[Paleopsych] Chirobase: What a Rational Chiropractor Can Do for You

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What a Rational Chiropractor Can Do for You

[Mr. Mencken praise chiropractioners many times, on the grounds that a 
visit to one would mean one less radio fan. He saw this as the Darwinian 
selection process at work.]

                             Samuel Homola, D.C.

    Spinal manipulation can relieve some types of back and neck pain and
    other conditions related to tightness and loss of mobility, such as
    tension headache or aching in muscles and joints. We also know that
    massage may be as effective as cervical manipulation in relieving
    tension headache. And physical therapy techniques may be as effective
    as spinal manipulation in long-term relief of back pain. Rational
    chiropractors can offer all of these modalities, when appropriate, and
    thus provide patients with a choice. They may also offer basic advice
    about nutrition, weight loss, exercise, ergonomics, relaxation
    techniques, body mechanics, home care (such as use of hot or cold
    packs), massage, and other self-help measures that might help relieve
    or prevent aches and pains.

    Science-based chiropractors make appropriate judgments about the
    nature of their patients' problems, determine whether these problems
    lie within their scope, and make appropriate referrals for problems
    that do not. If you can find one who uses manipulation and physical
    therapy appropriately and who is willing to coordinate with your
    personal physician, you can benefit from the best that both have to

     Diagnosis Essential

    While some types of back pain can benefit from spinal manipulation,
    not every patient who sees a chiropractor needs it. Proper diagnosis
    should precede treatment of any type. This is why, if you consult a
    chiropractor, it is crucial to choose one who can make an appropriate
    diagnosis, uses spinal manipulation only when indicated, does not
    order unnecessary x-rays, and refers to an appropriate physician when
    needed. Chiropractors whose practice is not based on subluxation
    theory are in the best position to judge whether your problem requires
    medical treatment. Never rely upon the diagnosis of a straight
    chiropractor or one who "specializes" in such fields as internal
    medicine, neurology, or pediatrics.

    Back-pain sufferers who have been diagnosed with musculoskeletal pain
    and have reservations about spinal manipulation should ask their
    physician whether a referral for physical therapy is appropriate for
    their condition. (Actually, many chiropractors offer physical therapy
    modalities as well as manipulation.) A study published in 1998 in The
    New England Journal of Medicine found that the long-term effectiveness
    of chiropractic manipulation was no better than the McKenzie method of
    physical therapy (an exercise program) [1]. However, many patients
    have told me that manipulation was more effective in providing
    immediate relief.

     Manipulation vs. Mobilization

    Manipulation and mobilization are used primarily in the treatment of
    conditions related to mechanical-type problems in joints and muscles.
    Manipulation is a hands-on procedure used to restore normal movement
    by loosening joints and stretching tight muscles. In some cases,
    manipulation will restore normal movement by unlocking a joint or by
    breaking down adhesions. A popping sound often occurs when a spinal
    joint is stretched a little beyond its normal range of motion.
    Mobilization simply stretches soft tissues by moving joints through a
    full range of movement. Mobilization can increase the range of motion
    of the arms, legs, and shoulders, but manipulation may be more
    effective in relieving pain and restoring normal movement in the
    spinal joints.

    Any portion of the spine that is tight, stiff, or painful on movement
    might benefit from appropriate manipulation. Different methods are
    used in different portions of the spine, since joint structure and the
    direction of movement in the neck and upper back differ from those of
    the lower back. For example: neck manipulation might be done while the
    patient sits on a stool; upper-back manipulation might be done while
    the patient lies facedown; and lower-back manipulation might be done
    while the patient lies on one side. Dozens of manipulative techniques
    can be used to meet the special needs of patients who must be
    positioned one way or another. Tables with specially designed cushions
    are used to support patients in certain postures.

     Neck Manipulation

    Manipulation may improve the mobility of a cervical spine that has
    been stiffened by osteoarthritis or by scar tissue from an old injury.
    Disc degeneration caused by wear and tear or by injury is a common
    cause of loss of range of motion in the cervical spine and can often
    benefit from manipulation. Neck manipulation or mobilization may
    improve range of motion and provide relief for neck pain and
    muscle-tension headache. But remember that benefit must be weighed
    against risk. Neck manipulation should not be used unless symptoms
    indicate a specific need for it. It should be done gently with care to
    avoid excessive rotation that could damage the patient's vertebral
    artery. Neck manipulation should not be done immediately after an
    injury that causes acute neck pain. When the acute pain subsides,
    usually after a few days, manipulation may be useful to relieve
    fixations and restore normal joint mobility. Once the patient is
    symptom-free, it should be discontinued. A small percentage of
    chiropractors advocate neck manipulation to "balance" or "realign" the
    spine no matter where the patient's problem is located. I recommend
    avoiding such chiropractors.

    Neck manipulation is safest when neck rotation does not exceed 50
    degrees. When rotation is not indicated or appropriate, special
    techniques can be used with the patient in a face-down position so
    that manipulative traction can be applied or there can be thumb
    contact with specific spinal segments.

    Patients who have pain caused by acute inflammation, as in rheumatoid
    arthritis or spondylitis, will rarely benefit from neck manipulation.
    Damage to upper cervical connective tissues in rheumatoid arthritis
    can also be a contraindication. When in doubt about whether you should
    undergo neck manipulation, check with an orthopedist. A competent
    chiropractor should not object to your seeing a specialist for a
    second opinion.

    Tension headaches, often called muscle-contraction headaches, may
    benefit from manipulation that loosens joints and stretches tight neck
    muscles. Some chiropractic case reports suggest that migraine headache
    can be relieved with cervical manipulation. However, true migraine is
    unlikely to be relieved by neck manipulation.

    Any kind of persistent headache should be brought to the attention of
    your family physician or a neurologist. And so should any headache
    accompanied by fever, vomiting, weakness, a change in speech or
    vision, or any other unexplained symptoms. Severe headaches may
    require medical attention for pain relief.

    Before submitting to the risk of cervical manipulation for the
    treatment of headache, it is essential to determine whether the
    problem might be caused by a sinus infection, food sensitivity, a
    brain tumor, or another cause unrelated to the cervical spine.
    Fortunately, most headaches are of the simple tension or
    muscle-contraction variety. So there is a good chance that simple
    massage or stretching of neck muscles will relieve them.

    A study published in 1998 in the Journal of the American Medical
    Association found that cervical manipulation may be no more effective
    than massage in the treatment of episodic or recurring tension
    headache [2]. Thus people with frequent tension headaches might want
    to first try massage rather than risk injury from cervical

     Up and Down the Back

    Pain in the upper and lower portions of the spine can often be treated
    successfully with manipulation and physical therapy. Low-back pain is
    more common, is usually more serious, and deserves more attention.
    Herniated discs are rarely a problem in the upper back or thoracic
    spine, for example, while a herniated disc in the lower back or lumbar
    spine can pinch spinal nerves and cause weakness and loss of sensation
    in the legs or encroach upon the spinal canal to impair bladder or
    bowel function (cauda equina syndrome). This is why the Agency for
    Health Care Policy and Research (AHCPR) guidelines for treating
    low-back pain caution against manipulating the lumbar spine when there
    is leg pain caused by nerve-root involvement [3].

    Except when the thoracic vertebrae have been softened by disease or by
    aging, appropriate thoracic spine manipulation is rarely harmful and
    often can relieve backache related to fatigue, postural strain,
    arthritis, myofacitis, or other problems involving muscles and joints.
    Many people undergo thoracic spine manipulation simply for the
    relaxing effect that results from "popping the back."

     Other Joints and Muscles

    Uncomplicated mechanical-type problems of the muscles or joints of the
    shoulder, elbow, wrist, knee, ankle, and foot can often be helped by a
    competent chiropractor who uses physical therapy. Most chiropractors
    learn manipulative techniques for treatment of extremity joints, but
    these joints often benefit as much from mobilization as from
    manipulation. And they are often best treated by a physical therapist
    or an orthopedist. While chiropractors who have additional
    postgraduate training in orthopedics or sports medicine can be
    expected to have more extensive knowledge of injuries involving the
    extremities, few can do more than the average chiropractor, since none
    of them can prescribe pain medication, reduce a dislocated joint, set
    a broken bone, drain a swollen knee, or perform injections or invasive
    diagnostic procedures. Thus, a chiropractor with a diplomate in
    orthopedics or sports medicine cannot do much more than a physical
    therapist other than manipulate the spine. Although some physical
    therapists are now manipulating the spine, most are using mobilization

    Severe or prolonged problems with extremity joints should always be
    brought to the attention of an orthopedist. As with back pain,
    diagnosis is essential. When a condition under chiropractic care has
    not improved after two to four weeks, a specialist should be consulted
    for a second opinion. On the other hand, there are many situations
    where home care can be effective once the diagnosis has been made and
    acute symptoms have subsided. A rational chiropractor will be able to
    advise when cost-saving self-care can be substituted for office
    treatment. It is rarely necessary to continue any form of chiropractic
    office treatment month after month.

    Pain in other joints is not often as ominous as shoulder pain that
    might occur as a result of a problem with the heart or the lungs or
    because of a disc herniation in the neck. But it is always necessary
    to rule out bone tumors, advanced forms of arthritis, and other
    problems before beginning long-course treatment of any kind.

     Tips on Choosing a Chiropractor

    If you decide to consult a chiropractor, try to find one whose
    practice is limited to conservative treatment of musculoskeletal
    problems. Ask your family doctor for the names of chiropractors who
    fit this description and who appear to be competent and trustworthy.
    If your doctor cannot provide a name, ask other people and, if they
    recommend one, be sure to ask what conditions the chiropractor treats.
    If the chiropractor claims to treat infections or a wide range of
    other diseases, look elsewhere. But don't depend upon the Yellow
    Pages. You should avoid chiropractors who make extravagant claims or
    who advertise extensively.

    When you have selected a chiropractor, go for a consultation or
    conduct a telephone interview to find out how he or she practices. If
    the chiropractor treats infants, offers spinal adjustments as a
    treatment for visceral disease or infection or as a method of
    preventing ill health, requires that every patient be x-rayed, or
    requires payments in advance for a long course of treatments, call
    another chiropractor. The [2]Chirobase Guidelines provide additional
    tips about what to avoid. Chiropractors who follow these guidelines
    have been invited to post their names in the Chirobase Referral

    Remember that diagnosis is critical to the establishment of proper
    treatment. Some chiropractors are competent in diagnosis, and some are
    not. For example, "straight" chiropractors who examine only the spine
    and who believe that "subluxated" vertebrae are the primary cause of
    illness may "analyze" the spine rather than offer a diagnosis. Such
    chiropractors may be unable to determine when chiropractic treatment
    should not be used. Since evaluating some chiropractors may be
    difficult, it might be wise to look for one who is willing to work
    with your family physician by exchanging office notes. This would
    offer the additional safeguard of assuring a second opinion.

    Once you have found a rational chiropractor, you may find effective
    relief for some types of back and neck pain as well as for various
    other musculoskeletal problems. You may also benefit from the
    comforting effect of a hands-on treatment that provides a pleasurable
    way of relieving the aches and pains of everyday stress and strain.
    Physical therapists, osteopaths, and a few physicians also offer
    manipulative therapy. Chiropractors can sometimes be found working
    with these practitioners in back-pain clinics. As the benefits of
    spinal manipulation become better known as a result of scientific
    research, such treatment will become more available from physical
    therapists and other practitioners, as well as well as from properly
    limited chiropractors.

     About the Author

    Dr. Homola, who lives in Panama City, Florida, retired in 1998 after
    practicing chiropractic for 43 years. His 12 books include
    [3]Bonesetting, Chiropractic, and Cultism; Backache: Home Treatment
    and Prevention; and Muscle Training for Athletes. He has also written
    many articles for magazines and journals, ranging from Cosmopolitan
    and Scholastic Coach to Chiropractic Technique and Archives of Family
    Medicine. This article is adapted from [4]Inside Chiropractic: A
    Patient's Guide (Prometheus Books, June 1999).


     1. Cherkin DC and others. [5]A comparison of physical therapy,
        chiropractic manipulation, and provision of an educational booklet
        for the treatment of patients with low back pain. New England
        Journal of Medicine 339:1021-1029, 1998.
     2. Bove G, Nilsson N. [6]Spinal manipulation in the treatment of
        episodic tension-type headache: A randomized controlled trial.
        JAMA 280:1576-1579, 1998.
     3. Bigos S and others. Acute Low Back Problems in Adults. Rockville,
        MD: Agency for Health Care Policy and Research, 1994. AHCPR
        publication 95-0642.

                            [7]Chirobase Home Page

                  This article was revised on May 19, 1999.


    1. http://www.chirobase.org/index.html
    2. http://www.chirobase.org/13RD/chiroguidelines.html
    3. http://www.chirobase.org/05RB/BCC/00c.html
    4. http://www.chirobase.org/03Edu/C/homola.html
    5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9761803&dopt=Abstract
    6. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9820258&dopt=Abstract
    7. http://www.chirobase.org/index.html

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