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Frequently Asked Questions (FAQ)


  1. What is Spinal Manipulation?
  2. Is Chiropractic Manipulation a Safe Procedure?
  3. What are the Contraindications for Chiropractic Spinal Manipulation?
  4. Do Chiropractors Treat Organic Disorders?
  5. Do Chiropractors Ever Release Their Patients?
  6. Neck Pain and Manipulation: Results of Prospective Randomized Controlled Trials
  7. Chiropractic Manipulation, PMS & Dysmenorrhea
  8. Chiropractic and Headaches of Cervical Origin
  9. Whiplash Associated Disorders & Chiropractic

1. What is Spinal Manipulation?


INTRODUCTION

Spinal manipulation is an ancient healing art practiced by a wide variety of cultures.  The earliest known recorded reference to spinal manipulation is found in a Chinese document dated to approximately 2700 BC(1).

But what exactly is spinal manipulation?

Indeed, there is much confusion regarding the term spinal manipulation.  The term has been used to connote anything from the gentle stroking of the paraspinal soft tissues all the way up to a "gross assault" upon the articulations of an unconscious patient(2).  Medical manipulators Bourdillon, Day and Bookhout state, "There is still disagreement as to the breadth of the meaning of the word manipulation.  In Europe the term is used, in this context, almost solely for procedures involving a high velocity, low amplitude, thrusting movement.  In North America it is used in a much wider sense, to include any active or passive movement initiated, assisted or resisted by the operator.  This includes treatments sometimes listed as articulation, mobilisation, isometric and isotonic techniques, myofascial, functional or indirect and even craniosacral techniques(3)."



SPECIFIC DESCRIPTIONS

Doctors of chiropractic utilize a wide variety of methods to induce controlled, forced movements of spinal joints in the treatment of the neuromusculoskeletal dysfunction syndromes with which their patients present.  Although using many different methods, the high velocity, short amplitude thrust, referred to above, is the method of manipulation most commonly used by doctors of chiropractic.  Two specific descriptions of the controlled, high velocity, short amplitude thrust have been proposed by chiropractors and physiotherapists.  These descriptions are presented below.

Paraphysiologic Joint Space Manipulation

Chiropractic manipulators Haldeman(4) and Kirkaldy-Willis and Cassidy(5) have described a model of the high velocity, short amplitude thrusting movements used by chiropractors which they refer to as the paraphysiologic joint space manipulation.  In this model of synovial joint manipulation three ranges of motion are discussed-the active range of motion, the passive range of motion, and the paraphysiologic range of motion of the involved joint(s).

The active range of motion is defined as that range in which the muscles acting over the joint can produce movement.  The passive range of motion is that range through which the joints can be moved by an external force acting on the joints.

For example, using the intrinsic muscles of your forearm and hand flex and extend your right index finger maximally.  This action would induce the maximum active range of motion of your right first metacarpophalangeal joint.  Next, extend your right first metacarpophalangeal joint maximally.  Then, with your left hand gently force your right index finger further into extension.  The additional extension you are able to induce beyond the active maximal extension of your right first metacarpophalangeal joint is the additional passive range of motion allowed by the joint tendons and ligaments.

The paraphysiological range of motion is the small amount of additional movement that may be passively forced beyond the maximal passive range of motion, but just short of the limits of the anatomical integrity of the joint (i.e. just before the joint would become dislocated).

Kirkaldy-Willis and Cassidy state: "At the end of the passive range of motion an elastic barrier of resistance is encountered.  This barrier has a spring-like end-feel which is the result of a negative subatmospheric intra-articular pressure.  This negative pressure is a stabilizing factor in the coaptation of the articular surfaces.  If the separation of the articular surfaces is forced beyond this elastic barrier, the joint surfaces suddenly move apart with a cracking noise.  This additional separation can only be achieved after cracking the joint.  This has been labeled the paraphysiological range of motion.  This constitutes a manipulation(5)."

A graphic representation of these three ranges of motion are presented in Figure 1.

image002.gif

Figure 1.  A graphic representation of the active, passive, and paraphysiological ranges of motion of a synovial joint.

Graded Mobilizations

Another model of controlled, forced, passive movements of synovial joints is presented by Saunders(6).Saunders, a medical physiotherapist, discusses the idea of graded mobilizations of synovial joints ranging from gentle movements performed within the beginning of the range of motion of a joint up to forced, controlled movements that take the joint in question to the limit of anatomical integrity (Figure 2).  The movements are graded as follows:

  • Grade 1-gentle movements of small amplitude done at the beginning of the available range of motion of the joint
  • Grade 2-gentle movements of large amplitude done into the available midrange of motion of the joint
  • Grade 3-moderate movements of large amplitude done through the available range of motion of the joint and extending into any restriction of movement
  • Grade 4-oscillating movements of small amplitude done at the end of the available range of the motion of the joint and into any restriction of movement
  • Grade 5-high velocity, short amplitude thrusting movements performed up to the anatomic limits of the joint
  • It should be obvious to the reader that a Grade 5 mobilization is equivalent to the paraphysiological joint space manipulation described above.

image004.gif

Figure 2.  Graphic representation of graded mobilizations of a synovial joint.


WHY DO CHIROPRACTORS MANIPULATE JOINTS?

Prolonged rest and/or immobilization have been shown to cause a variety of adverse biomechanical and biochemical changes in injured joint tissues.  In regards to these adverse effects, medical orthopedist Cyriax states, "When non-bacterial inflammation attacks the soft tissues that move, treatment by rest has been found to result in chronic disability later, although the symptoms may temporarily diminish.  Hence, during the past century, treatment by rest has given way to therapeutic movement in many soft tissue lesions.  Movement may be applied in various ways:  the three main categories are, 1) active and resistive exercises;  2) passive, especially forced movement; and  3) deep massage (7)."

Doctors of chiropractic have always advocated therapeutic movement as a means to limit these adverse effects and to promote health.  Although practicing for many years without research to validate what chiropractors believed to be true, recent research has been accumulating that confirms the clinical effectiveness of chiropractic manipulation.

For example, the recent clinical practice guidelines for acute low back problems in adults published by the Agency for Health Care Policy and Research (AHCPR), a division of the U.S. Department of Health and Human Services state that:  "Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation(8)."  The AHCPR recommendations for treatment for acute low back problems were made after an exhaustive review of over 350 scientific articles on the subject of low back pain.  Among the 350+ articles were over 37 randomized controlled trials of spinal manipulation for low back pain.


CONCLUSION

The purpose of this brief article was simply to provide a physiologic explanation of the mechanics of chiropractic spinal manipulation.  The two models discussed were the paraphysiological joint space manipulation and the model of graded mobilizations.

A minimal explanation was provided regarding the rationale as to why manipulation is beneficial for specific types of neuromusculoskeletal lesions to, hopefully, stimulate interest in related subjects.  In other parts of this website, you will find topics related to the clinical effectiveness of chiropractic manual methods, cost-effectiveness, safety, patient satisfaction with doctors of chiropractic and their methods, indications and contraindications for chiropractic manipulative therapy, and physiologic mechanisms of manipulation.  I believe you will find the information interesting.

REFERENCES

1. Breasted JH.The Edwin Smith surgical papyrus. Vol. I.Chicago:Univ. of Chicago Press.1930.

2. Mennel JM.History of the development of medical manipulative concepts;medical terminology.In:The research status of spinal manipulative therapy.Washington, DC:U.S. Dept. of Health, Education, and Welfare.NINCDS Monograph No. 15.1976.

3. Bourdillon JF, Day EA, Bookhout MR. Spinal manipulation. Oxford:Butterworth-Heinemann Ltd.1992.

4. Haldeman S.Modern developments in the principles and practice of chiropractic.New York:Churchill Livingstone1980.

5. Kirkaldy-Willis WH, Cassidy JD.Spinal manipulation the treatment of low back pain.Can Fam Physician1985;31:535-540.

6. Suanders HD.Evaluation, treatment and prevention of musculoskeletal disorders.Minneapolis:Viking1988.

7. Cyriax J.Orthopaedic medicine, diagnosis of soft tissue lesions (Vol I).London:Bailliere Tindall1982.

8. Bigos S, Bowyer O, Braen G, et al.Acute low back problems in adults.Clinical practice guideline no. 14.AHCPR Publication No. 95-0624.Rockville, MD:Agency for Health Policy and research, Public Health Service, U.S. Department of Health and Human Services.December 1994.

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2. Is Chiropractic Manipulation A Safe Procedure?


INTRODUCTION

A commonly held notion by medical physicians and uninformed lay persons is the idea that chiropractic manipulation is an unsafe procedure seriously injuring or killing hundreds or perhaps thousands of unsuspecting individuals every year.  Much of the misinformation that continues to exist regarding the safety of chiropractic manipulation stems from a well orchestrated campaign against the chiropractic profession by the American Medical Association's "Committee on Quackery."

According to AMA records, the Committee on Quackery was established by the AMA in 1963 with its sole mission to destroy the profession of chiropractic as a competitor in the health care market(1,2).  As part of their illegal campaign, the AMA commissioned and distributed the text, At Your Own Risk:The Case Against Chiropractic, a book written by journalist Ralph Lee Smith.  In his text Smith portrayed the chiropractic profession in an extremely unfavorable light and further implied that chiropractic manipulation was an unsafe treatment often resulting in serious injury(3).  Smith's book was distributed by the AMA to over 1,000 of the nation's largest libraries(1).

In 1987, the federal court system found the AMA guilty of violating federal antitrust laws in its campaign against the profession of chiropractic and was forced to pay damages and abandon its overt attacks against the profession(1,2).  Unfortunately, myths, legends, and lies die hard and residual effects continue to linger.  Perhaps one of the greatest injustices of the AMA's illegal tactics is that today, patients continue to be discouraged from seeking chiropractic services by primary care physicians due to the misinformation pedaled as "truth" in the early 1960s.  This makes you, a patient, as much a victim of the illegal actions of the AMA as any chiropractor or a prospective patient with a condition amenable to chiropractic treatment.

But, what is the truth?  Is chiropractic manipulation safe?  How does chiropractic manipulation compare in terms of safety to standard medical treatments used to deal with patients with similar conditions or complaints?  Below, evidence from the scientific literature will be presented that will shed light on this topic.


RISKS OF SPINAL MANIPULATION

                Vick et al. (4) performed a retrospective review of the English language medical literature over a 68-yr period from 1926 to 1993.  They discovered a total of 128 articles from fifteen different countries which reported injuries as a result of spinal manipulation. From these sources a total of 185 specific serious complications were reported from manipulation of the cervical, thoracic, or lumbar spine. The breakdown of the type and number of injuries reported as a result of this review is as follows:  cerebrovascular accident-123, disc herniation-23, bone fracture/dislocation-14, neural encroachment-12, general increase in pain-6, complication of undiagnosed tumor-3, cardiac arrest-1, tracheal rupture-1, abdominal aorta rupture-1, unreported injury-1.

Regarding these injuries, Vick et al. state, "Of the estimated several hundred million manipulative treatments performed each year, only 185 reports of injury were found in the published literature during the past 68 years.  Comparing these figures with the incidence of adverse effects (including death) associated with many pharmaceutical agents, manipulative treatment remains an extremely safe, therapeutic modality when performed by a knowledgeable and skilled practitioner(4)."

The 123 reported cerebrovascular accidents may lead one to conclude that manipulation of the cervical spine is a particularly risky procedure.  However, when placed in the proper context in relation to other health care interventions for patients with cervical spine conditions, it becomes readily apparent that cervical spine manipulation is a safe procedure when provided by a skilled practitioner.

A recent article authored in 1996 by Dabbs and Lauretti (5)compared the risks of serious complications or death for patients receiving a course of manipulative treatment or nonsteroidal anti-inflammatory drugs for the treatment of neck pain.  As a result of their review of the scientific literature on the subject the authors stated, "  . . . the best available data suggests that the risk of serious neurovascular complication from cervical manipulation is approximately one incident per 100,000 patients receiving a course of treatment per yr, or 0.00025%.  The risk of serious gastrointestinal complication requiring hospitalization because of NSAID use for similar conditions (i.e., a diagnosis of osteoarthritis [OA]) is 0.4% per year.  The risk of death from hemorrhage or ulcer perforation attributable to NSAID use for OA is 0.04%.  Therefore, based on the best available evidence, we calculate the risk of serious complications or death is 100-400 times greater for the use of NSAIDs than for the use of cervical manipulation in the treatment of similar conditions."(5, emphasis added)

In addition an article published in the medical journal Spine compares the risks for cervical spine manipulations, use of NSAIDs, and cervical spine surgery (6).  Hurwitz et al. (6) report an average risk of vertebrobasilar accident, major impairment or death as 7.5 per 10,000,000 manipulations.  They further report an average incidence rate of serious gastrointestinal event (bleeding, perforation, or other adverse event resulting in hospitalization or death) from the use of NSAIDs as 1 per 1000 subjects.  And finally, they report an average incidence rate of neurologic complication or death from cervical spine surgeries as 11.25 per 1000.

Although anyone would agree that even one tragic event is one too many, when placed in the proper context it becomes readily apparent that cervical spine manipulation is an extremely safe procedure when applied by appropriately trained professionals.

In-so-far as manipulation of the lumbar spine is concerned, the cauda equina syndrome would be the most serious complication that could potentially result.  Shekelle (7), a researcher with the prestigious Rand Corporation, reports, ". . . we used the available data from case reports on the number of complications and from our epidemiologic study on the use of chiropractic services to estimate the number of lumbar spinal manipulations received during a time period covered by the case reports.  Then, we estimated that the rate of occurrence of the cauda equina syndrome as a complication of lumbar spinal manipulation is about one case per 100 million manipulations(7)."



CONCLUSION

The safety issue of spinal manipulation can really be shown to be a "non-issue" when emotional embellishment and negative rhetoric give way to scientific fact.  Armed with this knowledge primary care physicians should be able to more accurately advise their patients who may wish to consult with a doctor of chiropractic for treatment of their ailments.

Finally, because chiropractic manipulation has been shown to be clinically effective (8,9-14), cost-effective (10,11,13-15), and safe (4-7,16,17), with high levels of patient satisfaction (9,12,16-18), it seems logical that a clinical trial of chiropractic treatment should perhaps be the standard of care for patients with conditions known to be responsive to such interventions.

REFERENCES

1. Wolinsky H, brune T.The serpent on the staff.New York:GP Putnam's Sons 1994.

2. Wardwell WI.Chiropractic:History and evolution of a new profession.St. Louis:Mosby Year Book1992.

3. Smith RL.At your own risk:The case against chiropractic.New York:Pocket Books1969.

4. Vick DA, McKay C, Zengerle CR.The safety of manipulative treatment:review of the literature from 1925 to 1993.JAOA1996;96:113-115.

5. Dabbs V, Lauretti WJ. Risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain.J Manip Physiol Ther1995;18:530-536.

6. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG.Manipulation and mobilization of the cervical spine:A systematic review of the literature.Spine1996;21:1746-1760.

7. Shekelle PG.Spine update:spinal manipulation.Spine1994;19:858-861.

8. Bigos S, Bowyer O, Braen G, et al.Acute low back problems in adults.Clinical practice guideline No. 14.AHCPR Publication No. 95-0642.Rockville, MD:Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.December 1994.

9. Meade TW, Dyer S, Browne W, Townsend J, Frank AO.Low back pain of mechanical origin:Randomised comparisons of chiropractic and hospital outpatient treatment.Br Med J1990;300:1431-1437.

10. Wolf C.Industrial back injury.Int Rev Chiro1974;26:6-7.

11. Wolk S.An analysis of Florida workers' compensation medical claims for back -related injuries.J Am Chiro Assoc1974;25:50-59.

12. Kane R, Olsen D, Leymaster C, Woolley F, Fisher F.Manipulating the patent, a comparison of the effectiveness of physician and chiropractic care.Lancet1974;1:1333-1336.

13. Johnson M, Schultz M, Ferguson A.A comparison of chiropractic, medical and osteopathic care for work-related sprains and strains. J Manipulative Physiol Ther1989;12:335-344.

14. Ebrall PS.Mechanical low-back pain:A comparison of medical and chiropractic management within the Victorian workcare scheme.Chiro J Australia1992;22:47-53.

15. Jarvis KB, Phillips RB, Morris EK.Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes.J Occupational Med1991;33:847-852.

16. Manga P.The effectiveness and cost effectiveness of chiropractic management of low-back pain.Ottawa, Ontario, Canada: Ontario Ministry of Health1993.

17. Commission of Inquiry into Chiropractic.Chiropractic in New Zealand.Wellington, New Zealand:Government Printer1979.

18. Cherkin D, MacCornack F, Berg A.Managing low back pain-A comparison of the beliefs and behaviors of family physicians and chiropractors.West J Med.1988;149:475-480.

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3.What are the contraindications for chiropractic spinal manipulation?


INTRODUCTION

Spinal pain syndromes are one of the most prevalent health care challenges in North America (1,2).  For working adults, low back pain is the most common ailment causing disability for men and women under 45 years of age (1).  On any given day, up to 2 percent of the U.S. population is disabled by low back pain, half of these victims are chronically disabled and half are temporarily disabled by their symptoms (3).

Recently, neck pain has been shown to be a significant factor causing disability in the adult population.  Up to 4.6% of the population may report neck pain of significant intensity that it, ". . . significantly restricts their activities of daily living (2)."

The costs of this health care epidemic are enormous.  Diagnostic and treatment costs, loss of time from work, and disability payments account for the up to $20-$50 billion annual estimated expense of dealing with low back problems alone in the U.S. (4)

Treatment for pain syndromes of spinal origin is controversial.  Little consensus exists among clinicians as to the best forms of treatment.  This is evidenced by the highly variable rates of surgery and hospitalization in different regions of the United States (5-7).

Recent guidelines published by the Agency for Health Care Policy and Research (AHCPR), a division of the U.S. Department of Health and Human Services, indicate that for acute low back problems (defined as low back or low back and back-related leg symptoms of less than three months duration), "Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation (8)."  Further, the AHCPR guidelines state that, "Within the first 3 months of low back symptoms, only patients with evidence of serious spinal pathology or severe, debilitating symptoms of sciatica, and physiologic evidence of specific nerve root compromise corroborated on imaging studies can be expected to benefit from surgery (8)."

In addition, the Quebec Task Force on whiplash-associated disorders has determined that, based upon the best available scientific evidence, manipulation and mobilization performed by trained persons, exercise, and the use of non-steroidal anti-inflammatory drugs are the most appropriate treatment for non-surgical cases of neck pain secondary to automobile accidents (9).

These findings suggest that the vast majority of patients with acute low back problems and/or neck pain may be managed appropriately within the domain of chiropractic treatment paradigms.



Table 1.  Relative and/or Absolute Contraindications to Spinal Manipulative Therapy

Articular derangements
  • Arthritides
  • Acute arthritis of any type
  • Rheumatoid arthritis
  • Acute anklyosing spondylitis
  • Cervical spondylosis with vertebrobasilar ischemia
  • Dislocation
  • Hypermobility
  • Ruptured ligaments
  • Bone weakening and destructive disease
    • Calve's disease
    • Fracture
    • Malignancy
    • Osteomalacia
    • Osteoporosis
    • Osteomyelitis
    • Tuberculosis (Pott's disease)
  • Circulatory disturbances
    • Aneurysm
    • Anticoagulant therapy
    • Vertebrobasilar insufficiency
    • Vertebral artery disease
  • Disc lesions with serious neurologic changes
  • Neurologic dysfunction
    • Cauda equina syndrome
    • Upper motor neuron lesion
  • Unclassified
    • Infectious disease
    • Psychologic intolerances

Adapted from Haldeman S. Modern Developments in the Principles & Practice of Chiropractic. New York: Appleton & Lange, 1980: 380-381.

But, chiropractic manual methods have relative and absolute contraindications for their use.  If a medical practitioner intends to recommend chiropractic treatment to a patient, then he/she must be confident that the chiropractic professional to which they might refer a patient is well acquainted with the relative and absolute contraindications to their particular method of treatment.  Fortunately, chiropractic education emphasizes this knowledge and standard teaching and reference texts discuss this topic in depth.


KNOWN CONTRAINDICATIONS

Table 1 lists the factors identified as relative and/or absolute contraindications to spinal manipulative therapy(10).  These factors can be divided into broad categories designated as articular derangements, bone weakening and destroying diseases, circulatory disturbances, disc lesions, neurologic dysfunction, and unclassified factors.

Although these factors have been identified as contraindicators for spinal manipulative therapy, the presence of any one factor in one area of the spine does not preclude the use of spinal manipulative therapy in other areas.  For example, Gatterman states, "Although hypermobility may be a relative contraindication to manipulation in one area of the spine, for example, it may be compensatory to movement restriction in another area where manipulation is the treatment of choice.  The patient who has suffered a "whiplash" injury frequently exhibits restricted motion in the upper cervical articulations, while stretching of the ligaments at the apex of the cervical curve in the midcervical spine has allowed the joints in this area to become hypermobile.  Specific short-lever manipulation to the upper cervical joint with restricted motion permits the stretched ligaments in the midcervical region to heal, but manipulation of the medcervical segments is contraindicated (11)."

Forceful manipulations may be contraindicated because of one or more factors presented in Table 1.  Less forceful procedures, however, may still be used (11).  For these reasons, the chiropractic physician must be keenly aware of the patient's medical history, so that he may adapt his technique as necessary to accommodate the patient's individual needs.

Table 2.  Standards governing clinical decisions in the application of spinal manipulative therapy.
  • Long-term anticoagulant therapy warrants caution when applying forceful spinal manipulative therapy.
  • Bone weakened by neoplasm is an absolute contraindication to forceful manipulation.
  • The presence of inflammatory joint disease is a relative contraindication to chiropractic manipulation of the affected articulation.
  • In systemic arthritides (eg, rheumatoid arthritis), an atlantoodontoid interspace greater than 5mm in children or 3mm in adults as determined by flexion radiograph precludes cervical manipulation.
  • Forceful manipulation of patients showing evidence of bone thinning is contraindicated in the adjacent joints.
  • Hypermobile and unstable vertebral motion units represent an absolute contraindication to forceful, nonspecific manipulation.
  • Emergency decompressive surgery is required in all patients who show signs of cauda equina syndrome.  Prompt referral of these patents, as of any patent showing advancing neurological deficits, is imperative.
  • Aneurysm involving a major blood vessel is an absolute contraindication to manipulation.
  • The physician must avoid techniques known to be hazardous, such as excessive rotation in the cervical spine or use of the knee-chest position for patients who are unable to relax in this posture or who have spondylolisthesis and hyperlordosis.
Source:  Adapted from Chiropractic Standards of Practice and Quality of Care (pp221-238) by HJ Vear, ed, Aspen Publishers, Inc, © 1992.

Table 2 lists general standards governing clinical decision making regarding spinal manipulative therapy.


CONCLUSION

In general, the vast majority of low back and neck pain patients can be managed with conservative treatment.  However, no form of treatment is suitable for every patient, and respect for the relative and absolute contraindications to chiropractic manipulation must be observed if chiropractic treatment is to be applied in a manner that is satisfactory for all concerned parties.

Because chiropractic manipulation has been shown to be clinically efficacious (8,12,13-17), cost-effective (13,14,16-18), and safe (8,19,20), with high levels of patient satisfaction (12,15,19-21), it seems logical that a clinical trial of chiropractic treatment is a logical alternative for patients with low back pain or neck pain of mechanical origin.


REFERENCES

1. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health 1983; 73: 389-395.

2. Cote P, Cassidy JD, Carroll L.The Saskatchewan health and back pain survey: the prevalence of neck pain and related disability in Saskatchewan adults.Spine 1998;23:1689-1698.

3. Andersson GBJ.The epidemiology of spinal disorders.In:Frymoyer JW, ed.The adult spine:principles and practice.New York:Raven Press, Ltd.1991:107-146.

4. Nachemson AL.Newest knowledge of low back pain.A critical look.Clin Orthop1992;279:8-20.

5. Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis:low back pain and the health of the public.Annu Rev Public Health1991;12:141-156.

6. Keller RB, Soule DN, Wennberg JE, Hanley DF.Dealing with geographic variations in the use of hospitals:The experience of the Maine medical assessment foundation orthopaedic study group.J Bone Joint Surg1990;72A:1286-1293.

7. Volinn E, Mayer J, Diehr P, Van Koevering D, Connell FA, Loeser JD.Small area analysis of surgery for low-back pain.Spine 1992;17:575-81.

8. Bigos S, Bowyer O, Braen G, et al.Acute low back problems in adults.Clinical practice guideline No. 14.AHCPR Publication No. 95-0642.Rockville, MD:Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.December 1994.

9. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec Task Force on whiplash-associated disorders:redefining "whiplash" and its management. Spine 1995;20(8S):10S-73S.

10. Kleynhans A.Complications of and contraindications to spinal manipulative therapy.In:Haldeman S, ed. Modern developments in the principles and practice of chiropractic.New York:Appleton & Lange, 1980:359-84.

11. Gatterman M.Standards for contraindications to spinal manipulative therapy.In:Vear HJ, ed. Chiropractic standards of practice and quality of care.Gaithersburg, MD:Aspen Publishers, Inc, 1992:221-38.

12. Meade TW, Dyer S, Browne W, Townsend J, Frank AO.Low back pain of mechanical origin:Randomised comparisons of chiropractic and hospital outpatient treatment.Br Med J1990;300:1431-1437.

13. Wolf C.Industrial back injury.Int Rev Chiro1974;26:6-7.

14. Wolk S.An analysis of Florida workers' compensation medical claims for back -related injuries.J Am Chiro Assoc1974;25:50-59.

15. Kane R, Olsen D, Leymaster C, Woolley F, Fisher F.Manipulating the patient, a comparison of the effectiveness of physician and chiropractic care.Lancet1974;1:1333-1336.

16. Johnson M, Schultz M, Ferguson A.A comparison of chiropractic, medical and osteopathic care for work-related sprains and strains.J Manipulative Physiol Ther1989;12:335-344.

17. Ebrall PS.Mechanical low-back pain:A comparison of medical and chiropractic management within the Victorian workcare scheme.Chiro J Australia1992;22:47-53.

18. Jarvis KB, Phillips RB, Morris EK.Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes.J Occupational Med1991;33:847-852.

19. Manga P.The effectiveness and cost effectiveness of chiropractic management of low-back pain.Ottawa, Ontario, Canada: Ontario Ministry of Health1993.

20. Commission of Inquiry into Chiropractic.Chiropractic in New Zealand.Wellington, New Zealand:Government Printer1979.

21. Cherkin D, MacCornack F, Berg A.Managing low back pain-A comparison of the beliefs and behaviors of family physicians and chiropractors.West J Med.1988;149:475-480.

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4. Do Chiropractors Treat Organic Disorders?


INTRODUCTION

The genesis of the chiropractic profession is reported to have occurred when a self-taught healer of the late 19th century, Daniel David Palmer, manually manipulated the upper dorsal spine of a partially deaf janitor, restoring his sense of hearing (1).  As a result of this event and other apparent "cures" or remissions of a wide variety of disease states by patients under the care of chiropractors, many early practitioners of this form of manual medicine made overly-zealous claims about the effects their treatments might have on human physiology (2).

Recently, an article in the New England Journal of Medicine which looked at the potential effects of chiropractic spinal manipulation on children with mild or moderate asthma (3) has rekindled discussions about what clinical conditions chiropractors think they can or cannot treat.

Do patients seek chiropractic treatment for organic diseases?  Do chiropractors treat organic disorders?  The answers to these questions may surprise you.



ORGANIC DISEASE AND MANUAL TREATMENT METHODS

Although on the surface it seems incredible that manual treatment methods may result in any improvement or cure of organic disorders, there are medical practitioners who have described the use of manual treatment methods for the management of many types of organic disorders.  Lewit, a practicing neurologist and advocate of manual treatment methods, has described his experimental and clinical experience using spinal manual therapy to treat conditions as varied as heart disease, digestive problems, dizziness, respiratory difficulties, migraine, gynecological disorders, tonsillitis, and other various human ailments (4).

Medical authors Bourdillon, Day, and Bookhout state, ". . . there is no doubt in the mind of at least one of the authors that dysfunction in the joints in the upper thoracic spine can affect the function of the inner ear, presumably by way of its sympathetic innervation (5)."

Kunert, a medical physician stated in a 1965 CIBA Symposium, ". . . lesions of the spinal column. . . are perfectly capable of simulating, accentuating or making a major contribution to organic diseases.  There can . . . be no doubt that the state of the spinal column does have a bearing on the functional status of the internal organs (6)."



THE COMMISSION OF INQUIRY INTO CHIROPRACTIC

Regarding the chiropractic profession and the treatment of organic disease, nearly twenty years ago this situation was addressed by a government commissioned study looking into the chiropractic profession.  The Commission of Inquiry into Chiropractic in New Zealand was an eighteen month government investigation into the profession of chiropractic and is considered to be the most in-depth dissection of the chiropractic profession to date.  In-so-far as the manual treatment of organic conditions is concerned (which the commission referred to as "Type O" disorders), the commission of inquiry found that essentially all practitioners of manual treatment methods (chiropractors, osteopaths, medical manipulators, physical therapists, and lay manipulators) can report improvement or cure in cases of organic disorders.  The Commission of Inquiry's published report states, "A number of medical experts told the Commission that the results chiropractors and their patients claimed in Type O (organic) cases were unlikely to be the results of spinal manual therapy. . . However, at the same time no medical expert was prepared to say that such results were impossible, simply because knowledge of neurophysiology had not advanced to a point where the possibility of such results from spinal manual therapy--however remote he might think they were--could positively be excluded." (7 pp. 57-58)

Due to the compelling neuroanatomic and anecdotal evidence presented, the commission concluded that such occurrences of improvement or cure in cases of organic disease by manual treatments were quite possible.  However, the commission also concluded that the results obtained by manual treatment methods in cases of visceral disease were so unpredictable that the patient should be under concurrent medical care.

It is also important to note that the New Zealand report clearly stated that chiropractors DO NOT treat organic disease, but rather, treat spinal column dysfunction.  To emphasize this point one may look again to the New Zealand report for an explanation:  "The chiropractor does not set out to cure or relieve a particular ailment.  What he sets out to do is to ensure that the spinal column is functioning normally.  If a particular ailment clears up or is relieved following therapy, so much the better.  If it does not, then at least the patient, now with no spinal impediment to the working of his nervous system, ought to be in a generally better condition and better able to cope with the ailment."(7 p. 57)

As a result of the testimony and evidence regarding chiropractic care and Type O disorders, the Commissioners of the New Zealand report came to several specific conclusions and recommendations.  The report states "If a patient with a Type O disorder wishes to consult a chiropractor in the hope that some relief can be obtained, there is no reason why he should not do so, provided there are no contraindications to spinal manual therapy, and provided he is encouraged to remain under medical care. . . Chiropractors should be careful to avoid giving any impression that spinal manual therapy will necessarily be beneficial to a patient with a Type O disorder.  In particular, chiropractors should in such cases do nothing which discourages a patient from remaining under medical care.  Ideally the chiropractor should regularly consult the patient's own doctor, although medical attitudes may rule that out as a realistic possibility."(2 p. 58.)

Responsible chiropractors treating patients with organic disease do so with these findings in mind.  Finding a chiropractor who subscribes to the above doctrine only requires asking the chiropractor's opinion on such matters.  His/her response will speak volumes regarding their individual practice philosophy.

The entire discussion presented above may be purely academic, however.  A recent article published in the American Journal of Public Health reported on the demographics of 1916 patients whose records were randomly selected from 131 chiropractic offices in five cities in North America (4 U.S., 1 Canadian).  Hurwitz et al. (8) reported that low back problems made up two-thirds of the patients treated by chiropractors, with headache, neck pain, and extremity problems making up almost all the rest.  Interestingly, only one percent of chiropractic patients had non-musculoskeletal diagnoses.



CONCLUSION

In the future, researchers may identify some types of organic disorders that may have a vertebrogenic etiology.  When and if this occurs, medical physicians and doctors of chiropractic will have a clearer map as to which organic entities might respond predictably to spinal manual therapies.  For the time being, however, improvement or cure in cases of organic disorders as a result of chiropractic treatment remains an unpredictable side effect of restoring mechanical integrity to patients' spines.


REFERENCES

1. Wardwell WI.Chiropractic:history and evolution of a new profession.St. Louis, Mo:Mosby-Year Book; 1992. pp55-7.

2. Armstrong D, Metzger-Armstrong E.The great American medicine show.New York, NY:Prentice Hall;1991. pp 149-158.

3. Balon JB, Aker PD, Crowther ER, et al.A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma.N Eng J Med 1998;339:1013-20.

4. Lewit K.Manipulative Therapy in Rehabilitation of the Motor System.Butterworth and Co., London & Boston, 1985.

5. Bourdillon JF, Day EA, Bookhout MR.Spinal Manipulation.Butterworth-Heinemann Ltd, Oxford, 1992.

6. Kunert W.Functional Disorders of Internal Organs due to Vertebral Lesions.CIBA Symposium, 1965;13(3):85-96.

7. Commission of Inquiry into Chiropractic.Chiropractic in New Zealand.Government Printer, Wellington, New Zealand, 1979.

8. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG.Use of chiropractic services from 1985 through 1991 in the United States and Canada.Am J Public Health1998;88:771-776.

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5. Do Chiropractors Ever Release Their Patients?



INTRODUCTION

Chiropractic treatment has been shown to be effective for a wide variety of musculoskeletal conditions of spinal origin(1,2,3).  Furthermore, chiropractic treatment has been shown to be safe (1-7) with high levels of patient satisfaction (6-10).  As a result of these facts, the use of doctors of chiropractic has doubled over a twenty year period (11).

In spite of these facts, many individuals still remain reluctant to visit a doctor of chiropractic due to the persistence of myths and misconceptions about the practice of chiropractic.  One myth is that chiropractors overtreat and promote dependence upon their healing methods, failing to terminate treatment when the patient's condition resolves or if their patients fail to improve with chiropractic treatment.

Do chiropractors overtreat their patients in an effort to promote dependence and turn patients into "chiropractic junkies?"



TREATMENT GUIDELINES

What constitutes appropriate, inappropriate, necessary, and unnecessary treatment are issues that confound and confuse practitioners of all methods of healing.  In the absence of randomized prospective clinical trials we are left with personal preference and local custom to make decisions regarding patient care.  Unfortunately, when it comes to valid scientific data, an article in the British Medical Journal states that only about 15% of all medical interventions are supported by solid scientific evidence, and many have never been investigated at all (12).

Such is not the case with spinal manipulation for the treatment of low back pain.  At least 37 randomized controlled trials exist for the treatment of low back pain by spinal manipulation (3), and four randomized trials exist for the treatment of neck pain by spinal manipulation (13-16).  Not coincidentally, neck and back pain patients make up almost 90% of all chiropractic patients (11).

Although chiropractic manipulation is supported by the scientific literature as an effective method of care, the scientific literature is unclear as to the frequency or duration of treatment necessary to achieve a beneficial outcome.  Consequently, consensus is a method that has been employed to provide guidelines as to what may be the appropriate frequency and duration of chiropractic manipulation for spinal pain syndromes.

In an attempt to provide guidelines for the chiropractic profession regarding a variety of treatment issues, a consensus conference was convened in 1992 for the chiropractic profession at the Mercy Conference Center in Burlingame, California.  At the conference, 35 panel members representing the chiropractic profession came together, following months of preliminary preparation, to discuss, debate, and produce a document designed to establish chiropractic clinical practice guidelines.  The document that was produced by the consensus procedure, among other things, provides guidelines concerning frequency and duration of chiropractic treatment.

In regards to treatment duration, the document states that for acute uncomplicated cases (defined as a first occurrence, recurrent, or exacerbation of a chronic condition), "After a maximum of two trial therapy series of manual procedures lasting up to two weeks each (four weeks total) without significant documented improvement, manual procedures may no longer be appropriate and alternative care should be considered . . . Repeated use of passive treatment/care normally designed to manage acute conditions should be avoided as it tends to promote physician dependence and chronicity . . . Patients at risk for becoming chronic should have treatment plans altered to de-emphasize passive care and refocus on active care approaches (17)."

In regards to the treatment frequency, the document states, "In general, more aggressive in-office intervention (three to five sessions per week for one to two weeks) may be necessary early.  Progressively declining frequency is expected to discharge of the patient, or conversion to elective care (17)."

Two years following the chiropractic consensus conference, clinical practice guidelines for the treatment of acute low back problems in adults (defined as low back and/or back-related leg symptoms of less than three months duration) were published by the Agency for Health Care Policy and Research (AHCPR), a division of the Department of Health and Human Services of the U.S. Government.  These practice guidelines state that for the treatment of acute low back problems, "Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation(3)."

As far as the duration of manipulative therapy is concerned, the AHCPR guidelines state, "If manipulation has not resulted in symptomatic improvement that allows increased function after 1 month of treatment, manipulation therapy should be stopped and the patient reevaluated(3)."  This recommendation essentially mirrors the recommendation for the duration of chiropractic treatment made by the chiropractic consensus panel in the earlier 1992 chiropractic document.



SUPPORTIVE AND ELECTIVE CARE

After a patient successfully completes a trial of chiropractic treatment for their spine or spinal related condition, doctors of chiropractic will often release the patient with discharge instructions that will include modification of activities of daily living, spinal exercises, and possibly dietary recommendations (e.g. calcium supplementation for patients predisposed to osteoporosis, etc.).

Patients with chronic incurable conditions often return for palliative treatment (also referred to as "supportive care") after they have been released from active acute treatment.  This treatment is provided in an "as needed" capacity for relief or control of uncomfortable symptoms not manageable by the patient's home methods of care (e.g. exercise, applications of heat or ice, etc.) and is typically limited to a small number of office visits (ordinarily 1-3 sessions).In-so-far as this type of treatment is concerned, the chiropractic consensus document states, "Supportive care using passive therapy may be necessary if repeated efforts to withdraw treatment/care result in significant deterioration of clinical status (17)."

Finally, a doctor of chiropractic may offer a patient the option to return for "wellness" or "maintenance" care.  The practice of doctors of chiropractic providing "maintenance" or "wellness" care has evolved empirically.  Contrary to popular medical belief, back pain is often NOT self-limiting and largely resolved within one month(18).  Recurrences are common and patients frequently fail to return to medical providers for subsequent treatment of such recurrences(18).  This may be due to a lack of satisfaction with medical management of low back pain expressed by many patients (10).

Many chiropractic patients subjectively report that "maintenance" or "wellness" care helps to prevent recurrences of their musculoskeletal complaints and consequently elect to maintain a monthly or bi-monthly appointment with a chiropractic physician.  It must be pointed out, however, that this type of care is elective in nature and no scientific studies exist to validate such ongoing patient management.  Therapeutic necessity is absent by definition and patients are informed that this type of "treatment" is not reimbursed through any insurance plans.



CONCLUSION

Doctors of chiropractic routinely release their patients following the resolution of their complaints.  The average number of visits per episode for all conditions treated by chiropractic physicians in North America is 12.8 (11).

Most patients seeking chiropractic treatment do so for the complaint of low back pain which, contrary to popular belief, is not 90% cured within one month.  The recurrent nature of low back pain, in combination with the high rates of satisfaction reported with chiropractic treatment by patients, likely accounts for the perception that persists that chiropractors never release their patients.

Elective "wellness" or "maintenance" care provided by chiropractic physicians may also drive the perception that chiropractors never release their patients.   However, since this elective form of patient management is not reimbursed through third party payment, perhaps the fact that patients are willing to pay for such treatment out of their own pockets is further evidence of the overall high rates of satisfaction with chiropractic.



REFERENCES

1. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG.Manipulation and mobilization of the cervical spine:A systematic review of the literature.Spine1996;21:1746-1760.

2. Shekelle PG.Spine update:spinal manipulation.Spine1994;19:858-861.

3. Bigos S, Bowyer O, Braen G, et al.Acute low back problems in adults.Clinical practice guideline No. 14.AHCPR Publication No. 95-0642.Rockville, MD:Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.December 1994.

4. Vick DA, McKay C, Zengerle CR.The safety of manipulative treatment:review of the literature from 1925 to 1993.JAOA1996;96:113-115.

5. Dabbs V, Lauretti WJ. Risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain.J Manip Physiol Ther1995;18:530-536.

6. Manga P.The effectiveness and cost effectiveness of chiropractic management of low-back pain.Ottawa, Ontario, Canada: Ontario Ministry of Health1993.

7. Commission of Inquiry into Chiropractic.Chiropractic in New Zealand.Wellington, New Zealand:Government Printer1979.

8. Meade TW, Dyer S, Browne W, Townsend J, Frank AO.Low back pain of mechanical origin:Randomised comparisons of chiropractic and hospital outpatient treatment.Br Med J1990;300:1431-1437.

9. Kane R, Olsen D, Leymaster C, Woolley F, Fisher F.Manipulating the patent, a comparison of the effectiveness of physician and chiropractic care.Lancet1974;1:1333-1336.

10. Cherkin D, MacCornack F, Berg A.Managing low back pain-A comparison of the beliefs and behaviors of family physicians and chiropractors.West J Med.1988;149:475-480.

11. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG.Use of chiropractic services from 1985 through 1991 in the United States and Canada.Am J Public Health1998;88:771-776.

12. Smith R.Where is the wisdom:The poverty of medical evidence.BMJ1991;303:798-799.

13. Howe DH, Newcome RG, Wade MT.Manipulation of the cervical spine:A pilot study.J Royal College of Gen Pract1983;33:546-579.

14. Sloop PR, Smith DS, Goldenberg E, Dore C.Manipulation for chronic neck pain:A double-blind controlled study.Spine1982;7:532-535.

15. Koes BW, Bouter LM, Van Mameren H, Essers AHM.The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints:A randomized clinical trial.Spine1992;17:28-35.

16. Cassidy JD, Lopes AA, Yong-Hing K.The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine:A randomized controlled trial.J Manipulative Physiol Ther 1992;15:570-575.

17. Haldeman S, Chapman-Smith D, Petersen DM, eds.Guidelines for Chiropractic Quality Assurance and Practice Parameters.Proceedings of the Mercy Center Consensus Conference.Gaithersburg, MD:Aspen Publishers, 1993.

18. Croft PR, MacFarlane GJ, Papageorgiou AC, Thomas E, Silman AJ.Outcome of low back pain in general practice:a prospective study.BMJ 1998;316:1356-1359.

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6. Neck Pain & Manipulation:  Results of Prospective Randomized Controlled Trials



INTRODUCTION

The costs associated with neck pain are a perplexing subset of the total annual cost for treatment of joint or back problems in the American public (1,2).  Researchers have extensively studied the possible causes and tissue origins of neck pain (2-12); most often, neck pain is attributed to disc disease or soft-tissue injury (2).  Approximately 20% of the American public sought treatment for problems of the joints or back in 1980.  The costs for this treatment represented 8% of national health care spending, or the equivalent of $60 billion if extrapolated to current spending (1).

Much of the focus of the treatment for neck pain has centered around providing palliative relief of symptoms, through the use of medications, and maintenance of range of motion through exercise. Unfortunately, this led to little improvement in the outcome of the treatment of neck pain and led to the characterization of neck pain treatment as "empirical at best."(7)



MANIPULATION & NECK PAIN

Approximately one-third of patients presenting to the office of a doctor of chiropractic do so for complaints of the head and neck(13).  This makes neck pain one of the most commonly treated conditions in the chiropractic physician's office.  The most common method of treatment used by chiropractic physicians is manual manipulation of the spine.

Although many common treatments used in the health care sciences do not have even one prospective randomized clinical trial to scientifically support their use (14), at least four prospective randomized clinical trials exist which seem to indicate that spinal manipulation is an effective treatment for neck pain.

In 1982, Sloop et al. (15) published the findings of their randomized controlled trial of twenty-one patients receiving a single neck manipulation as treatment for the diagnoses of cervical spondylosis or non-specific neck pain.  The patients receiving manipulation were compared to a control group of eighteen patients with the same diagnoses.  The authors state, "The simplest test of outcome was to ask the patient, 'did the treatment help you?'  At three weeks, 12 of 21 (57%) patients receiving manipulation responded affirmatively, compared with five of 18 (28%) controls."

In 1983, a randomized controlled trial of cervical spine manipulation for fifty-two patients was published in the Journal of the Royal College of General Practitioners.  Subjects were assessed over a three week period to determine the effect of cervical spine manipulation on self-reported pain and range of motion.  The authors found that, "Manipulation produced a significant immediate improvement in symptoms in those with pain or stiffness in the neck, and pain/paraesthesia in the shoulder, and a nearly significant improvement in those with pain/paraesthesia in the arm/hand.  Manipulation also produced a significant increase in measured rotation that was maintained for three weeks and an immediate improvement in lateral flexion that was not maintained (16)."

Koes et al. (17) performed a randomized clinical trial of 256 patients with nonspecific back and neck complaints lasting for at least six weeks duration.  Patients were randomly assigned to either manual therapy, physiotherapy, or continued treatment with their general practitioner.  Outcome measures consisted of severity of the chief complaint, global perceived effect, and functional status.  Based on their results, Koes et al. state, "Both physiotherapy and manual therapy decreased the severity of complaints more and had a higher global perceived effect compared to continued treatment by the general practitioner (17)."

Finally, Cassidy et al. (18) performed a prospective randomized trial on one hundred consecutive patients with unilateral neck pain.  Fifty-two received one high-velocity, low-amplitude rotational manipulation while the remaining forty-eight received a passive muscle energy technique applied to the neck.  Both treatments increased range of motion, however, the manipulation had a significantly greater effect on reducing pain intensity.  "Eighty-five percent of the manipulated patients reported pain improvement immediately after treatment.  However, the decrease in pain intensity was more than 1.5 times greater in the manipulated group (18)."



SAFETY ISSUES

It is widely thought that cervical spine manipulation is a dangerous treatment modality.  Nothing could be further from the truth.  An article authored in 1996 by Dabbs and Lauretti (19) compared the risks of serious complications or death for patients receiving a course of manipulative treatment or nonsteroidal anti-inflammatory drugs for the treatment of neck pain.  As a result of their review of the scientific literature on the subject, the authors stated, " . . . the best available data suggests that the risk of serious neurovascular complication from cervical manipulation is approximately one incident per 100,000 patients receiving a course of treatment per year, or 0.00025%.  The risk of serious gastrointestinal complication requiring hospitalization because of NSAID use for similar conditions (i.e., a diagnosis of osteoarthritis [OA]) is 0.4% per year.  The risk of death from hemorrhage or ulcer perforation attributable to NSAID use for OA is 0.04%.  Therefore, based on the best available evidence, we calculate the risk of serious complications or death is 100-400 times greater for the use of NSAIDs than for the use of cervical manipulation in the treatment of similar conditions."  (19, emphasis added)

In addition, an article published in the medical journal, Spine compares the risks for cervical spine manipulations, use of NSAIDs, and cervical spine surgery(20).  Hurwitz et al. (20) report an average risk of vertebrobasilar accident, major impairment or death as 7.5 per 10,000,000 manipulations.  They further report an average incidence rate of serious gastrointestinal event (bleeding, perforation, or other adverse event resulting in hospitalization or death) from the use of NSAIDs as 1 per 1000 subjects.  And finally, they report an average incidence rate of neurologic complication or death from cervical spine surgeries as 11.25 per 1000.

Although anyone would agree that even one tragic event is one too many, when placed in the proper context it becomes readily apparent that cervical spine manipulation is an extremely safe procedure.



CONCLUSION

Cervical spine manipulation is a safe and effective treatment for individuals with neck pain.  Because chiropractic manipulation has been shown to be clinically effective and safe, with high levels of patient satisfaction, it seems logical that a clinical trial of chiropractic treatment should perhaps be the standard of care for patients with conditions known to be responsive to such interventions.



REFERENCES

1. Stano M.A comparison of health care costs for chiropractic and medical patients.J Manipulative Physiol ther1993;16;291-299.

2. Dwyer A, Aprill C, Bogduk N.Cervical zygapophyseal joint pain patterns I:a study in normal volunteers.Spine1990;15:453-457.

3. Aprill C, Bogduk N.The prevalence of cervical zygapophyseal joint pain. Spine1992;17:744-747.

4. Bogduk N, Aprill C.On the nature of neck pain, discography and cervical zygapophyseal joint blocks.Pain1993;54:213-217.

5. Bogduk N, Windson M, Inglis A.The innervation of the cervical intervertebral discs. Spine1989;13:2-8.

6. Barnsley L, Lord S, Bogduk N.Clinical review:whiplash injury.Pain1994;58:283-307.

7. Cailliet R.Neck and arm pain.Philadelphia:FA Davis, 1981.

8. Cloward RB.Cervical diskography:a contribution to the etiology and mechanism of neck, shoulder, and arm pain.Ann Surg1959;150:1052-1064.

9. Barnsley l, Lord SM, Wallis BJ, bogduk N.Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints.N Engl J Med1994;330:1047-1050.

10. Barnsley L, Lord SM, Wallis BJ, Bogduk N.The prevalence of chronic cervical zygapophyseal joint pain after whiplash.Spine1995;20:20-26.

11. Bogduk N, Marsland A.The cervical zygapophyseal joints as a source of neck pain.Spine 1988;13:610-617.

12. Aprill C, Dwyer A, Bogduk N.Cervical zygapophyseal joint pain patterns II:a clinical evaluation.Spine 1990;15:458-461.

13. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG.Use of chiropractic services from 1985 through 1991 in the United States and Canada.Am J Public Health1998;88:771-776.

14. Smith R.Where is the wisdom:The poverty of medical evidence.BMJ1991;303:798-799.

15. Sloop PR, Smith DS, Goldenberg E, Dore C.Manipulation for chronic neck pain: a double-blind controlled study.Spine1982;7:532-535.

16. Howe DH, Newcome RG, Wade MT.Manipulation of the cervical spine: A pilot study.J Royal Coll Gen Pract1983;33:546-579.

17. Koes BW, Bouter LM, van Mameren H, Essers AHM.The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints: A randomized clinical trial.Spine1992;17:28-35.

18. Cassidy JD, Lopes AA, Yong-Hing K.The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: A randomized controlled trial.J Manipulative Physiol Ther1992;15:570-575.

19. Dabbs V, Lauretti WJ. Risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain.J Manip Physiol Ther1995;18:530-536.

20. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG.Manipulation and mobilization of the cervical spine: A systematic review of the literature.Spine1996;21:1746-1760.

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7. Chiropractic Manipulation, PMS & Dysmenorrhea


INTRODUCTION

Although the practice of chiropractic is one with a neuromusculoskeletal focus, a number of benign conditions appear to respond to chiropractic treatment methods.  As a result, some patients seek chiropractic treatment as a non-invasive, non-drug therapeutic intervention.  Premenstrual syndrome and dysmenorrhea are but two conditions that seem to respond to chiropractic manipulative therapy.


PREMENSTRUAL SYNDROME (PMS)

PMS is defined as a wide range of physical and psychological symptoms women may experience usually seven to fourteen days before menstruation.  The symptoms may include fatigue, headache, water retention (bloating), breast tenderness, irritability, depression, tension, anxiety, and mood swings.

Estimates suggest that up to ninety percent of women of child-bearing age experience symptoms of PMS at some time in their lives.  In some women, symptoms are so severe that work and social relationships are seriously disrupted.

In a study by Whittler (1), eleven women with histories of PMS symptoms that had occurred regularly for more than four months were evaluated and treated by an experienced chiropractor.  The treatment extended through four menstrual cycles and consisted of spinal manipulations that were provided 5-7 times per month.  The areas of the spine most often treated were the cervical spine and sacro-iliac joints.

Participants were given questionnaires at the beginning and end of the study period to evaluate changes in their symptoms.  The questionnaires evaluated changes in ten categories of symptoms including irritability and mood swings, tension, ineffectiveness, lack of motor coordination, mental/cognitive functioning, eating habits, variations in sexual drive and activity, overall physical symptoms, and social impairment.

The subjects reported improvement in all ten categories with the greatest improvement of symptoms relating to variations in sexual drive (70.7%), social impairment (64.5.%), and mood swings (60.8%).  The overall average improvement in all symptom categories was 44.2 percent.

Whittler's (1) study demonstrates that chiropractic manipulation may represent an effective adjunct or alternative to traditional medical care which often includes the use of diuretic drugs and/or birth control pills, which many women are unable to take.

In a case report by Stude (2), he describes the criteria for the accurate diagnosis of PMS and a device known as the PMT-Cator for converting a patient's subjective symptomatology into an objective menstrual cycle interval score.  According to Stude, using the PMT-Cator device, a 10 or more point differential between postmenstrual and premenstrual totals is suggestive of PMS.

Stude (2) goes on to describe the history of a patient with a baseline PMT-Cator score of 62 (3 month average of 73, 54, and 59) and how her menstrual cycle interval score dropped to an average of 5.67 (3 month average of 0, 9, and 8) with chiropractic treatment.

Stude concludes that although this case study design does not rule out the placebo effect, the, ". . . patient did report pursuing other medical treatment alternatives in the past, without subjective improvement."(2)

In yet another case report, Hubbs (3) presents a case of a 28-year-old female with a chronic history of low back pain and symptoms of premenstrual syndrome consisting of intermittent cramping for 24 hours prior and during early menstrual flow, depression, bloating, agitation, and nervous eating.  Spinal manipulations applied to the L1 area resulted in the patient reporting a significantly diminished pre- and peri-menstruation cramping time (approximately 30 minutes versus 24 hours) and the ease of other PMS symptomatology.  The patient's lumbar spine pain also remissed.

Hubbs (3) goes on to postulate that reflex sympathetic vasoconstriction to the uterine smooth muscle may result in diminished amounts of ovarian hormones reaching the uterus during menstruation causing the patient's cramping and other associated symptoms.  Normalization of sympathetic outflow through chiropractic adjustment of the upper lumbar spine might have accounted for the patient's symptom improvement.


DYSMENORRHEA

In 1990, Liebl(4) presented the findings of a time series, single case control study of a patient with chronic dysmennorhea.  The patient monitored her monthly menstrual cramps by using pain diaries during 4 months of a baseline phase and over a three month period of chiropractic treatment.

The patient received 19 treatment sessions over the two month treatment period - approximately twice per week for the first two months and once per week over the last month.  Liebl states, ". . . pain was rated four times daily, allowing for the possibility of 0 to 4 episodes of pain.  The months during the treatment phase realized fewer episodes of pain as well as lower pain ratings.  Pain was never rated above 2 in the treatment phase whereas the months of baseline all had some ratings of 3 or above.  The average number of recordings showing pain in the baseline phase was 8 per month compared to an average of 2.25 episodes of pain per month in the treatment phase."(4)

In yet another study (5), forty-five women with a history of primary dysmenorrhea were randomly assigned to groups receiving either side posture manipulative procedures (n=24) or a sham side posture manipulation (n=21).

Back pain and abdominal pain were assessed using visual analog scales and menstrual symptoms were assessed via questionnaire administered 15 minutes prior to, and 60 minutes following treatment interventions.  Blood samples were collected at those same times and tested for plasma levels of prostaglandins.

Both groups reported significant improvement in menstrual distress symptoms and decrease in back and abdominal pain, however, the effect was approximately twice as great in the group receiving the true spinal manual therapy.  These effects were associated with significant decreases in post-manipulative plasma levels for both groups.

The authors propose that their pilot findings, ". . . suggest that spinal manipulative therapy may be an effective and safe nonpharmacological alternative for relieving pain and distress of primary dysmenorrhea, at least for a short period of time after treatment.  The data presented here support the anecdotal claims of women that SMT (spinal manipulative therapy) reduces the pain and symptoms associated with menstruation."(5)

Finally, chiropractors are not the only members of the health care sciences to describe the positive effects of spinal manipulation on dysmenorrhea.  While describing his experimental results with spinal manual therapy in women with dysmenorrhea, Lewit (a medical neurologist) states, "In another group of 70 women with menstrual pain and negative gynecological findings, treatment of the spine mainly by manipulation gave excellent results in 43 cases, favourable in 13, and no change in 14. . .  From these data we may conclude that. . . Menstruation pain with otherwise normal gynecological findings, especially when localized in the low back, is usually of vertebrogenic origin and often the first clinical manifestation of disturbance in the lumbosacral region."(6)



CONCLUSION

As described earlier, chiropractors do not "treat" organic disease (Type O Disorders).  This would therefore be an excellent time to restate the findings of the Royal Commission of Inquiry into Chiropractic's findings.  The Royal Commission of Inquiry Into Chiropractic was an eighteen month government commissioned study investigating the profession of chiropractic in New Zealand, Australia, the United States and Europe.  In regards to the treatment of organic disorders, The Royal Commission of Inquiry stated, "The chiropractor does not set out to cure or relieve a particular ailment.  What he sets out to do is to ensure that the spinal column is functioning normally.  If a particular ailment clears up or is relieved following therapy, so much the better.  If it does not, then at least the patient, now with no spinal impediment to the working of his nervous system, ought to be in a generally better condition and better able to cope with the ailment."(7)

In other words, the findings reported above in the subjects with PMS and dysmenorrhea were pleasant side effects of spinal manipulative therapy for women with spinal dysfunction and concurrent PMS and dysmennorhea.

As the Royal Commission of Inquiry found, chiropractic is a profession whose aim is the improvement of the function of the nervous system by improving the structure of the "living conduit" in which part of that nervous system is housed.  Because chiropractors apply mechanical forces directly to that living conduit (the spinal column), this is presumably the reason why primarily musculoskeletal clinical entities respond most readily to the treatments chiropractors apply to their patients' spines.  This makes chiropractic a limited specialty much like the practices of optometry, podiatry, and dentistry.  Unlike optometry, podiatry, and dentistry, chiropractic is a limited specialty with documented full body ramifications.



REFERENCES


1. Wittler MA.Chiropractic approach to premenstrual syndrome.Chiropractic:The Journal of Chiropractic Research and Clinical Investigation1992;8(2):26-29.

2. Stude DE. The management of symptoms associated with premenstrual syndrome.J Manip Physiol Ther1991;14:209-216.

3. Hubbs EC.Vertebral subluxation and premenstrual tension syndrome:A case study.Res Forum1986;3:100-102.

4. Liebl NA, Butler LM.A chiropractic approach to treatment of dysmennorhea.J Manip Physiol Ther1990;13(3):101-106

5. Kokjohn K, Schmid DM, Triano JJ, Brennan PC.The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmeorrhea.J Manip Physiol Ther1992;15:279-285

6.Lewit K.Manipulative Therapy in Rehabilitation of the Motor System.Butterworth and Co., London & Boston,1985:341-342.

7. Commission of Inquiry into Chiropractic.Chiropractic in New Zealand.Government Printer, Wellington, New Zealand, 1979:57.

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8. Chiropractic and Headaches of Cervical Origin



INTRODUCTION

Headache is one of the most ubiquitous complaints in modern society.  Headache is also one of the most common complaints for which patients seek treatment from a doctor of chiropractic.  Fortunately, chiropractors have a long tradition of headache management and success, especially for the types of headaches known as cervicogenic headache or headache of cervical origin.



HEADACHE & THE CERVICAL SPINE

Chiropractors have long held the notion that dysfunction in the joints of the cervical spine may be a causative factor in tension headache.  A study published in the medical journal Headache in 1993 found a statistical connection between tension type headache and abnormal alignment of the cervical spine.  The study compared 372 patients with tension-type headache (pain located at the base of the skull, radiating into the crown of the head, or to the temples and forehead, or both) and 225 normal control subjects.(1)

The study states that, when viewed from the side, the normal circumstance is for the cervical spine to assume the shape of a gently forward bending lordotic curve.  The headache patients were found to have abnormally straightened cervical curves compared to the control subjects.  The researchers go on to conclude that the abnormally aligned neck position requires greater muscular effort to support the weight of the head and neck, likely leading to tension-type headache.

In addition, another study of 47 migraine and tension headache sufferers found that 77% of their subjects and 89% of their women subjects were found to have abnormally straightened cervical curves.  The study goes on to conclude that these findings support the theory that the neck plays an important, but largely ignored role, in the cause of many types of headache pain.  Furthermore, if the neck can be restored to its normal alignment, the frequency, intensity, or length of headache attacks may be reduced or eliminated.



CHIROPRACTIC METHOD RESTORES NORMAL NECK ALIGNMENT

As described above, an abnormally straightened lordotic curvature may be an underlying mechanical cause of tension-type or migraine headaches.  Few studies have been undertaken to investigate the effectiveness of various methods used to restore the normal lordotic curvature of the neck.  However, one such study has been published in the indexed medical literature.

In 1994, a study of two treatment methods intended to restore the normal cervical lordosis was published in the Journal of Manipulative and Physiological Therapeutics.(3)  In this study, one treatment group received chiropractic manipulation alone while a second group received chiropractic manipulation and a form of cervical traction intended to restore or increase the depth of the normal lordotic cervical curve.

The two patient groups were x-rayed and the depth of their neck curves were measured.  The patients received treatment over a three month period and were then x-rayed again so their cervical curves could be measured to see what effect, if any, the chiropractic treatment had on their abnormally straightened neck curvatures.  These groups of patients were compared to the radiographs of a control group receiving no treatment intervention over a similar three month period.

The control group and the group receiving only chiropractic manipulation demonstrated no net improvement in lordotic curvature while the group receiving the combination of chiropractic manipulation and cervical extension traction showed an average improvement in their neck curvatures of 13.2 degrees.  The study concluded that chiropractic manipulation along with this specific form of traction was necessary to restore or enhance the normal lordotic alignment of the cervical spine.



MULTIPLE STUDIES DEMONSTRATE SUPERIORITY OF NECK MANIPULATION IN TREATMENT OF HEADACHE

A review article published in the medical journal Spine reviewed the effectiveness of spinal manipulation for the treatment of neck pain and headaches.(4)  The article summarized the findings of multiple clinical trials of chiropractic manipulation as compared to different medications, physical therapy, cold packs, acupuncture, etc.  Almost without exception, chiropractic manipulation of the neck was found to be superior in terms of reducing tension headache frequency, intensity, and improving functional status of patients when compared to other standard medical treatments.  In the case of chiropractic manipulation of the neck for the treatment of migraine headache, which is also thought to have a cervical etiology in some cases, the article states, "Chiropractic patients reported greater reductions in frequency and intensity of attacks after 2 months and statistically significantly less pain intensity compared with the other groups.  Chiropractic patients were more likely to have had no recent attacks after 20 months."(4)



SAFETY

It is widely thought that cervical spine manipulation is a dangerous treatment modality.Nothing could be further from the truth.   An article authored in 1996 by Dabbs and Lauretti (5) compared the risks of serious complications or death for patients receiving a course of manipulative treatment or nonsteroidal anti-inflammatory drugs for the treatment of neck pain.  As a result of their review of the scientific literature on the subject the authors stated, " . . . the best available data suggests that the risk of serious neurovascular complication from cervical manipulation is approximately one incident per 100,000 patients receiving a course of treatment per yr, or 0.00025%.  The risk of serious gastrointestinal complication requiring hospitalization because of NSAID use for similar conditions (i.e., a diagnosis of osteoarthritis [OA]) is 0.4% per year.  The risk of death from hemorrhage or ulcer perforation attributable to NSAID use for OA is 0.04%.  Therefore, based on the best available evidence, we calculate the risk of serious complications or death is 100-400 times greater for the use of NSAIDs than for the use of cervical manipulation in the treatment of similar conditions." (5, emphasis added)

In addition the article described by Hurwitz et al. (4) compares the risks for cervical spine manipulations, use of NSAIDs, and cervical spine surgery.  Hurwitz et al. report an average risk of vertebrobasilar accident, major impairment or death as 7.5 per 10,000,000 manipulations.  They further report an average incidence rate of serious gastrointestinal event (bleeding, perforation, or other adverse event resulting in hospitalization or death) from the use of NSAIDs as 1 per 1000 subjects.  And finally, they report an average incidence rate of neurologic complication or death from cervical spine surgeries as 11.25 per 1000.

Although anyone would agree that even one tragic event is one too many, when placed in the proper context it becomes readily apparent that cervical spine manipulation is an extremely safe procedure.



CONCLUSION

Cervical spine manipulation is a safe and effective treatment for individuals with headaches of cervical origin.  Because chiropractic treatment has been shown to be clinically effective and safe, with high levels of patient satisfaction, it seems logical that a clinical trial of chiropractic treatment should perhaps be the standard of care for patients with conditions known to be responsive to such interventions.


REFERENCES

1.Nagasawa A, et al.Roentgenographic findings of the cervical spine in tension-type headache.Headache1993;33:90-95.

2.Vernon H, et al.Cervicogenic dysfunction in muscle contraction headache and migraine:A descriptive study.Journal of Manipulative and Physiological Therapeutics1992;15:418-429.

3.Harrison DD, Jackson BL, Troyanovich S, et al.The efficacy of cervical extenstion-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis:A pilot study.Journal of Manipulative and Physiological Therapeutics1994;17:454-464.

4.Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG.Manipulation and mobilization of the cervical spine:A systematic review of the literature.Spine1996;21:1746-1760.

5.Dabbs V, Lauretti WJ. Risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain.J Manip Physiol Ther1995;18:530-536.

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9. Whiplash Associated Disorders & Chiropractic


INTRODUCTION

Whiplash is the common term used to describe injury of the soft-tissues of the neck arising from an automobile accident.  Much controversy exists regarding this common cause of neck pain, headache, and disability.  The accumulated literature suggests that greater than 40% of patients suffering a "whiplash" injury will suffer some long-term symptoms, and that if they are still symptomatic after three months there is about a 90% chance that they will remain so.  Doctors of chiropractic routinely treat patients suffering this type of injury with remarkable results-even for those with chronic pain



THE QUEBEC TASK FORCE

The issue of "whiplash" is so controversial that an international task force of twenty-five experts was commissioned to review the available literature on the subject and report their findings to the medical community.  The findings of the Quebec Task Force on Whiplash Associated Disorders (1) was published in the medical journal Spine in April of 1995.

The Task Force recommended that patients be placed into one of five categories based upon their history, physical examination findings, and radiographic findings.  The clinical presentation of these categories follows.  Grade 0 Whiplash Associated Disorder (WAD) presents with a history of involvement in an automobile accident but no physical complaints about the neck and no physical signs.  Grade I WAD presents with symptomatic complaints of neck pain, stiffness, and tenderness but no objective physical signs upon examination.  Grade II WAD includes neck complaint and musculoskeletal signs of decreased cervical range of motion and point tenderness upon palpatory examination.  Grade III WAD includes all the above plus neurologic involvement of one or more of decreased or absent deep tendon reflexes, motor weakness, and/or sensory deficits.  Finally, Grade IV WAD includes the above plus fracture or dislocation.

In general, Grades I, II, and III WAD may be treated conservatively.  Recommendations include (A) reassurance that the condition is benign and generally self-limiting, (B) nonnarcotic analgesia and nonsteroidal anti-inflammatory agents (for not more than about three weeks), (C) range of motion exercises, (E) manipulation or mobilization by trained persons, and (F) return to normal activities as soon as possible.  Uncomplicated cases should resolve with such treatment within three to six weeks with a maximum of about twelve weeks prior to multidisciplinary team reassessment.

The Task Force recommendations further state that soft collars should NOT be used in Grade I-III WAD because studies indicate that they may prolong disability by promoting inactivity and lack of movement.  Prolonged rest is seldom indicated, and muscle relaxants are contraindicated since they tend to sedate muscles and do not promote mobility and movement.

These recommendations were made following an extensive review of the scientific literature.  Many common treatments were found to have little or no scientific validation regarding their use.



MANIPULATION AND THE SCIENTIFIC LITERATURE

Although many common treatments used in the health care sciences do not have even one prospective randomized clinical trial to scientifically support their use (2), at least four prospective randomized clinical trials exist which seem to indicate that spinal manipulation is an effective treatment for neck pain.

In 1982 Sloop et al. (3) published the findings of their randomized controlled trial of twenty-one patients receiving a single neck manipulation as treatment for the diagnoses of cervical spondylosis or non-specific neck pain.  The patients receiving manipulation were compared to a control group of eighteen patients with the same diagnoses.  The authors state, "The simplest test of outcome was to ask the patient, 'did the treatment help you?'  At three weeks, 12 of 21 (57%) patients receiving manipulation responded affirmatively, compared with five of 18 (28%) controls."

In 1983, a randomized controlled trial of cervical spine manipulation for fifty-two patients was published in the Journal of the Royal College of General Practitioners.  Subjects were assessed over a three week period to determine the effect of cervical spine manipulation on self-reported pain and range of motion.  The authors found that, "Manipulation produced a significant immediate improvement in symptoms in those with pain or stiffness in the neck, and pain/paraesthesia in the shoulder, and a nearly significant improvement in those with pain/paraesthesia in the arm/hand.  Manipulation also produced a significant increase in measured rotation that was maintained for three weeks and an immediate improvement in lateral flexion that was not maintained (4)."

Koes et al. (5) performed a randomized clinical trial of 256 patients with nonspecific back and neck complaints lasting for at least six weeks duration.  Patients were randomly assigned to either manual therapy, physiotherapy, or continued treatment with their general practitioner.  Outcome measures consisted of severity of the chief complaint, global perceived effect, and functional status.  Based on their results, Koes et al. state, "Both physiotherapy and manual therapy decreased the severity of complaints more and had a higher global perceived effect compared to continued treatment by the general practitioner(5)."

Finally, Cassidy et al. (6) performed a prospective randomized trial on one hundred consecutive patients with unilateral neck pain.  Fifty-two received one high-velocity, low-amplitude rotational manipulation while the remaining forty-eight received a passive muscle energy technique applied to the neck.  Both treatments increased range of motion, however, the manipulation had a significantly greater effect on reducing pain intensity.  "Eighty-five percent of the manipulated patients reported pain improvement immediately after treatment.  However, the decrease in pain intensity was more than 1.5 times greater in the manipulated group (6)."

More recently, Woodward et al. (7) have undertaken a pilot study of chiropractic treatment of patients suffering with chronic whiplash symptoms.  Twenty-eight patients with whiplash symptoms lasting an average of 15.5 months were assessed using a classification system placing them into categories of (A) symptom free, (B) mild nuisance symptoms not requiring medication or interfering with activities of daily living, (C) intrusive symptoms causing frequent use of analgesics and interfering with activities of daily living, or (D) severely disabling symptoms causing lost employment, repeated medical treatment and continual use of analgesics.

At the time of referral 27 of the 28 patients had category C or D symptoms.  Chiropractic treatment was carried out and the patients reassessed by two blinded examiners.  Following treatment, 26 of the 28 patients had improved (93%).  Sixteen had improved by one symptom category and 10 by two symptom categories.

Although a small study, these findings are compelling given the generally poor overall outcome of standard medical interventions with patients suffering WADs.



CONCLUSION

Whiplash Associated Disorder is a common affliction in the United States with up to 43% of patients suffering with long-term symptoms.  Most treatments used in dealing with this ubiquitous problem have not been shown to be effective by rigorously controlled scientific studies.  The one possible exception to this rule is chiropractic manipulation.  Randomized prospective studies have demonstrated success in reducing neck pain and increasing range of motion.

Finally, because chiropractic manipulation has been shown to be clinically effective (1-15), cost-effective (11,12, 14-16), and safe(8,9,18), with high levels of patient satisfaction (10,13,17-19), it seems logical that a clinical trial of chiropractic treatment should perhaps be the standard of care for patients with conditions known to be responsive to such interventions.



REFERENCES

1. Spitzer O, et al.Scientific monograph of the Quebec task force on whiplash-associated disorders:redefining 'whiplash' and its management.Spine1995;20(8S):2-73.

2. Smith R.Where is the wisdom:The poverty of medical evidence.BMJ1991;303:798-799.

3. Sloop PR, Smith DS, Goldenberg E, Dore C.Manipulation for chronic neck pain:a double-blind controlled study.Spine1982;7:532-535.

4. Howe DH, Newcome RG, Wade MT.Manipulation of the cervical spine:A pilot study.J Royal Coll Gen Pract1983;33:546-579.

5. Koes BW, Bouter LM, van Mameren H, Essers AHM.The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints: A randomized clinical trial.Spine1992;17:28-35.

6. Cassidy JD, Lopes AA, Yong-Hing K.The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine:A randomized controlled trial.J Manipulative Physiol Ther1992;15:570-575.

7. Woodward MN, Cook JCH, Gargan MF, Bannister GC.Chiropractic treatment of chronic 'whiplash' injuries.Injury1996;27:643-645.

8. Shekelle PG.Spine update:spinal manipulation.Spine1994;19:858-861.

9. Bigos S, Bowyer O, Braen G, et al.Acute low back problems in adults.Clinical practice guideline No. 14.AHCPR Publication No. 95-0642.Rockville, MD:Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.December 1994.

10. Meade TW, Dyer S, Browne W, Townsend J, Frank AO.Low back pain of mechanical origin:Randomised comparisons of chiropractic and hospital outpatient treatment.Br Med J1990;300:1431-1437.

11. Wolf C.Industrial back injury.Int Rev Chiro1974;26:6-7.

12. Wolk S.An analysis of Florida workers' compensation medical claims for back-related injuries.J Am Chiro Assoc1974;25:50-59.

13. Kane R, Olsen D, Leymaster C, Woolley F, Fisher F.Manipulating the patent, a comparison of the effectiveness of physician and chiropractic care.Lancet1974;1:1333-1336.

14. Johnson M, Schultz M, Ferguson A.A comparison of chiropractic, medical and osteopathic care for work-related sprains and strains.J Manipulative Physiol Ther1989;12:335-344.

15. Ebrall PS.Mechanical low-back pain:A comparison of medical and chiropractic management within the Victorian workcare scheme.Chiro J Australia1992;22:47-53.

16. Jarvis KB, Phillips RB, Morris EK.Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes.J Occupational Med1991;33:847-852.

17. Manga P.The effectiveness and cost effectiveness of chiropractic management of low-back pain.Ottawa, Ontario, Canada: Ontario Ministry of Health1993.

18. Commission of Inquiry into Chiropractic.Chiropractic in New Zealand.Wellington, New Zealand:Government Printer1979.

19. Cherkin D, MacCornack F, Berg A.Managing low back pain-A comparison of the beliefs and behaviors of family physicians and chiropractors.West J Med.1988;149:475-480.

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