Mr Keyur V Shastri
Chiropractic (from Greek chiros and praktikos meaning "done by hand") is a health care profession whose purpose is to diagnose and treat mechanical disorders of the spine and musculoskeletal system with the intention of affecting the nervous system and improving health.
Manual therapies have been practiced in virtually all societies and cultures throughout recorded history. In western civilization, its practice is recorded in the works of Hippocrates and Galen and has survived to the present in various forms in different societies. In Japan, the majority of practitioners of spinal manipulation are lay practitioners, while in Europe a large percentage are medical physicians who have additional training in the practice. In North America, some medical and osteopathic physicians offer spinal manipulation. Although the osteopathic profession was the first in the USA to organize a body of knowledge in the practice, the great majority of osteopaths do not practice manipulation. At this point of time chiropractors provide the vast majority of these services in North America as well as in many other parts of the world, and are equated in the public perception with the practice of spinal manipulation. Currently, well in excess of 90% of spinal manipulations in the USA are delivered by chiropractors. They also provide a growing percentage of these treatments in Japan, Australia, New Zealand, South Africa and many parts of Europe. This article concerns itself with the current state of chiropractic, focusing on its place in the health-care system in the USA.
Chiropractic: Basic Concept
Chiropractic is based on the premise that a spinal joint dysfunction can interfere with the nervous system and result in many different conditions of diminished health. It takes a different approach from standard medicine in treating health problems.
The basic concepts of chiropractic are:
1) Your body has a powerful self-healing ability
2) Your body's structure (mainly the spine) and its function are related
3) The goal of chiropractic therapy is to normalize this relationship
Chiropractic was founded in 1895 by D. D. Palmer, and it is now practiced in more than 100 countries. The history of Chiropractic has been shaped by philosophical conflicts within the profession and by criticism from outside the profession. Chiropractic treatments vary depending on the patient's condition and the type of approach taken by the particular chiropractor. They commonly include spinal adjustments, although other interventions may be used as well. Today there are four main groups of chiropractors: "traditional straights", "objective straights", "mixers", and "reform." All groups, except reform, treat patients using a subluxation-based system. Differences are based on the philosophy for adjusting, claims made about the effects of those adjustments, and various additional treatments provided along with the adjustment.
History of the basic premise
Chiropractic was founded in 1895 by Daniel David Palmer, based on his assertion that 95% of all health problems could be prevented or treated using adjustments of the spine (spinal adjustments), and 5% by adjustments of other joints, to correct what he termed vertebral subluxations. He, and later his son B.J. Palmer, proposed that subluxations were misaligned vertebrae, which caused nerve compression that interfered with the transmission of what he named Innate Intelligence. This interference interrupted the proper flow of Innate Intelligence from "above, down, inside, and out" (ADIO) to the organ to which it traveled. As a result, the human body would experience "dis-ease" or disharmony, which would result in loss of health.
Manipulation of the spine, when performed by a chiropractor, is frequently referred to as an adjustment. Though spinal manipulation for back pain has been documented from the time of the ancient Egyptians, and early osteopaths practiced generalized spinal maneuvers, the attempt to precisely correct theoretical vertebral subluxations is a uniquely chiropractic endeavor. A modern chiropractor may specialize in spinal manipulations only, or may use a wide range of methods intended to address an array of neuromusculoskeletal and general health issues. Examples include massage, strength training, dry needling (similar to acupuncture), functional electrical stimulation, traction, and nutritional recommendations. Some chiropractors specialize in chiropractic sports medicine, which includes manipulation of the extremities, and exercises to increase spinal strength. Chiropractors may also use other complementary alternative methods as part of a holistic treatment approach.
Origins of Chiropractic and the concept of subluxation
DD Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He held that a malposition of spinal bones, which protect the spinal cord and nerve roots, interfered with the transmission of nerve impulses. Because half of the nervous system is sensory and the other half motor (control), he postulated that living things had an Innate intelligence, a kind of "spiritual energy" or life force that received the sensory information from the various parts of the body and made a decision as to what the motor nerves should convey. DD Palmer claimed that subluxations interfered with this innate intelligence, and that by fixing them, all diseases could be treated. He qualified this by noting that knowledge of Innate Intelligence was not essential to the competent practice of chiropractic. The idea that all diseases were the result of a subluxation was in line with the common thinking of the day; that there was one cause for disease. The vitalistic concepts implied an intelligent governing entity that was readily perceived as spiritual constructs by many both inside and outside the profession. Chiropractors used these metaphorical concepts to rationalize their thinking about the body’s self-healing capacity. In 1998, Lon Morgan DC, a reform chiropractor, wrote that: "Innate Intelligence clearly has its origins in borrowed mystical and occult practices of a bygone era. It remains untestable and unverifiable and has an unacceptably high penalty/benefit ratio for the chiropractic profession. The chiropractic concept of Innate Intelligence is an anachronistic holdover from a time when insufficient scientific understanding existed to explain human physiological processes. It is clearly religious in nature and must be considered harmful to normal scientific activity." Debate about the need to remove the concept of subluxation from the chiropractic paradigm has been ongoing since the mid 1960s. While straights hold firmly to the term and its vitalistic construct, reformers suggest that the mechanistic model will allow chiropractic to better integrate into mainstream medicine without making claims inherent in the term. Anthony Rosner PhD, director of education and research at the Foundation for Chiropractic Education and Research (FCER) considered subluxation and the concept of Occam's razor. He suggests "there is no obvious reason to discard the concept of subluxation, while at the same time maintaining that it is not a rigid entity, but rather an important model and concept; a work in progress that undoubtedly will undergo extensive modification as our concepts of light or psychoanalysis have evolved over half a century." Despite the term's vitalistic roots, chiropractic today may still use the term Innate Intelligence; however, it has taken on a less metaphysical meaning. Innate Intelligence today is used to describe the self-healing power of the body.
Thus, a modern chiropractic view is that by removing the restrictions caused by subluxation, the chiropractor is improving the body's own potential for self-healing.
It should be noted, however, that not all chiropractic institutions subscribe to the vertebral subluxation theory; notably schools in Canada, Denmark and the United Kingdom have rejected the subluxation model in favour of an evidence-based framework.
Chiropractic’s approach to healthcare
According to Robert Mootz D.C. and Reed Phillips D.C., Ph.D., although chiropractic has much in common with other health professions, its philosophical approach distinguishes it from modern medicine. Chiropractic philosophy involves what has been described as a "contextual, naturopathic approach" to health care.The traditional, "allopathic" or "medical" model considers disease as generally the result of some external influence, such as a toxin, a parasite, an allergen, or an infectious agent: the solution is to counter the perceived environmental factor (e.g., using an antibiotic for a bacterial infection). By contrast, the naturopathic approach considers that lowered "host resistance" is necessary for disease to occur, so the appropriate solution is to direct treatment to strengthen the host, regardless of the environment. In contemporary clinical practice, one can find elements of both naturopathic and allopathic philosophy among all types of providers. The degree to which a practitioner emphasizes different tenets of these philosophies is one factor that determines the manner in which they practice.
Chiropractic Perspectives that reflect a hoilistic approach to patient care
§noninvasive, emphasizes patient’s inherent recuperative abilities.
§recognizes dynamics between lifestyle, environment, and health
§emphasizes understanding the cause of illness in an effort to eradicate, rather than palliate, associated symptoms
§recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body
§appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system
§balances the benefits against the risks of clinical interventions
§recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures
§prevents unnecessary barriers in the doctor-patient encounter
§emphasizes a patient-centered, hands-on approach intent on influencing function through structure
§strives toward early intervention, emphasizing timely diagnosis and treatment of functional, reversible conditions
Alternative, Complementary or Mainstream:
There has been considerable debate, both inside and outside the profession, regarding the role(s) chiropractors should play in health-care delivery system. The most common way in which chiropractors practice is as limited musculoskeletal specialists, dealing primarily with painful conditions either independently or, increasingly, as part of an interdisciplinary team. There are some chiropractors still advocating a broad practice as general primary (alternative/complementary) health-care providers not limited to musculoskeletal conditions. Although all three of these practice models can be found within the chiropractic profession, all the studies have shown that chiropractors treat a limited array of conditions, with up to two-thirds of patients presenting with low back pain.
Chiropractors has become so commonly utilized and tightly woven into fabric of health care in the USA that some have argued that it has entered the health-care mainstream.
Even when chiropractic services are not performed as an integrated part of medical care for their condition, most patients utilize chiropractic services in combination with traditional medical care. Therefore, it has become increasingly common to refer to chiropractic as ‘complementary’, rather than ‘alternative’
Treatment approaches utilized by Chiropractors
Throughout the slightly more than 100 years of the chiropractic profession, the predominant treatment tool has been the chiropractic adjustment or spinal manipulative therapy (SMT).In a retrospective review of office records of 1310 patients who sought chiropracitic care for low back pain, 1088 (83%) received spinal manipulation. Manipulation is the term typically applied to movements that are induced at end of normal range of motion and that intrude on the paraphysiological range. It is defined as beyond the passive range of motion but less than would be necessary to disrupt spinal integrity. Most manipulative techniques carry the joint to the end of passive range of motion, with subsequent introduction of a rapid but low amplitude force to move the joint into this paraphysiological range. These manipulative procedures have been termed high-velocity, low-amplitude (HVLA) manipulations. Manipulative methods that apply forces to one of the processes of a vertebra are termed ‘short-lever’ techniques. Other manipulative procedures direct the primary manipulative force through an arm or leg. These are termed ‘long-lever’ techniques. There are several other types of procedure employed by chiropractors under the broad rubric of spinal manipulative procedures are initiated from a neutral position, so-called ‘recoil’ techniques. There are procedures that employ instruments to introduce the adjustive force. The most common of these procedure, called activator technique, utilizes a hand-held, spring-loaded device. The precise technique used by most chiropractors varies on the basis of the particular area treated. There are literally dozens of short-lever HVLA procedures that have been incorporated into the body of procedures that has been termed ‘diversified technique’. Spinal manipulation is not the only form of treatment provided by chiropractors. Contemporary chiropractors incorporate many physical modalities such as heat, cold, ultrasound, electrical stimulation and traction. These are usually utilized in conjunction with, and often in preparation for, the spinal adjustment. Many chiropractors advise on therapeutic exercises as a regular part of their treatment regimen and increasingly incorporate full rehabilitation programs. In addition, chiropractors often counsel their patients on nutrition and at times will provide vitamins and supplements as a regular part of their treatment regimen.
Research Trials on Chiropractic and Manipulation
Chiropractic treatment is more than spinal manipulation and it is recognized that the more tightly controlled studies of spinal manipulation deviate the most from normal clinical practice. Therefore, there is a body of pragmatic investigation that has compared patients randomized to treatment by chiropractors versus those treated by other methods. Most of these studies have been conducted on back, neck and head pain, and the conditions that are most likely to appear in chiropractors’ practices.
The success rates reported for manipulation in uncontrolled case series and in comparative trials are between 60 and 100%. However, particularly in the case of spinal pain, the general tendency for many patients to improve spontaneously, the problem of different populations of patients and pathological conditions causing pain, coupled with the potentially potent placebo effect of treatment makes it difficult to compare these studies and determine success. Whenever there is no effective placebo group included in a clinical trial, the role of the placebo effect must be considered as a potential mechanism, to explain a beneficial outcome. Further more, it has been pointed out that designing an appropriate placebo for physical interventions may be particularly difficult. The majority of these studies have specifically evaluated outcomes of patients randomized to chiropractic treatment versus those managed by conventional medical means or by physical therapists.
Disc herniation and sciatica
Currently, there are no randomized clinical trials of chiropractic treatment of patients with sciatica and disc herniation. However, there have been a number of case studies and reports that suggest that SMT may be useful for such patients. In a review of data from the back pain clinic at the Royal University Hospital in Saskatoon, the use of side-lying chiropractic SMT (i.e. high-velocity, low-amplitude thrust techniques) was reported to be both safe and effective for the treatment of lumbar disc herniation.
In another case series, 71 patients presenting to a chiropractic clinic with low back pain plus sciatica were studied. Ninety per cent of the patients who received a course of treatment reported subjective improvement in both range of motion and nerve root tension signs. These authors concluded that SMT might be a safe, non-surgical treatment for low back and radiating leg pain. However, the lack of a control group makes it impossible to determine whether the improvement could be directly attributed to the manipulation. Despite these promising descriptive case series, it appears that patients with demonstrated disc herniation and sciatica do less well following manipulation than patients with uncomplicated back pain
Carpel tunnel Syndrome
There is one randomized, controlled trial that evaluated the effect of chiropractic in the treatment of carpal tunnel syndrome. This study by Davis and co-workers randomized patients with documented carpal tunnel syndrome into two treatment groups, one receiving chiropractic care and the other conventional medical treatment. The chiropractic group received manipulation of the soft tissues and bony joints of the upper extremities and spine (three treatments per week for 2 weeks, two treatments per week for 4 weeks), ultrasound over the carpal tunnel and nocturnal wrist supports. Those in the medical treatment group received ibuprofen (800 mg three times a day for 1 week, 800 mg twice a day for 1 week and 800 mg as needed to a maximum daily dose of 24000 mg go 7 weeks as well as nocturnal wrist supports. Outcome measures included pre and post-assessments of self-reported physical and mental distress, nerve conduction studies and vibrometry. There was significant improvement in both groups in terms of perceived comfort and function, nerve conduction values and finger sensation. However, these investigators found no significant differences between the groups. Since there was no control, if is again not clear whether either intervention was better than doing nothing. It is noteworthy that the manipulation group offered significant advantage in terms of complications, with 22% of those receiving ibuprofen reporting some intolerance and 11% reporting severe side-effects requiring discontinuation of the medication. In contrast, only one patient in the chiropractic group complained of a temporary sore neck because of the manipulation. This would at least suggest that chiropractic treatment is a viable alternative for management of carpal tunnel related symptoms.
More recent literature includes reference to treatment of conditions as diverse as myasthenia gravin, epilepsy, Parkinson’s disease, reflex sympathetic dystrophy, torticollis, cervical dystonia, fibromyalgia and Erb’s palsy without adequate explanation.
Chiropractic treatment of asthma has been investigated in two randomized clinical trials, which failed to find any objective benefit of manipulation in comparison to treatment as usual, although patients treated by chiropractors rated their symptoms after treatment as being less severe, and their quality of life as improved. A systematic review of the literature concluded that there was insufficient evidence to support the use of manual therapies for patients with asthma, while there was a need for additional studies on the subject.
Another observation that has been the subject of rigorous scrutiny is the potential effectiveness of chiropractic treatment of infantile colic. Two randomized controlled trials have been conducted, both of comparable design and of good quality.
The two major differences between these studies were in the degree of blinding of parents who completed the crying diary and in the treatments that were permitted. In one trial, parents were blinded as to the assigned treatment group, adding credence to their conclusion that chiropractic offers no greater efficacy in treating infantile colic than placebo.
Since the end of the 19th century, chiropractic has moved from a profession that was ostracized and marginalized to a position where integration into the mainstream health-care system is not only possible, but is actually in process. This has been largely due to the development of a defined and regulated chiropractic educational process, licensure, insurance recognition and a growing body of clinical research that supports the use of chiropractic treatment for some conditions. These privileges have come about primarily through a strong public demand for chiropractic and a commitment on the part of chiropractic academic institutions to outcomes-based research to evaluate clinical claims.
The exact role of chiropractors in the treatment of disorders outside the classic realm of the musculoskeletal system, however, remains controversial. Although there is a reasonable body of controlled clinical research to support a role for chiropractors in the treatment of low back pain, neck pain and certain types of headache, it is not yet easy to identify the patient most likely to respond to manipulative treatment. The exact mechanism by which manipulation obtains its success is not well understood, although this is an arena of increased study. The issue of claims for effectiveness based on anecdotal experience and case reports remains a source of contention between chiropractors and medical practitioners. These issues are slowly being addressed and it can be expected that the future will bring greater clarity in our understanding of the role of chiropractic, if any, in the care of patient with disorders beyond the musculoskeletal system. It can be anticipated that patient will continue to seek the care of chiropractors in ever-greater numbers. Improvement in understanding of the role of chiropractors and other alternative and complementary practices should therefore be considered to in the best interest of the significant fraction of patients who combine these treatments with more conventional medical care.
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Mr Keyur V Shastri
M.Pharm, P.D.C.R, Lecturer, Abhinav Education Society’s College of Pharmacy (B.Pharm)
A/P. Narhe, Tal Haveli, Narhe Dist Pune- 411046 India
Dr. Vishal Vijay Pande
Ph D, M Pharm, Asstt Prof.- Dept. Of Pharmaceutical Analysis
JSPM’S, Jayawantrao Sawant, College of Pharmacy & Research, Hadapsar, Pune -411028. India.
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Prof. Jain Brijendra Brajmohan
Ph D, M Pharm, M M S. Principal, JSPM’S, Jayawantrao Sawant , College of Pharmacy & Research, Hadapsar, Pune -411028. India.
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M Pharm, Lecturer, Allana College of Pharmacy, Pune.
Prof. Avinash R. Tekade
M Pharm, Asstt. Prof - Dept. of Pharmaceutics & Quality Assurance, SES’R.C. Patel College of Pharmacy, Shirpur, Dist. Dhule.
Prof. Rajendra D Patankar
M Pharm, Principal, Abhinav Education Society’s College of Pharmacy (B.Pharm)
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