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About
Chiropractic Health Care
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Center for Complementary and Alternative Medicine.
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Chiropractic ("kye-roh-PRAC-tic")
is a form of health care that focuses on the
relationship between the body's structure, primarily
of the spine, and function. Doctors of chiropractic,
who are also called chiropractors or chiropractic
physicians, use a type of hands-on therapy called manipulation (or adjustment) as
their core clinical procedure. While there are some
differences in beliefs and approaches within the
chiropractic profession, this Research Report will
give you a general overview of chiropractic, discuss
scientific research findings on chiropractic
treatment for low-back pain, and suggest other
sources of information. Terms that are linked are
defined in the "Definitions"
section of this report.
Key Points
- Chiropractic
is most often used to treat musculoskeletal
conditions--problems with the muscles, joints,
bones, and connective tissue such as cartilage,
ligaments, and tendons.
- Research
studies of chiropractic treatment for low-back
pain have been of uneven quality and
insufficient to allow firm conclusions.
Nonetheless, the overall sense of the data is
that for low-back pain, chiropractic treatment
and conventional medical treatments are about
equally helpful. It is harder to draw
conclusions about the relative value of
chiropractic for other clinical conditions.
- The risk of
experiencing complications
from chiropractic adjustment of the low back
appears to be very low. However, the risk
appears to be higher for adjustment of the neck.
- It is
important to inform all of your health care
providers about any treatment that you are using
or considering, including chiropractic. This
will help each provider make sure that all
aspects of your health care are working
together.
1. What is
chiropractic?
The word
"chiropractic" combines the Greek words
cheir
(hand) and praxis (action) and means "done
by hand." Chiropractic is an
alternative medical system and takes a different
approach from conventional medicine (see
box) in diagnosing, classifying,
and treating medical problems.
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What
is conventional medicine?
Conventional medicine is medicine
as practiced by holders of M.D. (Doctor of
Medicine) or D.O. (Doctor of Osteopathic Medicine)
degrees and by their allied health
professionals, such as physical therapists,
psychologists, and registered nurses. Other
terms for conventional medicine include
allopathy; Western, mainstream, orthodox,
and regular medicine; and biomedicine.
What
is complementary and alternative medicine
(CAM)?
Health care
practices and products that are not
presently considered to be part of
conventional medicine are called CAM.
Complementary medicine is
used together with
conventional medicine. Alternative
medicine is used in place of
conventional medicine.
For more
information on conventional medicine and
CAM, see the NCCAM fact sheet "What
Is Complementary and Alternative Medicine
(CAM)?" |
The basic concepts
of chiropractic can be described as follows:
- The body has a
powerful self-healing ability.
- The body's
structure (primarily that of the spine) and its
function are closely related, and this
relationship affects health.
- Chiropractic
therapy is given with the goals of normalizing
this relationship between structure and function
and assisting the body as it heals.
2. What is the
history of the discovery and use of chiropractic?
Chiropractic is a
form of spinal manipulation, which is one of the
oldest healing practices. Spinal manipulation was
described by Hippocrates in
ancient Greece.1-3 In
1895, Daniel David Palmer founded the modern
profession of chiropractic in Davenport, Iowa.
Palmer was a self-taught healer and a student of
healing philosophies of the day. He observed that
the body has a natural healing ability that he
believed was controlled by the nervous system. He
also believed that subluxations, or misalignments of
the spine (a concept that had already existed in the bonesetter and osteopathic
traditions), interrupt or interfere with this "nerve
flow." Palmer suggested that if an organ does not
receive its normal supply of impulses from the
nerves, it can become diseased. This line of
thinking led him to develop a procedure to "adjust"
the vertebrae, the bones of the spinal column, with
the goal of correcting subluxations.
Some chiropractors
continue to view subluxation as central to
chiropractic health care.2
However, other chiropractors no longer view the
subluxation theory as a unifying theme in health and
illness or as a basis for their practice. Other
theories as to how chiropractic might work have been
developed.
3. Who uses
chiropractic and for what health problems?
In 1997, it was
estimated that Americans made nearly 192 million
visits a year to chiropractors.4
Over 88 million of those visits were to treat back
or neck pain.5 In one
recent survey, more than 40 percent of patients
receiving chiropractic care were being treated for
back or low-back problems.6
More than half of those surveyed said that their
symptoms were chronic. Conditions commonly treated
by chiropractors include back pain, neck pain,
headaches, sports injuries, and repetitive strains.
Patients also seek treatment of pain associated with
other conditions, such as arthritis.7
Low-back pain is a
common medical problem, occurring in up to
one-quarter of the population each year. Most people
experience significant back pain at least once
during their lifetime.8
Several recent reviews on
low-back pain have noted that in most cases acute
low-back pain gets better in several weeks, no
matter what treatment is used.8-10
Often, the cause of back pain is unknown, and it
varies greatly in terms of how people experience it
and how professionals diagnose it.11
This makes back pain challenging to study.
4. What kind of
training do chiropractors receive?
Chiropractic
training is a 4-year academic program consisting of
both classroom and clinical instruction (see
box). At least 3 years of
preparatory college work are required for admission
to chiropractic schools.12,13
Students who graduate receive the degree of Doctor
of Chiropractic (D.C.) and are eligible to take
state licensure board examinations in order to
practice. Some schools also offer postgraduate
courses, including 2- to 3-year residency programs
in specialized fields.14
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Chiropractic Training
Chiropractic training typically includes12:
- Coursework in anatomy, physiology,
microbiology, biochemistry, pathology,
nutrition, public health, and many other
subjects
- The
principles and practice of chiropractic
- Research methods and procedures
- Direct
experience in caring for patients
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The Council on
Chiropractic Education, an agency certified by the
U.S. Department of Education, is the accrediting
body for chiropractic colleges in the United States.14
5. What do
chiropractors do in treating patients?
If you become a
chiropractic patient, during your initial visit the
chiropractor will take your health history. He will
perform a physical examination, with special
emphasis on the spine, and possibly other
examinations or tests such as x-rays.15
If he determines that you are an appropriate
candidate for chiropractic therapy, he will develop
a treatment plan.
When the
chiropractor treats you, he may perform one or more
adjustments. An adjustment (also called a
manipulation treatment) is a manual therapy, or
therapy delivered by the hands. Given mainly to the
spine, chiropractic adjustments involve applying a
controlled, sudden force to a joint. They are done
to increase the range and quality of motion in the
area being treated. Other health care
professionals--including physical therapists, sports
medicine doctors, orthopedists,
physical medicine specialists, doctors of
osteopathic medicine, doctors of
naturopathic medicine, and
massage therapists--perform various types of
manipulation. In the United States, chiropractors
perform over 90 percent of manipulative treatments.16
Most chiropractors
use other treatments in addition to adjustment, such
as mobilization, massage, and
nonmanual treatments (see examples in the box).1
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Examples of Nonmanual Chiropractic
Treatments1
- Heat
and ice
- Ultrasound
- Electrical stimulation
- Rehabilitative exercise
- Magnetic therapy
- Counseling about diet, weight loss, and
other lifestyle factors
- Dietary supplements
- Homeopathy
- Acupuncture
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6. Have side
effects or problems been reported from using
chiropractic to treat back pain?
Patients may or may
not experience side effects from chiropractic
treatment. Effects may include temporary discomfort
in parts of the body that were treated, headache, or
tiredness. These effects tend to be minor and to
resolve within 1 to 2 days.7,17
The rate of serious
complications from chiropractic has been debated.
There have been no organized
prospective studies on the number of serious
complications. From what is now known, the risk
appears to be very low.14,16,17
It appears to be higher for cervical-spine, or neck,
manipulation (e.g., cases of stroke have been
reported18,19).
The rare complication of concern from low-back
adjustment is cauda equina syndrome,
estimated to occur once per millions of treatments
(the number of millions varies; one study placed it
at 100 million16).1,20,a
For your safety, it
is important to inform all of your health care
providers about any care or treatments that you are
using or considering, including chiropractic. This
is to help ensure a coordinated course of care.
More information on the topic of
complications can be found in references 1-3, 14,
21, and 22, and
in scientific databases such as CAM on PubMed (see "For
More Information").
7. Does the
government regulate chiropractic?
Chiropractic
practice is regulated individually by each state and
the District of Columbia. Most states require
chiropractors to earn continuing education credits
to maintain their licenses.1,13
Chiropractors' scope of practice varies by
state--including with regard to laboratory tests or
diagnostic procedures, the dispensing or selling of
dietary supplements, and the use of other CAM
therapies such as acupuncture or homeopathy.13,14,23
Chiropractors are not licensed in any state to
perform major surgery or prescribe drugs.b
bIn Oregon, chiropractors can become certified
to perform minor surgery (such as stitching cuts)
and to deliver children by natural childbirth.14,23,24
8. Do health
insurance plans pay for chiropractic treatment?
Compared with CAM
therapies as a whole (few of which are reimbursed),
coverage of chiropractic by insurance plans is
extensive. As of 2002, more than 50 percent of
health maintenance organizations (HMOs), more than
75 percent of private health care plans, and all
state workers' compensation systems covered
chiropractic treatment.1
Chiropractors can bill Medicare, and over two dozen
states cover chiropractic treatment under Medicaid.23
If you have health
insurance, check whether chiropractic care is
covered before you seek treatment. Your plan may
require care to be approved in advance, limit the
number of visits covered, and/or require that you
use chiropractors within its network
9. What has
scientific research found out about whether
chiropractic works for low-back pain?
For this report,
the results of individual clinical
trials and reviews of groups of clinical trials
were examined. Sources were drawn from the National
Library of Medicine's PubMed database; were
published in English; and studied chiropractic
techniques that were identified as such (e.g.,
"chiropractic manipulation") rather than some other
forms of "manipulation" or "spinal manipulation
therapy"--which, as noted above, may be delivered by
certain other health care providers.c
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Clinical Trials
A clinical
trial is a research study in which a
treatment or therapy is tested in people to
see whether it is safe and effective.
Clinical trials are a key part of the
process in finding out which treatments
work, which do not, and why. Clinical trial
results also contribute new knowledge about
diseases and medical conditions.
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So far, the
scientific research on chiropractic and low-back
pain has focused on if, and how well, chiropractic
care helps in relieving pain and other symptoms that
people have with low-back pain. This research often
compares chiropractic to other treatments.
Research studies
Appendix I gives detailed
findings from seven controlled
clinical trials and one prospective
observational study of
chiropractic treatment for low-back pain published
between January 1994 and June 2003.
Summary of the
research findings
The studies all found at least some benefit to the
participants from chiropractic treatment. However,
in six of the eight studies, chiropractic and
conventional treatments were found to be similar in
effectiveness.22,25-29
One trial found greater improvement in the
chiropractic group than in groups receiving either
sham manipulation or back
school.30. Another
trial found treatment at a chiropractic clinic to be
more effective than outpatient hospital treatment.31
General
reviews, systematic reviews, and meta-analyses
Appendix II lists three reviews
of clinical trials on chiropractic treatment for
back pain, published between October 1996 and June
2003.
Summary of the
research findings
Overall, the evidence was seen as weak and less than
convincing for the effectiveness of chiropractic for
back pain. Specifically, the 1996
systematic review reported that there were major
quality problems in the studies analyzed; for
example, statistics could not be effectively
combined because of missing and poor-quality data.
The review concludes that the data "did not provide
convincing evidence for the effectiveness of
chiropractic."32 The
2003 general review states that
since the 1996 systematic review, emerging trial
data "have not tended to be encouraging…. The
effectiveness of chiropractic spinal manipulation
for back pain is thus at best uncertain."33
The 2003 meta-analysis found
spinal manipulation to be more effective than sham
therapy but no more or no less effective than other
treatments.10
Several other
points are helpful to keep in mind about the
research findings. Many clinical trials of
chiropractic analyze the effects of chiropractic
manipulation alone, but chiropractic practice
includes more than manipulation (see
Question 5).34
Results of a trial performed in one setting (such as
a managed care organization or a chiropractic
college) may not completely apply in other settings.29,35
And, researchers have observed that the
placebo effect may be at work
in chiropractic care,34
as in other forms of health care.
cThis fact sheet often uses the term
"adjustment" to refer to chiropractic manipulation.
In Question 9 and
Appendices I and II,
"manipulation" is used where it is used in the
source(s) on chiropractic being discussed.
10. Are there
scientific controversies associated with
chiropractic?
Yes, there are
scientific controversies about chiropractic, both
inside and outside the profession. For example,
within the profession, there have been disagreements
about the use of physical therapy techniques, which
techniques are most appropriate for certain
conditions, and the concept of subluxations. Outside
views have questioned the effectiveness of
chiropractic treatments, their scientific basis, and
the potential risks in subsets of patients (for
example, the risks of certain types of adjustments
to patients with osteoporosis
or risk factors for osteoporosis, compared to
patients with healthier bone structures33,36).
Research studies on
chiropractic are ongoing. The results are expected
to expand scientific understanding of chiropractic.
A key area of research is the basic science of what
happens in the body (including its cells and nerves)
when specific chiropractic treatments are given.
11. Is NCCAM
funding research on chiropractic?
Yes. For example,
recent projects supported by NCCAM include:
- Comparing
conventional medical care for acute back pain
with an "expanded benefits" package (consisting
of conventional care plus a choice of
chiropractic, massage, or acupuncture)
- Finding out
what happens (through measurement) in the lumbar
portion of the spine after chiropractic
positioning and adjustment
- Evaluating the
effects of the speed of spinal adjustment on
muscles and nerves
- Studying the
effectiveness of chiropractic adjustment for a
variety of conditions, including neck pain,
chronic pelvic pain, and temporomandibular
disorders (TMD) in the jaw.
Definitions
Acupuncture: A health care practice that
originated in traditional Chinese medicine.
Acupuncture involves inserting needles at specific
points on the body, in the belief that this will
help improve the flow of the body's energy (or qi,
pronounced "chee") and thereby help the body achieve
and maintain health.
Acute pain:
Pain that has lasted a short time (e.g., less than 3
weeks) or is severe.
Alternative
medical system: A medical system built upon
a complete system of theory and practice; these
systems have often evolved apart from and earlier
than the conventional medical approach used in the
United States. An example from a Western culture is
naturopathic medicine; from a non-Western culture,
traditional Chinese medicine.
Bonesetter:
A health care practitioner (not necessarily a
licensed physician) whose occupation is setting
fractured or dislocated bones.
Cauda
equina syndrome: A syndrome that occurs
when the nerves of the cauda equina (a bundle of
spinal nerves extending beyond the end of the spinal
cord) are compressed and damaged. Symptoms include
leg weakness; loss of bowel, bladder, and/or sexual
functions; and changes in sensation around the
rectum or genitalia.
Chronic
pain: Pain that has lasted a long time
(more than 3 months).
Clinical
trial: A clinical trial is a research study
in which a treatment or therapy is tested in people
to see whether it is safe and effective. Clinical
trials are a key part of the process in finding out
which treatments work, which do not, and why.
Clinical trial results also contribute new knowledge
about diseases and medical conditions.
Complication: A secondary disease or
condition that develops in the course of a primary
disease or condition, or as the result of a
treatment.
Controlled
clinical trial: A clinical study that
includes a comparison (control) group. The
comparison group receives a placebo, another
treatment, or no treatment at all.
General
review: An analysis in which information
from various studies is summarized and evaluated;
conclusions are made based on this evidence.
Hippocrates: A Greek physician born in 460
B.C. who became known as the founder of Western
medicine.
Homeopathy:
Also known as homeopathic medicine. It is an
alternative medical system that was invented in
Germany. In homeopathic treatment, there is a belief
that "like cures like," meaning that small, highly
diluted quantities of medicinal substances are given
to cure symptoms, when the same substances given at
higher or more concentrated doses would actually
cause those symptoms.
Manipulation: Passive joint movement beyond
the normal range of motion. The term adjustment is
preferred in chiropractic.
Massage:
A therapy in which muscle and connective tissue are
manipulated to enhance function of those tissues and
promote relaxation and well-being.
Meta-analysis: A type of research review
that uses statistical techniques to analyze results
from a collection of individual studies.
Mobilization: A technique, used by
chiropractors and other health care professionals,
in which a joint is passively moved within its
normal range of motion.
Myofascial
therapy: A type of physical therapy that
uses stretches and massage.
Naturopathic medicine: Also known as
naturopathy. It is an alternative medical system in
which practitioners work with natural healing forces
within the body, with a goal of helping the body
heal from disease and attain better health.
Practices may include dietary modifications,
massage, exercise, acupuncture, minor surgery, and
various other interventions.
Observational study: A type of study in
which individuals are observed or certain outcomes
are measured. No attempt is made to affect the
outcome (for example, no treatment is given).
Orthopedist: Doctor of Medicine (M.D.) who
is a surgeon specializing in disorders of the
musculoskeletal system.
Osteopathic
medicine: Also known as osteopathy. It is a
form of conventional medicine that, in part,
emphasizes diseases arising in the musculoskeletal
system. There is an underlying belief that all of
the body's systems work together, and disturbances
in one system may affect function elsewhere in the
body. Most osteopathic physicians practice
osteopathic manipulation, a full-body system of
hands-on techniques to alleviate pain, restore
function, and promote health and well-being.
Osteoporosis: A reduction in the amount of
bone mass, which can lead to breaking a bone after a
minor injury, such as a fall.
Placebo:
Resembles a treatment being studied in a clinical
trial, except that the placebo is inactive. One
example is a sugar pill. By giving one group of
participants a placebo and the other group the
active treatment, the researchers can compare how
the two groups respond and get a truer picture of
the active treatment's effects. In recent years, the
definition of placebo has been expanded to include
other things that could affect the results of health
care, such as how a patient feels about receiving
the care and what she expects to happen from it.
Prospective
study: A type of research study in which
participants are followed over time for the
effect(s) of a health care treatment.
Randomized
clinical trial: A study in which the
participants are assigned by chance to separate
groups that compare different treatments; neither
the researchers nor the participants can choose
which group. Using chance to assign people to groups
means that the groups will be similar and that the
treatments they receive can be compared objectively.
At the time of the trial, it is not known which
treatment is best. It is the patient's choice to be
in a randomized trial.
Review:
See general review, systematic review, or
meta-analysis.
Sham:
A treatment or device that is a type of placebo. An
example would be positioning the patient's body and
placing the chiropractor's hands in a way that
mimics an actual treatment, but is not a treatment.
Subacute
pain: Pain that has lasted somewhat longer
than acute pain (for example, more than a few days
or weeks) but is not yet chronic pain.
Systematic
review: A type of research review in which
data from a set of studies on a particular question
or topic are collected, analyzed, and critically
reviewed.
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