Claims made for the benefits of spinal adjustments range from temporary, palliative (pain relieving) effects to long term wellness and preventive care. Some claims are controversial, particularly with regard to indications and health benefits. There is debate concerning the safety of some of the procedures used in spinal adjustments, particularly those including upper cervical manipulations.
Spinal adjustment is the chiropractic term for a procedure otherwise known as spinal manipulation. When used by straight chiropractors, it is specifically intended to correct vertebral subluxations. Spinal manipulation has documented use as far back as Hippocrates and the ancient Egyptians. The techniques were often handed down from generation to generation by families of bonesetters. The modern form of spinal manipulation techniques have characteristic biomechanical features, and are usually associated with an audible "popping" sound. There is strong evidence that this sound is the result of a phenomenon known as cavitation. Many adjustment techniques and methods have been developed through the years by chiropractors, not all of which involve high velocity low amplitude (HVLA) thrust manipulation.
In a section entitled "Spinal Manipulation: The Chiropractic Adjustment", chiropractic authors and researchers Meeker and Haldeman write that the core clinical method that all chiropractors agree upon is spinal manipulation, although chiropractors much prefer to use the term spinal "adjustment", a term which reflects "their belief in the therapeutic and health-enhancing effect of correcting spinal joint abnormalities." (p. 218)
Defined as unique to chiropractic
The International Chiropractor's Association (ICA) states that the "chiropractic spinal adjustment is unique and singular to the chiropractic profession", and that it "is characterized by a specific thrust applied to the vertebra utilizing parts of the vertebra and contiguous structures as levers to directionally correct articular malposition. Adjustment shall be differentiated from spinal manipulation in that the adjustment can only be applied to a vertebral malposition with the express intent to improve or correct the subluxation, whereas any joint, subluxated or not, may be manipulated to mobilize the joint or to put the joint through its range of motion... Chiropractic is a specialized field in the healing arts, and by prior rights, the spinal adjustment is distinct and singular to the chiropractic profession."[unreliable medical source?] One author claims that this concept is now repudiated by mainstream chiropractic. The definition of this procedure describes the use of a load (force) to specific body tissues with therapeutic intent. This ‘load’ is traditionally supplied by hand, and can vary in its velocity, amplitude, duration, frequency, and body location (p. 218) and is usually abbreviated HVLA (high velocity low amplitude) thrust.
Intention: to correct vertebral subluxations
The intention of a chiropractic adjustment is to affect or correct the alignment, motion and/or function of a vertebral joint. Specifically, they are intended to correct "vertebral subluxations", the term given to the signs and symptoms that are said by chiropractors to result from abnormal alignment of vertebrae. (p. 218) This intention forms the legal and philosophical foundation of the profession, and US Medicare law formulates it in this manner:
- "Coverage of chiropractic services is specifically limited to manual manipulation of the spine to correct a subluxation... Medicare will not pay for treatment unless it is 'manual manipulation of the spine to correct a subluxation'."
As the chiropractic profession engaged in the pursuit of improving health through adjustments to the nervous system, individual practitioners and institutions proposed and developed various proprietary techniques and methods. While many of these techniques did not endure, hundreds of different approaches remain in chiropractic practice today. Not all of them involve HVLA thrust manipulation. Most cite case studies, anecdotal evidence, and patient testimonials as evidence for effectiveness. These techniques include:
- Toggle Drop - this is when the chiropractor, using crossed hands, presses down firmly on a particular area of the spine. Then, with a quick and precise thrust, the chiropractor adjusts the spine. This is done to improve mobility in the vertebral joints.
- Lumbar Roll (aka side posture) - the chiropractor positions the patient on his or her side, then applies a quick and precise manipulative thrust to the misaligned vertebra, returning it to its proper position.
- Release Work - the chiropractor applies gentle pressure using his or her fingertips to separate the vertebrae.
- Table adjustments - The patient lies on a special table with sections that drop down. The chiropractor applies a quick thrust at the same time the section drops. The dropping of the table allows for a lighter adjustment without the twisting positions that can accompany other techniques.
- Instrument adjustments - often the gentlest methods of adjusting the spine. The patient lies on the table face down while the chiropractor uses a spring-loaded activator instrument to perform the adjustment. This technique is often used to perform adjustments on animals as well.
- Manipulation under anesthesia (MUA) - this is performed by a chiropractor certified in this technique in a hospital outpatient setting when the patient is unresponsive to traditional adjustments.
There are many techniques which chiropractors can specialize in and employ in spinal adjustments. Some of the most notable techniques include:
- Activator Methods - uses the Activator Adjusting Instrument instead of by-hand adjustments to give consistent mechanical low-force, high-speed clicks to the body. Utilizes a leg-length analysis to determine segmental aberration. (http://en.wikipedia.org/wiki/Activator_technique)
- Active Release Techniques - soft tissue system/movement based massage technique that treats problems with muscles, tendons, ligaments, fascia and nerves.
- Bio-Geometric Integration - a framework for understanding the body's response to force dynamics. Can be utilized with many techniques. Focuses on the body's full integration of forces and on assessment for choosing the most appropriate adjustive force application, ranging from light pressure to traditional joint cavitation, for each particular case presentation.
- Blair Upper Cervical Technique - an objective upper cervical technique focusing primarily on misalignments in the first bone of the spine (Atlas) as it comes into contact with the head (Occiput).
- Cox Flexion-Distraction - a gentle, non-force adjusting procedure which mixes chiropractic principles with osteopathic principles and utilizes specialized adjusting tables with movable parts.
- Hole-in-one technique - developed by B.J. Palmer. He, at some point, claimed that the "pure, unadulterated & straight" chiropractors should only treat the upper two cervical vertebrae (C1-C2) , which is the cause of most, if not all, disorders by being misaligned.
- Directional Non-Force Technique - utilizes a diagnostic system for subluxation analysis consisting of gentle challenging and a unique leg check allowing the body to indicate the directions of misalignment of structures that are producing nerve interference. A gentle but directionally specific thumb impulse provides a long lasting correction to bony and soft tissue structures.
- Diversified - the classic chiropractic technique, developed by D.D. Palmer, DC. Uses specific manual thrusts focused on restoring normal biomechanical function. Has been developed to adjust extremity joints as well.
- Gonstead Technique - Developed by an automotive engineer turned chiropractor, this technique uses a very specific method of analysis by the use of nervoscopes, full spine x-rays and precise adjusting techniques that condemns "torquing" of the spine, which may harm the Intervertebral disc.
- Kale Technique (Specific Chiropractic) - gentle technique which utilizes a special adjusting table that helps adjust and stabilize the upper cervical region surrounding the brain stem.
- Logan Basic Technique - a light touch technique that works to "level the foundation" or sacrum. Its concept employs the use of heel lifts and specific contacts.
- NUCCA Technique - manual method of adjusting the atlas subluxation complex based on 3D x-ray studies which determine the correct line of drive or vector of force.
- Orthospinology Procedure - is a method of analyzing and correcting the chiropractic upper cervical subluxation complex based on vertebral alignment measurements on neck x-rays taken from three different directions. The adjustment can be delivered by hand, hand-held or table mounted instruments along a pre-calculated vector using approximately 1 to 7 pounds of force. The patient is in a side-lying posture with a solid mastoid support. The procedure is based on the work of the late John F. Grostic, D.C.
- Thompson Terminal Point Technique (Thompson Drop-Table Technique) - uses a precision adjusting table with a weighing mechanism which adds only enough tension to hold the patient in the "up" position before the thrust is given.
- Toggle Recoil Technique - a quick thrust and release to the upper cervical vertebra, the recoil is to allow the vertebra to oscillate into its proper position.
Mechanisms and effects
The effects of spinal adjustment vary depending on the method performed. All techniques claim effects similar to other manual therapies, ranging from decreased muscle tension to reduced stress. Studies show that most patients go to chiropractors for musculoskeletal problems: 60% with low back pain, and the rest with head, neck and extremity symptoms. (p. 219) Also the article "Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine" states that, “chiropractic was to be a revolutionary system of healing based on the premise that neurologic dysfunction caused by ‘impinged’ nerves at the spinal level was the cause of most dis-ease”. (p. 218) The mechanisms that are claimed to alter nervous system function and affect overall health are seen as speculative in nature, however, clinical trials have been conducted that include “placebo-controlled comparisons [and] comparisons with other treatments”. (p. 220) The American Chiropractic Association promotes chiropractic care of infants and children under the theory that “poor posture and physical injury, including birth trauma, may be common primary causes of illness in children and can have a direct and significant impact not only on spinal mechanics, but on other bodily functions”.[unreliable medical source?]
The effects of spinal manipulation have been shown to include: temporary relief of musculoskeletal pain, increased range of joint motion, changes in facet joint kinematics, increased pain tolerance and increased muscle strength. (p. 222) Common side effects of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort. (p. 222)
The World Health Organization states that when "employed skillfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems." As with all interventions, there are risks associated with spinal manipulative therapy (SMT). Common, but nonserious side effects include: discomfort, headache, and fatigue which will go away after 24 to 48 hours. Extremely infrequent, but potentially serious side effects include: strokes, spinal disc herniation, vertebral and rib fractures and cauda equina syndrome. (p. 222).
A 2010 systematic review stated that there is no good evidence to assume that manipulation to the neck is an effective treatment for any condition and thus concluded, "the risks of chiropractic neck manipulations by far outweigh their benefits."
- ^ a b c d e f g h i Meeker WC, Haldeman S (2002). "Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine" (PDF). Ann Intern Med 136 (3): 216–27. PMID 11827498. http://www.annals.org/cgi/reprint/136/3/216.pdf.
- ^ ADJUSTMENT AND SPINAL MANIPULATION ICA Policy Statements: Spinal Adjustment and Spinal Manipulation. ICA.
- ^ David Chapman-Smith (2000). The Chiropractic Profession: Its Education, Practice, Research and Future Directions. NCMIC Group. pp. 160. ISBN 1-89273-402-8.
- ^ A.Lisi, M.Bhardwaj. Chiropractic High-Velocity Low-Amplitude Spinal Manipulation in the Treatment of a Case of Postsurgical Chronic Cauda Equina Syndrome. Journal of Manipulative and Physiological Therapeutics, Volume 27, Issue 9, Pages 574-578
- ^ Peter Gibbons, Philip Tehan. Manipulation of the spine, thorax, and pelvis: an osteopathic approach
- ^ American Chiropractic Association "Commentary on Centers for Medicare and Medicaid Services (CMS)/PART. Clinical Documentation Guidelines"
- ^ American Chiropractic Association (1994). "Infant and child care policy". Dyn Chiropr 12 (17). http://chiroweb.com/archives/12/17/01.html.
- ^ WHO guidelines on basic training and safety in chiropractic, World Health Organization, Geneva, 2005. ISBN 92-4-159371-7. available online
- ^ Senstad O, Leboeuf-Yde C, Borchgrevink C (February 1997). "Frequency and characteristics of side effects of spinal manipulative therapy". Spine 22 (4): 435–40; discussion 440–1. doi:10.1097/00007632-199702150-00017. PMID 9055373. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0362-2436&volume=22&issue=4&spage=435.
- ^ E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715.
- Changing Views of Chiropractic - RAND Health
- In the Quest for Cultural Authority - Keating, Hyde, Menke, Seaman, Vincent, Wyatt
- About Chiropractic Adjusting, a.k.a. Spinal Manipulation - Frank M. Painter, D.C.
- About Instrument Adjusting
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