Chiropractic is a health care discipline concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal manipulation (“chiropractic adjustment”) and other joint and soft-tissue therapies. Although it is one of the youngest of the natural healing arts, chiropractic has gained tremendous growth. Chiropractors are trained as non-pharmaceutical, non-surgical specialists of the spine and musculoskeletal system. While many chiropractors acknowledge the important use of medication and surgery in appropriate cases, they do not prescribe drugs or perform any invasive procedures, including injections. The primary treatment administered by chiropractors is spinal manipulation or other manual therapies. Often chiropractors will include exercise prescription, stretching, lifestyle modifications, and/or nutritional counseling in their treatments.
On your initial visit, your chiropractor should perform a thorough examination, reviewing your past health, family and social history as well as your past/current treatments and medications. If indicated, your chiropractor may order imaging such as X-ray, MRI or CT.
Once a proper diagnosis has been established, your chiropractic physician should thoroughly review your condition with you and initiate a treatment plan that may consist of spinal manipulation or other manual therapies, exercise prescription, stretching, lifestyle modifications, and/or nutritional counseling. Subsequent treatment sessions typically last about 20 minutes. However, depending upon the depth and scope of care necessary, ranges of treatment duration may vary.
Spinal manipulation is an intervention commonly administered by chiropractors or physical therapists with the goal of restoring proper joint function and decreasing pain. This therapy is most often done by hand (manually) in the form of a high-velocity low-amplitude (HVLA) thrust, or, in some cases, with the use of a special instrument or specifically designed table. Clinicians perform HVLA spinal manipulation by applying a rapid thrust to a targeted joint. Often when this is completed, a popping or clicking sound called “joint cavitation” occurs. This is thought to occur as a result of pressure changes within the normal fluid of the joint and is considered a natural and generally pain-free response.
Spinal mobilization, a similar form of manual therapy, is often interchangeably utilized with spinal manipulation. The goal of spinal mobilization is the same as spinal manipulation; to restore proper joint function and decrease pain. Spinal mobilization is typically performed by hand (manually) in the form of a lower-velocity low-amplitude thrust compared to HVLA spinal manipulation.
Currently, there is no specific explanation on how spinal manipulation works. The exact mechanism is not clear. Current models that may explain the treatment benefits appreciated following spinal manipulation include: release of entrapped synovial folds or plica, relaxation of hypertonic paraspinal musculature, disruption of articular/periarticular lesions, unbuckling of vertebral motion segments, facet joint distraction, and stimulation of neural and central nervous system mediated reflexes.
When the correct manipulation technique is paired with the appropriately selected patient, spinal manipulation is a safe procedure. Potential side effects and complications have been associated with spinal manipulation and have been identified in scientific literature. Most adverse events reported are considered “benign and transitory”. More common side effects can include temporary headaches, tiredness, or discomfort in the area of treatment.
Rare, yet concerning, potential complications have been identified with spinal manipulation, particularly when performed on the upper spine, such as vertebral basilar artery (VBA) injury. True incidence of such events is unknown and frequencies of serious adverse events associated with chiropractic utilization vary within scientific literature. However a 2008 study published in SPINE, encompassing 9 years of medical records and over 100 million patient years, found no evidence of increased risk of VBA stroke associated with chiropractic treatments, compared to primary medical care. Additional studies have indicated the risk of death associated with cervical spine manipulation is 100-400 times less than the risk of death for NSAID medication for osteoarthritis. Although it appears the relative risk of adverse events associated with cervical spine manipulation is low, recent studies show that adverse reactions are more likely to be reported ensuing cervical spine manipulation as opposed to cervical spine mobilization. It has been suggested that cervical spine mobilization may be a preferred treatment to cervical spine manipulation.
Chiropractors typically treat musculoskeletal ailments, particularly spine related disorders. Common conditions by chiropractors include:
Mechanical/Non-Specific Back or Neck Pain
Muscle or Soft Tissue Pain Syndromes
Sprains/Strains of the Spine
Sacroiliac Joint Pain
Intervertebral Disc Disorders
Certain Types of Headache
Controlled Radiculopathies of Spinal Origin
Pregnancy Related Back Pain
Although it is not necessary to obtain a referral, you may consider asking your primary care provider for a recommendation for a chiropractor. Additionally, The Journal of Family Practice (1992) has published the following guidelines to consider when selecting a chiropractor:
Treats mainly musculoskeletal disorders
Does not radiograph every patient
Willing to be clinically observed
Positive feedback from patients
Communicates with the referring physician
Administers reasonable treatment programs
Does not charge a global, up-front fee
World Federation of Chiropractic. Definitions of Chiropractic. (Accessed 2013 April 22). http://www.wfc.org/website/index.php?option=com_content&view=article&id=90&Itemid=110&lang=en.
Yeh GY, Phillips RS, Davis RB, Eisenberg DM, Cherkin DC. Visit time as a framework for reimbursement: time spent with chiropractors and acupuncturists. Alternative Therapies in Health and Medicine. 2003, 9(5):88-94.
National Center for Complementary and Alternative Medicine (NCCAM). Spinal Manipulation for Low-Back Pain. (Accessed 2013 April 22). http://nccam.nih.gov/health/pain/spinemanipulation.htm.
American Chiropractic Association. Frequently Asked Questions. (Accessed 2013 April 22). http://www.acatoday.org/level3_css.cfm?T1ID=13&T2ID=61&T3ID=152#select.
Reggars JW. The manipulative crack. Frequency analysis. Australas Chiropr Osteopathy. 1996 Jul;5(2):39-44.
Mierau D, Cassidy JD, Bowen V, Dupuis P, Notfall F. Manipulation and mobilization of the third metacarpophalangeal joint - a quantitative radiographic and range of motion study. Manual Med. 1988; 3: 135-40
Unsworth A, Dowson D, Wright V. Cracking joints - a bioengineering study of cavitation in the metacarpophalageal joint. Ann Rheum Dis 1971; 30: 348-58.12.
Roston JB, Wheeler-Haines R. Cracking in the metacarpophalangeal joint. J Anat. 1947; 81: 165-73.
Herzog W. The biomechanics of spinal manipulation. Journal of Bodywork & Movement Therapies. (2010) 14, 280e286.
Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics. Volume 25, Issue 4, May 2002, Pages 251–262.
Maigne JY, Vautravers P. Mechanism of action of spinal manipulative therapy. Joint Bone Spine. 2003 Sep;70(5):336-41.
Sung PS, Kang YM, Pickar JG. Effect of spinal manipulation duration on low threshold mechanoreceptors in lumbar paraspinal muscles: a preliminary report. Spine (Phila Pa 1976). 2005 Jan 1;30(1):115-22.
Dishman JD, Bulbulian R. Spinal reflex attenuation associated with spinal manipulation. Spine (Phila Pa 1976). 2000 Oct 1;25(19):2519-24;discussion 2525.
Pickar JG. Neurophysiological effects of spinal manipulation. Spine J. 2002 Sep-Oct;2(5):357-71.
Bicalho E, Setti JA, Macagnan J, Cano JL, Manffra EF. Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects. Man Ther. 2010 Oct;15(5):469-75. doi:10.1016/j.math.2010.03.012. Epub 2010 May 5.
Cramer GD, Cambron J, Cantu JA, Dexheimer JM, Pocius JD, Gregerson D, Fergus M, McKinnis R, Grieve TJ. Magnetic resonance imaging zygapophyseal joint space changes (gapping) in low back pain patients following spinal manipulation and side-posture positioning: a randomized controlled mechanisms trial with blinding. J Manipulative Physiol Ther. 2013 May;36(4):203-17. doi: 10.1016/j.jmpt.2013.04.003. Epub 2013 May 3.
Cramer GD, Ross K, Raju PK, Cambron J, Cantu JA, Bora P, Dexheimer JM, McKinnis R, Habeck AR, Selby S, Pocius JD, Gregerson D. Quantification of cavitation and gapping of lumbar zygapophyseal joints during spinal manipulative therapy. J Manipulative Physiol Ther. 2012 Oct;35(8):614-21. doi: 10.1016/j.jmpt.2012.06.007. Epub 2012 Aug 14.
Haavik Taylor H, Murphy B. The effects of spinal manipulation on central integration of dual somatosensory input observed after motor training: a crossover study. J Manipulative Physiol Ther. 2010 May;33(4):261-72. doi: 10.1016/j.jmpt.2010.03.004.
Haavik-Taylor H, Murphy B. Cervical spine manipulation alters sensorimotor integration: a somatosensory evoked potential study. Clin Neurophysiol. 2007 Feb;118(2):391-402. Epub 2006 Nov 29.
Pickar JG, Bolton PS. Spinal manipulative therapy and somatosensory activation. J Electromyogr Kinesiol. 2012 Oct;22(5):785-94. doi: 10.1016/j.jelekin.2012.01.015. Epub 2012 Feb 19.
Clark BC, Goss DA Jr, Walkowski S, Hoffman RL, Ross A, Thomas JS. Neurophysiologic effects of spinal manipulation in patients with chronic low back pain. BMC Musculoskelet Disord. 2011 Jul 22;12:170. doi: 10.1186/1471-2474-12-170.
Gouveia, LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine (Phila Pa 1976). 2009 May 15;34(11):E405-13. doi: 10.1097/BRS.0b013e3181a16d63
National Center for Complementary and Alternative Medicine (NCCAM). Chiropractic: An Introduction. (Accessed 2013 April 22). http://nccam.nih.gov/health/chiropractic/introduction.htm.
Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012 Oct;22(5):740-6. doi: 10.1016/j.jelekin.2012.03.005. Epub 2012 Apr 5.
Boyle E, Côté P, Grier AR, Cassidy JD. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S170-5. doi: 10.1097/BRS.0b013e31816454e0.
Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S176-83. doi: 10.1097/BRS.0b013e3181644600.
Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Man Ther. Aug 2010;15(4):355-363.
Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther. Oct 1995;18(8):530-536.
Hurwitz EL, Morgenstern H, Vassilaki M, Chiang, LM. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA neck pain study. Journal of Manipulative and Physiological Therapeutics. 2004 Jan;27(1):16-25.
Hurwitz EL, Morgenstern H, Vassilaki M, Chiang, LM. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study. Spine (Phila Pa 1976). 2005 Jul 1;30(13):1477-84.
Shekelle PG, Brook RH. A community based study of the use of chiropractic services. Am J Public Health. 1991;81(4):439–442.
Christensen M, Kollasch M, Hyland JK. Practice Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners; 2010.
Nyiendo J, Haldeman S. A prospective study of 2,000 patients attending a chiropractic college teaching clinic. Med Care. 1987;25(6):516–527.
Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle P. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine. 2002;27(3):291–296.
Ailliet L, Rubinstein SM, de Vet HC. Characteristics of chiropractors and their patients in Belgium. J Manipulative Physiol Ther. 2010;33(8):618–625.
Curtis P, Bove G. Family physicians, chiropractors and back pain. J Fam Pract. 1992;35:551-5.
Pregnancy & Back Pain
Radiographic Assessment of Spinal Disorders
Sacroiliac Joint Pain