Chiropractic treatment techniques
Chiropractors primarily use manipulation ("adjustment") of the spine as a treatment. Such treatments trace back to ancient China, Greece and Egypt. It gained popularity in the late 19th century, with the development of osteopathic and chiropractic medicine in North America.
Spinal manipulation (SMT) became more popular in the 1980s. It includes manipulation and massage to "adjust" the spine and related tissues, and is a primary basis of chiropractic. Systematic reviews have not found evidence that chiropractic manipulation is effective for any medical condition, with the possible exception of treatment for back pain. The safety of manipulation, particularly on the cervical spine has been debated. Adverse results, including death, are rare, with very low mortality rates. Chiropractors may use exercise and other treatments and advice.
Skilled, specific hands-on techniques, including manipulation and mobilization, are used to diagnose and treat soft tissues and joint structures, to reduce pain and to increase range of motion and general health.
The approach is generally conservative, and treatment may include:
- manual procedures, including spinal or joint manipulation or mobilization, soft‐tissue and reflex techniques;
- exercise, and other active care;
- psychosocial aspects of patient management;
- patient education on spinal health, posture, nutrition and lifestyle modifications;
- emergency treatment and acute pain management;
- other supportive measures, including the use of back supports and orthotics;
- recognition of the limitations of chiropractic care, and of the need for referral to other health professionals.
Manual and manipulative therapy
Treatment is usually for neck or low back pain and related disorders.
National guidelines vary; some recommend the therapy for those who do not improve with other treatment. It may be effective for lumbar disc herniation with radiculopathy, as effective as mobilization for neck pain, some forms of headache, and some extremity joint conditions. A 2011 Cochrane review found strong evidence that suggests there is no clinically meaningful difference between spinal manipulation therapy and other treatments for reducing pain and improving function for chronic low back pain. A 2008 review found that with the possible exception of back pain, chiropractic manipulation has not been shown to be effective for any medical condition.
The use of spinal manipulation for non-musculoskeletal is controversial. It has not been shown to be effective for asthma, headache, hypertension, or dysmenorrhea. There is no scientific data that supports the use of SMT for idiopathic adolescent scoliosis.
Spinal manipulation is generally regarded as cost-effective treatment of musculoskeletal conditions when used alone or in combination with other treatment approaches. Evidence supports the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain whereas the results for acute low back pain were inconsistent.
Relative contraindications, such as osteoporosis are conditions where increased risk is acceptable in some situations and where mobilization and soft-tissue techniques may be treatments of choice. Most contraindications apply to the manipulation of the affected region.
While safety has been debated, and serious injuries and deaths can occur and may be under-reported, these are generally rare and spinal manipulation is relatively safe when employed skillfully and appropriately.
Adverse events are believed to be under-reported  and appear to be more common following high velocity/ low amplitude manipulation than mobilization. Mild, frequent and temporary adverse events occur in SMT which include temporary increase in pain, tenderness and stiffness. These effects generally are reduced within 24–48 hours  Serious injuries and fatal consequences, especially to SM in the upper cervical region, can occur. but are regarded as rare when spinal manipulation is employed skillfully and appropriately.
The relationship to stroke has been debated. Stroke is statistically associated with both general practitioner and chiropractic services in persons under 45 years of age, and these associations may be related to preexisting conditions. Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy and vertebrobasilar artery stroke. A 2012 review found that there is not enough evidence to support a strong association or no association between cervical manipulation and stroke. A 2008 review found chiropractic are more commonly associated with serious related adverse effects than other professionals following manipulation and concluded that the risk of death from manipulations to the neck outweighs the benefits.
According to the American Chiropractic Association the most frequently used techniques by chiropractors are Diversified 95.9%, Extremity manipulating/adjusting 95.5%, Activator Methods 62.8%, Gonstead 58.5%, Cox Flexion/Distraction 58.0%, Thompson 55.9%, Sacro Occipital Technique [SOT] 41.3%, Applied Kinesiology 43.2%, NIMMO/Receptor Tonus 40.0%, Cranial 37.3%, Manipulative/Adjustive Instruments 34.5%, Palmer upper cervical [HIO] 28.8%, Logan Basic 28.7%, Meric 19.9%, and Pierce-Stillwagon 17.1%.
- Swedlo DC (2002). "The historical development of chiropractic" (PDF). In Whitelaw WA (ed.). Proc 11th Annual History of Medicine Days. Faculty of Medicine, The University of Calgary. pp. 55–58. Retrieved 2008-05-14.
- Keating JC Jr (2003). "Several pathways in the evolution of chiropractic manipulation". J Manipulative Physiol Ther 26 (5): 300–21. doi:10.1016/S0161-4754(02)54125-7. PMID 12819626.
- Francis RS (2005). "Manipulation under anesthesia: historical considerations". International MUA Academy of Physicians. Retrieved 2008-07-06.
- Winkler K, Hegetschweiler-Goertz C, Jackson PS et al. (2003). "Spinal manipulation policy statement" (PDF). American Chiropractic Association. Retrieved 2008-05-24.
- Christensen MG, Kollasch MW (2005). "Professional functions and treatment procedures" (PDF). Job Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners. pp. 121–38. ISBN 1-884457-05-3. Retrieved 2014-09-06.
- Ernst E (2008). "Chiropractic: a critical evaluation". J Pain Symptom Manage 35 (5): 544–62. doi:10.1016/j.jpainsymman.2007.07.004. PMID 18280103.
- Ernst, E (Jul 2007). "Adverse effects of spinal manipulation: a systematic review". Journal of the Royal Society of Medicine 100 (7): 330–8. doi:10.1258/jrsm.100.7.330. ISSN 0141-0768. PMC 1905885. PMID 17606755. Lay summary – Med News Today (2 July 2007).
- 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.
- World Health Organization (2005). WHO guidelines on basic training and safety in chiropractic (PDF). ISBN 92-4-159371-7. Retrieved 2008-02-29.
- Gatterman MI, Hansen DT. (1994). "Development of chiropractic nomenclature through consensus". J Manipulative Physiological Therapeutics 17 (5): 302–309.
- Hawk C, Long CR, Boulanger KT (2001). "relevance of nonmusculoskeletal complaints in chiropractic practice: report from a practice-based research program.". J Manipulative Physiol Ther 24 (3): 157–169. PMID 11313611.
- Rubinstein SM; Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. (Sep 2012). "Spinal manipulative therapy for acute low-back pain.". Cochrane Database Syst Rev 12 (9): CD008880. doi:10.1002/14651858.CD008880.pub2. PMID 22972127.
- Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM (2010). "NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain". Spine J 10 (10): 918–940. doi:10.1016/j.spinee.2010.07.389. PMID 20869008.
- Bronfort G, Haas M, Evans R, Leininger B, Triano J (2010). "Effectiveness of manual therapies: the UK evidence report". Chiropractic & Osteopathy 18 (3): 3. doi:10.1186/1746-1340-18-3. PMC 2841070. PMID 20184717.
- Koes, BW; van Tulder, M; Lin, CW; Macedo, LG; McAuley, J; Maher, C (December 2010). "An updated overview of clinical guidelines for the management of non-specific low back pain in primary care.". European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 19 (12): 2075–94. doi:10.1007/s00586-010-1502-y. PMID 20602122.
- Leininger B, Bronfort G, Evans R, Reiter T (2011). "Spinal manipulation or mobilization for radiculopathy: a systematic review". Phys Med Rehabil Clin N Am 22 (1): 105–25. doi:10.1016/j.pmr.2010.11.002. PMID 21292148.
- Hahne AJ, Ford JJ, McMeeken JM (2010). "Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review". Spine 35 (11): E488–504. doi:10.1097/BRS.0b013e3181cc3f56. PMID 20421859.
- Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL (2010). "Manipulation or mobilisation for neck pain: a Cochrane Review". Manual Therapy 15 (4): 315–333. doi:10.1016/j.math.2010.04.002. PMID 20510644.
- Chaibi A, Tuchin PJ, Russell MB (2011). "Manual therapies for migraine: a systematic review". J Headache Pain 12 (2): 127–33. doi:10.1007/s10194-011-0296-6. PMC 3072494. PMID 21298314.
- Bronfort G, Nilsson N, Haas M et al. (2004). "Non-invasive physical treatments for chronic/recurrent headache". In Brønfort, Gert. Cochrane Database Syst Rev (3): CD001878. doi:10.1002/14651858.CD001878.pub2. PMID 15266458.
- Posadzki, P; Ernst, E (June 2011). "Spinal manipulations for the treatment of migraine: a systematic review of randomized clinical trials.". Cephalalgia : an international journal of headache 31 (8): 964–70. doi:10.1177/0333102411405226. PMID 21511952.
- Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W (2009). "Manipulative therapy for lower extremity conditions: expansion of literature review". J Manipulative Physiol Ther 32 (1): 53–71. doi:10.1016/j.jmpt.2008.09.013. PMID 19121464.
- Pribicevic, M.; Pollard, H.; Bonello, R.; De Luca, K. (2010). "A Systematic Review of Manipulative Therapy for the Treatment of Shoulder Pain". Journal of Manipulative and Physiological Therapeutics 33 (9): 679–689. doi:10.1016/j.jmpt.2010.08.019. PMID 21109059.
- Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW (June 2011). "Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review". Spine (Systematic review) 36 (13): E825–46. doi:10.1097/BRS.0b013e3182197fe1. PMID 21593658.
- Singh S, Ernst E (2008). "The truth about chiropractic therapy". Trick or Treatment: The Undeniable Facts about Alternative Medicine. W.W. Norton. pp. 145–90. ISBN 978-0-393-06661-6.
- Everett CR, Patel RK (2007). "A systematic literature review of nonsurgical treatment in adult scoliosis". Spine 32 (19 Suppl): S130–4. doi:10.1097/BRS.0b013e318134ea88. PMID 17728680.
- Romano M, Negrini S (2008). "Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review". Scoliosis 3 (1): 2. doi:10.1186/1748-7161-3-2. PMC 2262872. PMID 18211702.
- Michaleff ZA, Lin CW, Maher CG, van Tulder MW (2012). "Spinal manipulation epidemiology: Systematic review of cost effectiveness studies". J Electromyogr Kinesiol. doi:10.1016/j.jelekin.2012.02.011. PMID 22429823.
- Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW (2011). "Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review". European Spine Journal 20 (7): 1024–1038. doi:10.1007/s00586-010-1676-3. PMC 3176706. PMID 21229367.
- Anderson-Peacock E, Blouin JS, Bryans R et al. (2005). "Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash" (PDF). J Can Chiropr Assoc 49 (3): 158–209. PMC 1839918. PMID 17549134.
• Anderson-Peacock E, Bryans B, Descarreaux M et al. (2008). "A Clinical Practice Guideline Update from The CCA•CFCREAB-CPG" (PDF). J Can Chiropr Assoc 52 (1): 7–8. PMC 2258235. PMID 18327295.
- Ernst E, Posadzki P (2012). "Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review". N Z Med J 125 (1353): 87–140. PMID 22522273.
- Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM (July 2005). "Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study". Spine 30 (13): 1477–84. doi:10.1097/01.brs.0000167821.39373.c1. PMID 15990659.
- Gouveia LO, Castanho P, Ferreira JJ (2009). "Safety of chiropractic interventions: a systematic review". Spine 34 (11): E405–13. doi:10.1097/BRS.0b013e3181a16d63. PMID 19444054.
- Thiel HW, Bolton JE, Docherty S, Portlock JC (2007). "Safety of chiropractic manipulation of the cervical spine: a prospective national survey". Spine 32 (21): 2375–8. doi:10.1097/BRS.0b013e3181557bb1. PMID 17906581.
- Hurwitz EL, Carragee EJ, van der Velde G et al. (2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders". Spine 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386.
- Paciaroni M, Bogousslavsky J (2009). "Cerebrovascular complications of neck manipulation". Eur Neurol 61 (2): 112–8. doi:10.1159/000180314. PMID 19065058.
- Cassidy, JD; Boyle, E; Côté, P; He, Y; Hogg-Johnson, S; Silver, FL; Bondy, SJ (15 Feb 2008). "Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.". Spine 33 (4 Suppl): S176–83. doi:10.1097/BRS.0b013e3181644600. PMID 18204390.
- Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM (2008). "Does cervical manipulative therapy cause vertebral artery dissection and stroke?". Neurologist 14 (1): 66–73. doi:10.1097/NRL.0b013e318164e53d. PMID 18195663.
- Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ. (2012). "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice 66 (10): 940–947. doi:10.1111/j.1742-1241.2012.03004.x. PMC 3506737. PMID 22994328.
- "Chiropractic Techniques". American Chiropractic Association. August 2003.