Chiropractic treatment techniques

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Chiropractors use their version of spinal manipulation (known as chiropractic adjustment) as their primary treatment method, with non-chiropractic use of spinal manipulation gaining more study and attention in mainstream medicine in the 1980s. [1] There is no evidence that chiropractic spinal adjustments are effective for any medical condition, with the possible exception of treatment for lower back pain. [2] The safety of manipulation, particularly on the cervical spine has been debated. [3] Adverse results, including strokes and deaths, are rare. [4] [5]

Contents

There are about 200 chiropractic techniques, most of which are variations of spinal manipulation, but there is a significant amount of overlap between them, and many techniques involve slight changes of other techniques. [6]

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%. [7]

Techniques

Manual and manipulative therapy

Lumbar, cervical and thoracic chiropractic spinal manipulation Manuellterapi5.jpg
Lumbar, cervical and thoracic chiropractic spinal manipulation

In the late 19th century in North America, therapies including osteopathy and chiropractic became popular. [8] Spinal manipulation gained mainstream recognition during the 1980s. [1]

In this system, hands are used to manipulate, massage or otherwise influence the spine and related tissues. [9] It is the most common and primary intervention used in chiropractic care. [10]

Diversified technique

Diversified technique is a non-proprietary and eclectic approach to spinal manipulation that is commonly used by chiropractors. [11] The technique, as it is applied today, is largely attributed to the work of Joe Janse [11] [12] Diversified is the most common spine manipulation technique used by chiropractors, with approximately 96% of chiropractors using it for approximately 70% of their patients. [13] [14] Diversified is also the technique most preferred for use during future practice by chiropractic students. [15] Diversified is the only spine manipulation technique taught in Canadian chiropractic programs. [16] Like many chiropractic and osteopathic manipulative techniques, Diversified is characterized by a high-velocity, low-amplitude thrust. [11] 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. [11]

Atlas orthogonal technique

Atlas Orthogonal Technique is an upper cervical chiropractic treatment technique created by Frederick M. Vogel and Roy W. Sweat in 1979, focused on the alignment of the atlas (see gif on right, atlas highlighted in pink). It is a non-invasive technique which uses a percussion instrument in attempts to adjust the atlas based off the angles of the bones that articulate in the upper cervical vertebrae. [17] These angles are measured from specific X-rays and found to be a vertebral subluxation. 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, as it is focused on the correct alignment of the atlas as to allow for minimal obstruction for the nerves channeled through the atlas and down the spinal cord. [18] [19] 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." [20]

Placement of the atlas bone in the skeletal system Atlas Bone and Spine.gif
Placement of the atlas bone in the skeletal system

Extremity manipulating/adjusting

Activator methods

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. [21]

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. [21]

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. [22] Measurements in the standing position are far more reliable. [23] 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. [24] Fuhr claims that properly trained doctors show good interexaminer reliability. [21]

In 2003, the National Board of Chiropractic Examiners found that 69.9% of chiropractors used the technique, and 23.9% of patients received it. [25] 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. [21]

There have been a number of studies of AMCT, including case reports, clinical studies and controlled trials, but there are still unanswered questions. A few low-quality studies have suggested that the activator may be as effective as manual adjustment in treatment of back pain. [21] A single high-quality study has suggested that activator-assisted manipulation directed by leg-length testing was significantly inferior to manual spinal manipulation guided by palpation and was more similar to the use of paracetamol for the treatment of low back pain. [26]

Graston technique

GrastonTechnique shoulder-treat.jpg
GT-Instruments 400pixelswide.jpg

Graston Technique (GT) is a trademarked therapeutic method for diagnosing and treating disorders of the skeletal muscles and related connective tissue. The method was started by David Graston and employs a collection of six stainless steel instruments of particular shape and size, which are used by practitioners to rub [27] patients' muscles in order to detect and resolve adhesions in the muscles and tendons. [28] Practitioners must be licensed by the parent corporation (Graston Technique, LLC.) in order to use the Graston Technique trademark or the patented instruments. [29]

Several examples of Graston treatment have been used in contact sports where scars and contusions are common. [30] 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. [31]

Koren Specific Technique

Koren specific technique (KST) is a technique developed by Tedd Koren around 2004. [32] [33] While the technique is associated with chiropractic techniques, Koren has variously described it as an "analysis protocol" or "healthcare protocol". [33] KST may use their hands, or they may use an electric device known as an "ArthroStim" for assessment and adjustments. [34] KST can use different postures. [32] The insurers Aetna, [34] NHS Leeds West CCG, [35] North Dakota Department of Human Services, [36] and The Ohio State University [37] cover other chiropractic techniques but exclude KST from coverage because they consider it to be "experimental and investigational." [34] [35] [36] [37] Aetna's policy states there is a lack of efficacy regarding this method. [34]

Gonstead technique

The Gonstead technique is a chiropractic method that was developed by Clarence Gonstead in 1923. [38] The technique focuses on hands-on adjustment and is claimed to expand "standard diversified technique" by removing rotation from the adjusting thrust and implementing additional instrumentation including X-rays, Gonstead Radiographic Parallel, a measuring device to undertake specific biomechanical analysis of the X-ray, and the development of Nervo-Scope, [39] a device said to detect the level of neurophysiologic activity due to the existence of vertebral subluxation based on changes in skin temperature. [40] Heat detector devices are unreliable and lack scientific evidence. [40] The technique gained popularity in the 1960s. [41] About 28.9% of patients[ specify ] have been treated with the Gonstead technique. [42]

Torque release technique

Trigenics Technique

Trigenics is a neurological-based manual or instrument-assisted assessment and treatment system [43] developed and patented by Allan Oolo Austin. [44] The technique is relatively infrequently used by chiropractors compared to other chiropractic techniques such as Diversified, trigger point therapy and Activator. [45]

Effectiveness

Neuromusculoskeletal disorders

Treatment is usually for neck or low back pain and related disorders. [46]

For acute low back pain, low quality evidence has suggested no difference between real and sham spine manipulation, [47] and moderate quality evidence has suggested no difference between spine manipulation and other commonly used treatments, such as medication and physical therapy. [47] [48] [49]

National guidelines vary; some recommend the therapy for those who do not improve with other treatment. [50] It may be effective for lumbar disc herniation with radiculopathy, [51] [52] as effective as mobilization for neck pain, [53] some forms of headache, [54] [55] and some extremity joint conditions. [56] [57] 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. [58] A 2008 review found that with the possible exception of lower back pain, chiropractic manipulation has not been shown to be effective for any medical condition. [2] [59]

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. [49] There is no scientific data that supports the use of spinal manipulation for idiopathic adolescent scoliosis. [60] [61]

Cost-effectiveness

Spinal manipulation is generally regarded as cost-effective treatment of musculoskeletal conditions when used alone or in combination with other treatment approaches. [62] 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. [63]

Safety

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

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. [64]

While safety has been debated, [3] and serious injuries and deaths can occur and may be under-reported, [4] these are generally rare and spinal manipulation is relatively safe [47] when employed skillfully and appropriately. [5]

Adverse events are believed to be under-reported [65] and appear to be more common following high velocity/low amplitude manipulation than mobilization. [66] Mild, frequent and temporary adverse events occur in spinal manipulation which include temporary increase in pain, tenderness and stiffness. [3] These effects generally are reduced within 24–48 hours [67] Serious injuries and fatal consequences, especially from spinal manipulation in the upper cervical region, can occur, [68] but are regarded as rare when spinal manipulation is employed skillfully and appropriately. [64]

Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy and vertebrobasilar artery stroke. [69] A 2012 review found that there is not enough evidence to support a strong association or no association between cervical manipulation and stroke. [70] A 2008 review found chiropractic spinal manipulation is 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. [4]

Related Research Articles

<span class="mw-page-title-main">Chiropractic</span> Form of pseudoscientific alternative medicine

Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. It has esoteric origins and is based on several pseudoscientific ideas.

<span class="mw-page-title-main">Vertebral subluxation</span> Chiropractic concept

In chiropractic, a vertebral subluxation means pressure on nerves, abnormal functions creating a lesion in some portion of the body, either in its action or makeup. Subluxations are not necessarily visible on X-rays.

<span class="mw-page-title-main">Sciatica</span> Lower back pain that extends down leg

Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described as shooting. Typically, symptoms are only on one side of the body. Certain causes, however, may result in pain on both sides. Lower back pain is sometimes present. Weakness or numbness may occur in various parts of the affected leg and foot.

<span class="mw-page-title-main">Low back pain</span> Medical condition

Low back pain or lumbago is a common disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can vary from a dull constant ache to a sudden sharp feeling. Low back pain may be classified by duration as acute, sub-chronic, or chronic. The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain. The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people recovered by six weeks.

Manual therapy, or manipulative therapy, is a physical treatment primarily used by physical therapists, occupational therapists to treat musculoskeletal pain and disability; it mostly includes kneading and manipulation of muscles, joint mobilization and joint manipulation. It is also used by Rolfers, massage therapists, athletic trainers, osteopaths, and physicians.

<span class="mw-page-title-main">Spinal adjustment</span>

Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe their approaches to spinal manipulation, as well as some osteopaths, who use the term adjustment. Despite anecdotal success, there is no scientific evidence that spinal adjustment is effective against disease.

<span class="mw-page-title-main">Spinal manipulation</span> Intervention performed on spinal joints

Spinal manipulation is an intervention performed on synovial joints of the spine, including the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse and costovertebral joints. It is typically applied with therapeutic intent, most commonly for the treatment of low back pain.

<span class="mw-page-title-main">Traction (orthopedics)</span> Process for straightening broken bones

Traction is a set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system. There are two types of traction: skin traction and skeletal traction. They are used in orthopedic medicine.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

Joint manipulation is a type of passive movement of a skeletal joint. It is usually aimed at one or more 'target' synovial joints with the aim of achieving a therapeutic effect.

<span class="mw-page-title-main">Radiculopathy</span> Medical condition

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. Radiculopathy can result in pain, weakness, altered sensation (paresthesia) or difficulty controlling specific muscles. Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.

Manipulation under anesthesia (MUA) or fibrosis release procedures is a multidisciplinary, chronic pain-related manual therapy modality which is used for the purpose of improving articular and soft tissue movement. This is accomplished by way of a combination of controlled joint mobilization/manipulation and myofascial release techniques. MUA is used by osteopathic/orthopedic physicians, chiropractors and specially trained physicians. It aims to break up adhesions on or around spinal joints or extremity joints to which a restricted range of motion can be painful and limit function. Failed attempts at other standard conservative treatment methods, over a sufficient time-frame, is one of the principal patient qualifiers.

<span class="mw-page-title-main">Neck pain</span> Medical condition

Neck pain, also known as cervicalgia, is a common problem, with two-thirds of the population having neck pain at some point in their lives.

<span class="mw-page-title-main">Activator technique</span> Chiropractic treatment method and device

The Activator Method Chiropractic Technique 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.

Throughout its history, chiropractic has been the subject of internal and external controversy and criticism. According to magnetic healer Daniel D. Palmer, the founder of chiropractic, "vertebral subluxation" was the sole cause of all diseases and manipulation was the cure for all disease. A 2003 profession-wide survey found "most chiropractors still hold views of Innate Intelligence and of the cause and cure of disease consistent with those of the Palmers". A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today." Chiropractors, including D.D. Palmer, were jailed for practicing medicine without a license. D.D. Palmer considered establishing chiropractic as a religion to resolve this problem. For most of its existence, chiropractic has battled with mainstream medicine, sustained by antiscientific and pseudoscientific ideas such as vertebral subluxation.

<span class="mw-page-title-main">Veterinary chiropractic</span>

Veterinary chiropractic, also known as animal chiropractic, is chiropractic for animals – a type of spinal manipulation. Veterinary chiropractors typically treat horses, racing greyhounds, and pets. Veterinary chiropractic is a controversial method due to a lack of evidence as to the efficacy of chiropractic methods. Contrary to traditional medicine, chiropractic therapies are alternative medicine. There is some degree of risk associated with even skilled manipulation in animals as the potential for injury exists with any technique used. The founder of chiropractic, Daniel David Palmer, used the method on animals, partly to challenge claims that the placebo effect was responsible for favorable results in humans. Chiropractic treatment of large animals dates back to the early 1900s. As of 2019, many states in the US provide statutory or regulatory guidelines for the practice of chiropractic and related treatments on animals, generally requiring some form of veterinary involvement.

Osteomyology is a multi-disciplined form of alternative medicine found almost exclusively in the United Kingdom and is loosely based on aggregated ideas from other manipulation therapies, principally chiropractic and osteopathy. It is a results-based physical therapy tailored specifically to the needs of the individual patient. Osteomyologists have been trained in osteopathy and chiropractic, but do not require to be regulated by the General Osteopathic Council (GOsC) or the General Chiropractic Council (GCC).

<span class="mw-page-title-main">McKenzie method</span> Method of physical therapy

The McKenzie method is a technique primarily used in physical therapy. It was developed in the late 1950s by New Zealand physiotherapist Robin McKenzie. In 1981 he launched the concept which he called "Mechanical Diagnosis and Therapy (MDT)" – a system encompassing assessment, diagnosis and treatment for the spine and extremities. MDT categorises patients' complaints not on an anatomical basis, but subgroups them by the clinical presentation of patients.

Primary spine practitioners are health care professionals who are specially trained to provide primary care for patients with spinal disease.

Cervical manipulation, commonly known as neck manipulation, is a procedure involving adjustment of the upper seven vertebrae of the spinal column. This procedure is most often utilized by chiropractors, as well as osteopathic physicians who practice osteopathic manipulation. This type of manipulation may increase the risk of stroke and other issues, with studies suggesting the relationship is causative.

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