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. Havard Medical Special Reports

Fact and Fiction About Chiropractic

Relieving low back pain — which affects 80%-90% of American adults at some point in their lives — has become one of modern medicine's holy grails. Even though nine out of ten people recover within a month without any treatment, our society spends more than $20 billion annually on medical care and disability compensation for back pain and injuries.

Despite decades of research, back pain remains as immutable as it is ubiquitous. Chiropractic is a system of treatment that attempts to solve the problem of back pain — and beyond. Practitioners of this century-old method carefully twist, press, or pull on a person's neck, shoulders, back, and hips in an attempt to restore normal motion and relieve pain. Each year, 15 million to 20 million Americans visit chiropractors.

Indeed, nearly everyone knows someone who swears by chiropractic — and not necessarily for back problems alone. Some chiropractors, a vocal minority, assert that manipulating the spine can alleviate such conditions as headache, asthma, and high blood pressure. Critics, on the other hand, counter that such claims remain unproven.

The truth about chiropractic probably lies somewhere in between. Although there is some evidence that spinal manipulation can temporarily relieve low back pain and, to a lesser extent, muscle spasms, strains, or sprains in the neck and shoulders, claims that chiropractic can treat other medical conditions lack scientific support.


How Chiropractic Began

Chiropractic derives from a Greek word meaning "done by hand." It was born in 1895, when an Iowa grocer named Daniel Palmer allegedly restored the hearing of a nearly deaf man by manipulating his spine. Palmer became convinced that pinched nerves caused by misalignments — or subluxations — of the vertebrae were responsible for almost all diseases. He thought that people would be healed of whatever ailed them once their spinal columns were adjusted to the correct position. Fueled by this belief, Palmer and his original supporters eschewed the modern medicine of the day.

Over time, chiropractors split into numerous factions. Some continued to focus solely on manually manipulating the spine to correct the subluxations that they believed triggered disease; others broadened their scope to include nutritional counseling or holistic healing approaches, such as homeopathy and herbal therapy.

Chiropractors of another small but growing faction renounce the chiropractic philosophy of subluxation and disease, but believe that there is a legitimate role for spinal manipulation in the treatment of low back pain. The National Association of Chiropractic Medicine (NACM) represents this view.

Because there is no scientific evidence to support the theory on which chiropractic was founded — that most diseases are caused by malfunctioning nerves — medical doctors have traditionally been skeptical of the field. Until 1980, the American Medical Association (AMA) deemed chiropractic an "unscientific cult" and declared it unethical for doctors to refer their patients to chiropractors. That policy changed in 1987 after five chiropractors won an antitrust suit against the AMA in which the medical association was found to have engaged in a conspiracy in restraint of trade.

Since then, chiropractic has slowly gained some acceptance from the medical community, in part, because chiropractors have become more willing to have their treatments evaluated in clinical studies. Today, chiropractors are licensed to practice in all 50 states, and most health insurers cover chiropractic — although, in general, only for back and neck pain.


Chiropractic in Practice

A landmark event in support of spinal manipulation came in 1994, when the federal Agency for Health Care Policy and Research (AHCPR) issued practice guidelines for treating acute low back pain (discomfort lasting less than a month that does not appear to arise from a serious underlying cause). After reviewing more than 4,000 studies on low back pain, an expert panel concluded that spinal manipulation appears to provide temporary relief of acute low back pain.

However, the panelists emphasized that the data support spinal manipulation only when used as a short-term therapy. Whether numerous visits to a chiropractor can provide additional benefit or whether manipulation can reduce the rate of recurrent episodes of back pain remains unknown.

Subsequently, however, in a study published in the New England Journal of Medicine, researchers from the University of Washington provided new data that qualified the AHCPR's conclusions. The researchers divided 321 people who had low back pain that had lasted for at least a week into three groups. One group received up to nine visits with a chiropractor; the second had a similar number of sessions with a physical therapist; and the final group had no special treatment other than an educational booklet on back pain. The people who went to physical therapists learned specific exercises designed to alleviate back pain; those who visited chiropractors underwent spinal manipulation.

While the results did not contradict AHCPR recommendations about chiropractic, they didn't show that undergoing spinal manipulation was any better than performing back exercises. The chiropractic and physical therapy groups recovered at the same rate, which was slightly faster than that of the control group. There was no difference among the three groups in terms of missed work, reduced activity, or recurrent episodes of low back pain during the subsequent year.

Back to Basics

Keeping in mind that 90% of people with acute back pain recover on their own within six weeks, individuals must weigh for themselves whether visiting a chiropractor for short-term relief is worth their time or money. People who feel it works for them should not hesitate to stick with it. However, it's important to see a primary care doctor when back pain interferes with daily activities so he or she can rule out conditions that would require medical attention such as a fracture, infection, or tumor.

In general, spinal manipulation appears to be safe for people with uncomplicated back pain; very few adverse effects have been reported in clinical studies. However, people with rheumatoid arthritis, sciatica (leg pain caused by nerve pressure or damage), and osteoporosis should consult a medical doctor first, because it is possible that spinal manipulation could worsen these conditions.

There is some, although less convincing, research indicating that chiropractic adjustment of the upper back can temporarily ease neck pain. Experts sound a note of caution when it comes to manipulation of the high spine (neck area); this sort of manipulation can worsen an already damaged spinal cord and, in rare cases, can compress a neck artery and cause a stroke.

Choosing a Chiropractor

An individual with low back pain who decides to try chiropractic should ask his or her doctor to recommend a chiropractor with a good track record. Look for one who treats primarily musculoskeletal conditions and who frequently consults with medical doctors. The NACM can also provide referrals.

Although a chiropractor may have reason to take a back x-ray during an initial visit, be skeptical if he or she orders such x-rays repeatedly or performs full-spine x-rays, which are believed to be of little diagnostic benefit. Find another chiropractor if you are being pushed to use nutritional supplements or herbal products as part of the therapy. Finally, use common sense. Stop therapy immediately if you feel the adjustments have made the pain significantly worse.

Guidelines for Chiropractic

Here are guidelines from the Agency for Health Care Policy and Research for chiropractic manipulation for the treatment of acute low back pain:
  • Chiropractic manipulation can be helpful for patients with acute low back problems (without nerve involvement) when used within the first month of symptoms.


  • When findings suggest progressive or severe neurologic defects, appropriate diagnostic assessment to rule out serious neurologic conditions is indicated before beginning manipulation therapy.


  • There is insufficient evidence to recommend chiropractic manipulation for patients with spinal nerve problems.


  • A trial of chiropractic manipulation in patients without spinal nerve problems is probably safe but effectiveness is unproved.


  • If manipulation has not resulted in improvement of symptoms that allows increased functioning after one month of treatment, manipulation should be stopped and patient should be reevaluated.



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Source: from "Alternative Medicine", Harvard Health Publications, Copyright � March 2001 by President and Fellows of Harvard College. All rights reserved. Used with permission of StayWell.