment against no treatment. However, studies of this type cannot provide reliable evidence about the efficacy of a treatment. If a benefit is seen, there is no way to determine whether it was caused by chiropractic manipulation specifically, or just attention generally. (Attention alone will almost always produce some reported benefit.)
More meaningful trials used some sort of unrelated fake treatment for the control group, such as phony laser acupuncture. However, it is less than ideal to use a placebo treatment that is so very different in form from the treatment under study.
Better studies compare real chiropractic manipulation against sham forms of manipulation, such as light touch. Studies of this type are a definite step forward. However, it is quite likely that the practitioners at least unconsciously conveyed more enthusiasm and optimism when performing the real therapy than the fake therapy; this, too, could affect the outcome.
It has been suggested that the only way to get around this problem would be to compare the effectiveness of trained practitioners to actors trained only enough to provide a simulation of treatment; however, such studies have not been reported.
Still other studies have simply involved treating people with chiropractic spinal manipulation and seeing whether they improve. These trials are particularly meaningless; it has been long since proven that both participants and examining physicians will at least think that they observe improvement in people given a treatment, regardless of whether the treatment does anything on its own.
Finally, other trials have compared chiropractic manipulation to competing therapies, such as massage therapy or conventional physical therapy. However, neither of these therapies has been proven effective. When you compare unproven therapies to each other, the results cannot possibly prove that any of the tested treatments are effective.
Given these caveats, we discuss below what science knows about the effects of chiropractic.
Besides effectiveness, another important consideration is cost of care. There are many aspects to the cost of treatment, including number of visits to the chosen provider, cost of evaluation procedures such as x-rays, insurance reimbursement versus patient out-of-pocket expense, and costs for missed work time.
However, it is difficult to develop accurate cost-comparison figures because there are many complicating factors in research on the subject. For example, one approach is to simply identify people with similar injuries who choose one treatment or another and add up the total cost. Unfortunately, the results of such a study can be misleading. People with more or less severe back pain might tend to choose different forms of treatment; if those with more severe pain usually chose surgical treatment, this would tend to inflate the comparative costs of conventional care and make chiropractic seem less expensive.
Another potentially complicating factor is that, to a great extent, insurance companies control utilization of treatment. If they are less inclined to authorize chiropractic visits, people who choose chiropractic care might find their care cut off more rapidly than others who choose, say, physical therapy. This too would lead to artificially low costs of chiropractic treatment compared to physical therapy, skewing the results of the study.
These problems could be solved by conducting a study in which researchers randomly assign participants to certain treatments, with the length of treatment determined entirely by the treating physician. Unfortunately, studies of this type have not yet been conducted.
Upper Extremity Pain
Tension Headaches and Cervicogenic Headaches
There is some evidence that chiropractic manipulation may provide both long- and short-term benefits for migraine headaches .
After 2 months of treatment, those receiving chiropractic manipulation showed statistically significant improvement in headache severity and frequency compared to the control group. Furthermore, these benefits persisted to a 2-month follow-up evaluation.
Chiropractic has been evaluated for many other conditions as well, but the results as yet provide little evidence of benefit.
Infantile colic is a common and frustrating problem. Although chiropractic manipulation has been promoted as a treatment for this condition, there is as yet little evidence that it offers specific benefits.
What to Expect With Chiropractic Treatment
Depending on the condition, chiropractic treatment is usually conducted two- or three times per week, for a month or more. Chiropractic is also sometimes used on an as-needed basis, or in a once- or twice-a-month maintenance form. For many chiropractors, x-rays are essential at the first visit and at some follow-up visits.
Each session involves hands-on manipulation following the methods of whatever manipulation technique the practitioner chooses to use. Sometimes other modalities may be used as well, such as massage or hot or cold packs.
Certain health conditions preclude spinal manipulation, such as nerve impingement causing severe nerve damage, or significant disease of the spinal bones.
- Reviewer: EBSCO CAM Review Board
- Review Date: 07/2012 -
- Update Date: 03/12/2013 -