A Guide for People Seeking Chiropractic Treatment
One evening my daughter called me from the city where she was attending college. She asked me, on behalf of her roommate, if the advice the roommate had received from a chiropractor seemed sound. The young woman had sought care from a local chiropractor for back pain. The chiropractor examined her (presumably), took a full-spine set of X-rays, and told her she required thrice weekly treatments for at least 3 months. It's not a prescription I would recommend for anyone no matter what presumably treatable spine problem was diagnosed, so I said the treatment plan did not sound reasonable. My daughter had thought the same. But I was puzzled why her roommate, a graduate student, would even consider such a prolonged course of care.
No doubt the chiropractor's perceived credibility had a lot to do it. Societal, cultural, and scientific authority is implicit in the role of doctor. The title of doctor, the use of X-rays, and other accoutrements of apparent legitimacy such as a white coat and authoritative documents like a diploma and a license issued by the state board of examiners give the chiropractor the aura of culturally sanctioned approval. Also, implicit in the doctor-patient relationship is the expectation of responsibility, that the doctor can be trusted to place the patient's interests before his own. I have no doubt this chiropractor earned the certificates displayed on his wall. (1) Counting undergraduate education, a minimum of seven years is necessary to earn a DC (doctor of chiropractic) degree. (2) Unfortunately, many chiropractors' recommendations are self-serving. Education and other trappings of legitimacy don't guarantee the reasonableness and necessity of the recommended treatment plan, especially when the chiropractor has based it upon the very shaky foundation of vertebral subluxation ideology. (See my posts on vertebral subluxations — The Silent Killer — beginning here.)
The large majority of people seeking chiropractic care do so for back pain, neck pain, and other musculoskeletal complaints. (3) A lot of chiropractors try to "educate" these patients to come back for the "right reasons," i.e., subluxation correction, often referred to as wellness care or maintenance care, a kind of bait-and-switch tactic. This deceit is evident in the following example of a notice given to patients in some chiropractic offices. Spelling and other errors are in the original.
This disclaimer could be summarized as follows: We are not here to help you if you are actually sick. Our thing is nonmedical mumbo-jumbo, as expressed in phrases like “interference with the transmission of mental impulses,” “the body’s maximum health potential,” and "eliminating interference to the body’s expression of its innate wisdom.”
So, considering the dubious nature of many chiropractors' beliefs and the tendency for people to uncritically accept them, I offer this guide to help people know what conditions to seek chiropractic care for, what methods will be used, how long treatment should continue, and what the anticipated outcome should be.
Why are you going? For what kinds of problems?
Scientific evidence supports the treatment of back pain, neck pain, and some forms of headache with CMT (chiropractic manipulative therapy), aka spinal adjustments. There may be some benefit for musculoskeletal conditions of the extremities as well, such as shoulder, hip, knee, ankle, elbow, and wrist problems. The claims of chiropractors who purport to treat conditions other than musculoskeletal ones are not supported by evidence. Of course, subluxation-based chiropractors learned long ago not to make such claims lest they get sued or arrested for practicing medicine. Instead, these docs will tell you they do not treat any disease; rather, they are correcting subluxations in order to remove interference to the flow of energy ("Innate Intelligence") so that the body may heal itself. Run away from chiropractors who tell you this.
Back pain is by far the main reason for seeking chiropractic care. Most back pain results from mechanical or nonspecific causes. Strains and minor sprains are some of the most common types of mechanical back pain. Postural strains, muscle imbalances, and degenerative changes (i.e., osteoarthritis) are additional conditions that fall under this category. So-called nonspecific back pain refers to back pain for which a cause cannot be determined, which is often the case. Many back pain cases are diagnosed through a process of elimination. If you don't have a more serious condition like an infection, a tumor, or referred pain from an internal organ, then you probably have mechanical or nonspecific back pain. Back pain accompanied by symptoms like those in the following list may indicate a serious problem for which chiropractic treatment is unlikely to help and may in fact make you worse:
Pain worse at night or unrelieved by rest.
Pain accompanied by fever or night sweats.
Loss of bladder or bowel control.
Saddle anesthesia (numbness in the area of the groin and perineum).
In men, sexual dysfunction.
Symptoms in the upper and lower extremities such as shooting pain, numbness or tingling, or loss of strength are not contraindications to chiropractic treatment in and of themselves but could indicate a more serious problem which should be thoroughly evaluated by your chiropractor or other healthcare provider.
Who should you see? Who should you stay away from?
A chiropractor who treats musculoskeletal conditions with manual manipulation/adjustments, who may employ myofascial types of massage techniques, and who teaches patients exercises to help them develop a home exercise program is probably a safe bet. Many DCs also utilize physiotherapy such as ultrasound and electric muscle stimulation (aka interferential current) as well as heat or ice. These modalities are acceptable as long as their use is limited to a few treatments. They can facilitate recovery in acute cases but should be avoided after the first two weeks or so in most cases as they can promote dependence on passive forms of therapy and have no evidence for improvement. Chiropractors who send patients to gyms located in their offices may be providing therapeutic exercise inappropriately. In-office rehabilitation facilities are for athletes recovering from sports injuries and for patients who require strengthening or work-hardening programs before returning to work. Patients who present with common types of back and neck pain are best helped by supervised exercise instruction which the patient then performs at home.
A chiropractor who has been credentialed by your health plan may be more helpful than one whom you choose because they have an attractive website or because their office is conveniently located. One reason is that chiropractors who are HMO providers are more closely scrutinized by your health insurance plan and may be required to meet standards higher than those necessary for state licensure. They may also be expected to adhere to evidence-based guidelines that dictate the types of conditions they can treat, when X-rays and other diagnostic tests should be performed, and the length of treatment for various diagnoses.
Be wary of a chiropractor who will not commit to an end point of treatment. It's not always possible to predict the exact number of treatments or length of time necessary for treatment to succeed, but it should be possible to make a reasonable estimate of how long a particular condition will take to resolve with care, especially if it is one commonly treated by chiropractors. Many musculoskeletal complaints are self-limiting, i.e., they will improve or resolve on their own with the passage of time. It is the chiropractor's job to help you get better faster than time alone. If the chiropractor cannot provide at least an educated guess as to how long treatment will last, if she wants you to pay for treatments in advance, or if she tries to convert you to life-long care by claiming that regular adjustments will prevent illnesses or enhance your immune system, then you are in the wrong office.
What should you expect at the first visit?
It may surprise readers that X-ray examinations for the most common types of neck and back pain are rarely helpful and can actually be harmful. The harm lies not only in exposure to ionizing radiation (nobody has an X-ray deficiency), but in misinterpreting the findings or exaggerating their significance. (4) Arthritis, the degenerative wear-and-tear kind, can be seen in almost everyone over age 35. In most cases it is considered a coincidental finding. It often does not correlate with the presence of pain. Merely noting the presence of degenerative disease, as this type of arthritis is sometimes referred to, is enough to frighten some patients and push them toward chronic pain. Some chiropractors will try to convince you that subluxations are the cause of degeneration, and that their correction will prevent further deterioration. Evidence-based, peer-reviewed guidelines exist to help healthcare providers determine when radiographs (X-rays) are necessary. Chiropractors who have their own in-office X-ray equipment may be less trustworthy than those who refer patients to an independent X-ray facility as their opinion of the necessity of X-rays may be clouded by the profit made from taking X-rays.
Patients should never submit to X-rays taken for the purpose of determining the presence of vertebral subluxations. There are so many different methods for analyzing X-rays for this purpose that the likelihood of two chiropractors agreeing on where subluxations supposedly exist probably approaches chance alone. Full spine X-rays are to be avoided in almost all cases. (5) They not only require a large dose of radiation but very often result in poor diagnostic quality.
Another diagnostic technique that is best avoided is surface electromyography. sEMG uses electrodes applied to the skin surface to measure activity in the underlying muscles. Imbalances between the two sides of the spine at the various vertebral levels purportedly indicate subluxations. There is no scientific evidence to support such claims. Chiropractors often use these graphic printouts to "educate" patients on the presence of subluxations and the alleged need for frequent, prolonged treatment.
An ethical, evidence-based chiropractor will take your medical history, which means he will talk with you about your current problems and your past history of various maladies, not just musculoskeletal ones. A systems review should also be performed in which an inventory of body systems including cardiovascular, gastrointestinal, hematologic, and neurologic functions is reviewed. This chiropractor will also perform an appropriate physical examination focusing on the area(s) of complaint. This evaluation should consist of postural observations, a palpatory (manual) examination, range of motion assessment, orthopedic tests, and, if indicated, a neurological assessment of reflexes, muscle strength, and sensation.
The chiropractor should then inform you of his diagnostic impression and the recommended treatment plan. The risks of treatment, including the possibility of stroke from cervical (neck) manipulation, and the risks of forgoing care should be discussed as well as reasonable alternatives to the recommended course of care. Be wary of any chiropractor who wants to treat you first and then have you return to discuss your case. You should be given a clear explanation of your problem, the proposed treatment, and the expected outcome, and all your questions should be answered to your satisfaction. If the chiropractor tells you that she will first have to review the results of the history and physical examination before recommending a treatment plan, or if you are asked to return for a "report of findings" before treatment can be started, you can be certain that you will be given a sales presentation to persuade you to receive more care than your condition requires.
What treatment methods are used or recommended?
SMT (spinal manipulative therapy), CMT (chiropractic manipulative therapy), spinal manipulation, vertebral adjustments. These interchangeable terms are used to describe the kind of treatment a chiropractor will almost invariably perform. Chiropractors prefer the term adjustment as it implies a manipulation precisely applied to a specific vertebra (although research has determined that adjustments are not nearly as exact as chiropractors would believe). Adjustments intended to produce a pop or crack (6) performed by hand are the most common form of spinal manipulation. Most published research studies demonstrating effectiveness for chiropractic techniques have reported on manual manipulation.
Instrument-assisted adjustments are also widely employed but, depending on the technique, are supported by evidence either poorly or not at all. (7) Many chiropractors use the Activator instrument or one of several knock-off brands. This is a spring-loaded device that delivers an impulse to a spinal or extremity bone similar to a manual adjustment but doesn't produce an audible release — a crack or pop. Some people prefer this gentler technique. On the Activator Methods website you will find references to hundreds of research articles, but randomized controlled trials — the gold standard in medical research — are few. (8)
How long should treatment last?
If chiropractic treatments are going to help, there should be notable improvement within a short time, about three to six visits or 10 to 14 days. In my experience treating patients as well as performing independent examinations and record reviews for third parties, many patients attain maximum benefit by the end of the third week of care. There is often significant progress followed by a period of much slower progress, no improvement, or even worsening. Patients are best served by releasing them from care when they are significantly improved rather than trying to reach 100% resolution. Encouragement to continue a prescribed home exercise program should be given.
A reexamination performed at the end of the second week of care should be done. If meaningful improvement has not been attained, a different type of chiropractic treatment might be considered such as another adjusting technique or an alternative form of therapy. Depending on the condition, a short course of over-the-counter NSAIDs (nonsteroidal anti-inflammatory medicine like ibuprofen or naproxen) may be helpful. (9) If little or no improvement has been attained by the end of the fourth week, it's time to get a second opinion, either from another chiropractor or a different kind of healthcare provider. Diagnostic imaging — X-ray, CT, MRI — might be indicated at this time. If your chiropractor insists that a longer course of treatment is required, it may be time to take a walk. Remember that most conditions for which people seek chiropractic care will improve over time, and it is possible that spinal manipulation can make certain problems worse.
Beware of chiropractors who advertise themselves as Diplomates of the National Board of Chiropractic Examiners. It's not a bogus claim, but I suspect most people don't realize that all licensed chiropractors are diplomates of the NBCE. A diplomate is someone with a diploma or a certificate issued by a professional examining board. This title means that the chiropractor has passed the four-part examination given by the National Board of Chiropractic Examiners, which is a requirement for licensure in all 50 states. If your chiropractor advertises this certificate, you can be certain the doc is not a constipated termite because she has passed her boards ;) back
US Bureau of Labor Statistics, Occupational Outlook Handbook, https://www.bls.gov/ooh/healthcare/chiropractors.htm, accessed May 20, 2022. back
https://chiromt.biomedcentral.com/articles/10.1186/s12998-017-0165-8, accessed May 20, 2022. This global review of chiropractic services found that the most common reported reasons for people attending chiropractic care were low back pain (49.7%), neck pain (22.5%), and extremity problems (10.0%). back
A review of current evidence for the use of spinal X-ray in chiropractic practice published in 2018 concluded, "Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement." Jenkins et al. Current evidence for spinal X-ray use in the chiropractic profession: a narrative review. Chiropractic & Manual Therapies (2018) 26:48. back
The only legitimate reason for obtaining a full spine radiograph is for the evaluation of scoliosis, which is most often done for pubescent females who fail a scoliosis screening and may be at risk for progressive spinal curvatures. back
Schneider, Haas et al compared Activator to manual adjusting and usual medical care for low back pain. They concluded that manual thrust manipulation "provides greater short-term reductions in self-reported disability and pain scores" compared to usual medical care or mechanically assisted manipulation. (Schneider, Michael et al. “Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial.” Spine vol. 40,4 (2015): 209-17.) back
At least two states allow chiropractors to prescribe drugs. In Oregon, chiropractors can recommend prescription doses of over-the-counter drugs. New Mexico chiropractors have limited prescription privileges. back