Chiropractic treatment techniques

Many chiropractic treatment techniques are available for use by chiropractors. They primarily specialize in manual and manipulative therapies with an emphasis on spinal manipulation. The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "father of medicine" used manipulative techniques,^[1] as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of the osteopathic medicine and chiropractic medicine.^[2] SMT gained mainstream recognition during the 1980s.^[3] Spinal manipulation/adjustment describes techniques where the hands are used to manipulate, massage, mobilize, adjust, stimulate, apply traction to, or otherwise influence the spine and related tissues.^[4] It is the most common and primary intervention used in chiropractic care;^[5] In North America, chiropractors perform over 90% of all manipulative treatments^[6] with the balance provided by osteopathic medicine, physical therapy and naturopathic medicine. Manipulation under anesthesia or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anesthesia.^[7] Typically, it is performed on patients who have failed to respond to other forms of treatment.^[8] There has been considerable debate on the safety of spinal manipulation, in particular with the cervical spine.^[9] Although serious injuries and fatal consequences can occur and may be under-reported,^[10] these are generally considered to be rare, with mortality rates far lower than those seen in allopathic medicine.^[11] Chiropractors may also use other conservative therapies such as exercise, electrical modalities, health, nutrition and wellness counselling and ergonomic advice in a holistic paradigm espoused by in traditional/complementary and alternative medicine.^[5]

Interventions

Manual therapy is defined as a clinical approach utilizing skilled, specific hands-on techniques, including but not limited to manipulation/mobilization to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function. It can also be defined as^[12] procedures by which the hands directly contact the body to treat the articulations and/or soft tissues.

Chiropractors primarily use a manual and conservative approach towards neuromusculoskeletal disorders. Interventions are typically multi-modal and can include:

• manual procedures, particularly spinal manipulation, other joint manipulation, joint mobilization, soft‐tissue and reflex techniques;
• exercise, rehabilitative programmes and other forms of active care;
• psychosocial aspects of patient management;
• patient education on spinal health, posture, nutrition and other lifestyle modifications;
• emergency treatment and acute pain management procedures as indicated;
• other supportive measures, which may include the use of back supports and orthotics;
• recognition of contraindications and risk management procedures, the limitations of chiropractic care, and of the need for protocols relating to referral to other health professionals.

Manual and manipulative therapy

Lumbar, cervical and thoracic chiropractic spinal manipulation.

The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "Father of Medicine" used manipulative techniques^[1] as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of the osteopathic medicine and chiropractic medicine.^[2] Spinal manipulation gained mainstream recognition during the 1980s.^[3] Spinal manipulation/adjustment describes techniques where the hands are used to manipulate, massage, mobilize, adjust, stimulate, apply traction to, or otherwise influence the spine and related tissues.^[4] It is the most common and primary intervention used in chiropractic care;^[5] In North America, chiropractors perform over 90% of all manipulative treatments^[13] with the balance provided by osteopathic medicine, physical therapy and naturopathic medicine. Manipulation under anesthesia or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anesthesia.^[7] Typically, it is performed on patients who have failed to respond to other forms of treatment.^[8] There has been considerable debate on the safety of spinal manipulation, in particular with the cervical spine.^[9] Although serious injuries and fatal consequences can occur and may be under-reported,^[10] these are generally considered to be rare when spinal manipulation is employed skillfully and appropriately.^[11]

Definitions

High-velocity low amplitude (HVLA) spinal manipulative therapy (SMT) is also known as adjustment, thrust manipulation, and Grade V mobilisation ^[14] It is distinct in biomechanics from non-thrust, low-velocity low amplitude (LVLA) manipulative techniques.

Categories

Manual and manipulative techniques can be categorized by different modes depending on therapeutic intent, indications, contraindications and safety.^[15] Manual and mechanically assisted articular manipulative procedures can include:

• HVLA manipulation
• HVLA manipulation with recoil
• LVLA manipulation (mobilization)
• Drop tables and terminal point manipulative thrust
• Flexion-distraction and traction-type tables
• Pelvic blocks
• Instrument assisted manipulative devices

Manual non-articular manipulative procedures can include:

• Reflex and muscle relaxation procedures
• Muscle energy techniques
• Myofascial ischemic compression procedures
• Myofascial, and soft tissue manipulative techniques

Chiropractic manipulative techniques

Over the years, many variations of these techniques have been delivered, most as proprietary techniques developed by individual practitioners. WebMD has made a partial list:^[16]

List of chiropractic treatment techniques

In addition to the manipulative techniques sourced in the WebMD list, the following chiropractic techniques have articles on them in the English Wikipedia:

• Activator technique
• Active Release Technique
• Applied kinesiology
• Atlas Orthogonal Technique
• Diversified technique
• Graston Technique
• Joint manipulation
• Joint mobilization
• Manipulation under anesthesia
• Neuro Emotional Technique
• NUCCA
• Spinal adjustment
• Spinal manipulation
• Spinal mobilization
• Upper Cervical Specific Chiropractic

Neuromusculoskeletal disorders

Manual and manipulative therapies commonly used by chiropractors other manual medicine practitioners are used primarily to help treat low back pain and other neuromusculoskeletal disorders. Spinal manipulation appears as effective to other commonly prescribed treatments for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy.^[17] For acute low back pain, spinal manipulative therapy does not appear better than commonly recommended therapies such as analgesics, acupuncture, back pain education or exercise therapy.^[18][19][20] National guidelines regarding spinal manipulation vary country to country; some do not recommend, while others recommend a short course of manipulative therapy for those who do not improve with other interventions.^[21] Manipulation under anaesthesia, or medically assisted manipulation, currently has insufficient evidence to make any strong recommendations. Spinal manipulation may be effective for lumbar disc herniation with radiculopathy,^[22][23] as effective as mobilization for neck pain,^[24] some forms of headache,^[25][26][27] and some extremity joint conditions. .^[28][29] There is insufficient evidence regarding the effectiveness of spinal manipulation on non-musculoskeletal conditions.^[30]. There is considerable debate regarding the safety of spinal manipulation, particularly with the upper cervical spine.^[9] Although serious injuries and fatal consequences can occur and may be under-reported,^[10] these are generally considered to be rare as spinal manipulation is relatively safe^[18] when employed skillfully and appropriately.^[11] Spinal manipulation is generally regarded as cost-effective treatment of musculoskeletal conditions when used alone or in combination with other treatment approaches.^[31] 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.^[32]

Non-musculoskeletal disorders

The use of spinal manipulation for non-musculoskeletal conditions remains controversial. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation. Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.^{[20] [33]} and no scientific data for idiopathic adolescent scoliosis.^[34]

Safety

The safe application of spinal manipulation requires a thorough medical history, assessment, diagnosis and plan of management. Manipulative therapists, including chiropractors, must rule out contraindications to HVLA spinal manipulative techniques. Absolute contraindications refers to diagnoses and conditions that put the patient at risk to developing adverse events. For example, a diagnosis of rheumatoid arthritis and other conditions that structurally destabilizes joints, is an absolute contraindication of SMT to the upper cervical spine. Relative contraindications, such as osteoporosis are conditions where increased risk is acceptable in some situations and where mobilization and soft-tissue techniques would be treatments of choice. Most contraindication apply only to the manipulation of the affected region.^[35]

Adverse events in spinal manipulation studies are believed to be under-reported ^[36] and appear to be more common following HVLA manipulation than mobilization.^[37] Mild, frequent and temporary adverse events occur in SMT which include temporary increase in pain, tenderness and stiffness.^[9] These events typically dissipates within 24–48 hours ^[38] Serious injuries and fatal consequences, especially to SM in the upper cervical region, can occur.^[39] but are regarded as rare when spinal manipulation is employed skillfully and appropriately.^[35]

There is considerable debate regarding the relationship of spinal manipulation to the upper cervical spine and stroke. Stroke is statistically associated with both general practitioner and chiropractic services in persons under 45 years of age suggesting that these associations are likely explained by preexisting conditions.^[40][41][42] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy and vertebrobasilar artery stroke.^[43] A 2012 systematic review determined that there is insufficient evidence to support a strong association or no association between cervical manipulation and stroke.^[44]

Cost-effectiveness

Spinal manipulation is generally regarded as cost-effective treatment of musculoskeletal conditions when used alone or in combination with other treatment approaches.^[45] 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.^[32]

References