Chiropractic ("kye-roh-PRAC-tic") is a form of health care that focuses on the relationship between the body's structure, primarily of the spine, and function. Doctors of chiropractic, who are also called chiropractors or chiropractic physicians, use a type of hands-on therapy called manipulation (or adjustment) as their core clinical procedure. While there are some differences in beliefs and approaches within the chiropractic profession, this Research Report will give you a general overview of chiropractic, discuss scientific research findings on chiropractic treatment for low-back pain, and suggest other sources of information.

Key Points

• Chiropractic is most often used to treat musculoskeletal conditions--problems with the muscles, joints, bones, and connective tissue such as cartilage, ligaments, and tendons.
  
  
• Research studies of chiropractic treatment for low-back pain have been of uneven quality and insufficient to allow firm conclusions. Nonetheless, the overall sense of the data is that for low-back pain, chiropractic treatment and conventional medical treatments are about equally helpful. It is harder to draw conclusions about the relative value of chiropractic for other clinical conditions.
  
  
• The risk of experiencing complications from chiropractic adjustment of the low back appears to be very low. However, the risk appears to be higher for adjustment of the neck.
  
  
• It is important to inform all of your health care providers about any treatment that you are using or considering, including chiropractic. This will help each provider make sure that all aspects of your health care are working together.

What is chiropractic?

The word "chiropractic" combines the Greek words cheir (hand) and praxis (action) and means "done by hand." Chiropractic is an alternative medical system and takes a different approach from conventional (see box) in diagnosing, classifying, and treating medical problems.

The basic concepts of chiropractic can be described as follows:

• The body has a powerful self-healing ability.
  
  
• The body's structure (primarily that of the spine) and its function are closely related, and this relationship affects health.
  
  
• Chiropractic therapy is given with the goals of normalizing this relationship between structure and function and assisting the body as it heals.

What is the history of the discovery and use of chiropractic?

Chiropractic is a form of spinal manipulation, which is one of the oldest healing practices. Spinal manipulation was described by Hippocrates in ancient Greece.^1-3 In 1895, Daniel David Palmer founded the modern profession of chiropractic in Davenport, Iowa. Palmer was a self-taught healer and a student of healing philosophies of the day. He observed that the body has a natural healing ability that he believed was controlled by the nervous system. He also believed that subluxations, or misalignments of the spine (a concept that had already existed in the bonesetter and osteopathic traditions), interrupt or interfere with this "nerve flow." Palmer suggested that if an organ does not receive its normal supply of impulses from the nerves, it can become diseased. This line of thinking led him to develop a procedure to "adjust" the vertebrae, the bones of the spinal column, with the goal of correcting subluxations.

Some chiropractors continue to view subluxation as central to chiropractic health care.² However, other chiropractors no longer view the subluxation theory as a unifying theme in health and illness or as a basis for their practice. Other theories as to how chiropractic might work have been developed.

Who uses chiropractic and for what health problems?

In 1997, it was estimated that Americans made nearly 192 million visits a year to chiropractors. Over 88 million of those visits were to treat back or neck pain.  In one recent survey, more than 40 percent of patients receiving chiropractic care were being treated for back or low-back problems. More than half of those surveyed said that their symptoms were chronic. Conditions commonly treated by chiropractors include back pain, neck pain, headaches, sports injuries, and repetitive strains. Patients also seek treatment of pain associated with other conditions, such as arthritis.

Low-back pain is a common medical problem, occurring in up to one-quarter of the population each year. Most people experience significant back pain at least once during their lifetime. Several recent reviews on low-back pain have noted that in most cases acute low-back pain gets better in several weeks, no matter what treatment is used. Often, the cause of back pain is unknown, and it varies greatly in terms of how people experience it and how professionals diagnose it. This makes back pain challenging to study.

What kind of training do chiropractors receive?

Chiropractic training is a 4-year academic program consisting of both classroom and clinical instruction (see box). At least 3 years of preparatory college work are required for admission to chiropractic schools. Students who graduate receive the degree of Doctor of Chiropractic (D.C.) and are eligible to take state licensure board examinations in order to practice. Some schools also offer postgraduate courses, including 2- to 3-year residency programs in specialized fields.

The Council on Chiropractic Education, an agency certified by the U.S. Department of Education, is the accrediting body for chiropractic colleges in the United States.

What do chiropractors do in treating patients?

If you become a chiropractic patient, during your initial visit the chiropractor will take your health history. He will perform a physical examination, with special emphasis on the spine, and possibly other examinations or tests such as x-rays.¹⁵ If he determines that you are an appropriate candidate for chiropractic therapy, he will develop a treatment plan.

When the chiropractor treats you, he may perform one or more adjustments. An adjustment (also called a manipulation treatment) is a manual therapy, or therapy delivered by the hands. Given mainly to the spine, chiropractic adjustments involve applying a controlled, sudden force to a joint. They are done to increase the range and quality of motion in the area being treated. Other health care professionals--including physical therapists, sports medicine doctors, orthopedists, physical medicine specialists, doctors of osteopathic medicine, doctors of naturopathic medicineA whole medical system that originated in Europe. Naturopathy aims to support the body's ability to heal itself through the use of dietary and lifestyle changes together with CAM therapies such as herbs, massage, and joint manipulation., and massagePressing, rubbing, and moving muscles and other soft tissues of the body, primarily by using the hands and fingers. The aim is to increase the flow of blood and oxygen to the massaged area. therapists--perform various types of manipulation. In the United States, chiropractors perform over 90 percent of manipulative treatments.

Most chiropractors use other treatments in addition to adjustment, such as mobilization, massage, and nonmanual treatments (see examples in the box).

Have side effects or problems been reported from using chiropractic to treat back pain?

Patients may or may not experience side effects from chiropractic treatment. Effects may include temporary discomfort in parts of the body that were treated, headache, or tiredness. These effects tend to be minor and to resolve within 1 to 2 days.

The rate of serious complications from chiropractic has been debated. There have been no organized prospective studies on the number of serious complications. From what is now known, the risk appears to be very low. It appears to be higher for cervical-spine, or neck, manipulation (e.g., cases of stroke have been reported). The rare complication of concern from low-back adjustment is cauda equina syndrome, estimated to occur once per millions of treatments (the number of millions varies; one study placed it at 100 million).

For your safety, it is important to inform all of your health care providers about any care or treatments that you are using or considering, including chiropractic. This is to help ensure a coordinated course of care.

Does the government regulate chiropractic?

Chiropractic practice is regulated individually by each state and the District of Columbia. Most states require chiropractors to earn continuing education credits to maintain their licenses. Chiropractors' scope of practice varies by state--including with regard to laboratory tests or diagnostic procedures, the dispensing or selling of dietary supplements, and the use of other CAM therapies such as acupuncture or homeopathy. Chiropractors are not licensed in any state to perform major surgery or prescribe drugs.

Do health insurance plans pay for chiropractic treatment?

Compared with CAM therapies as a whole (few of which are reimbursed), coverage of chiropractic by insurance plans is extensive. As of 2002, more than 50 percent of health maintenance organizations (HMOs), more than 75 percent of private health care plans, and all state workers' compensation systems covered chiropractic treatment. Chiropractors can bill Medicare, and over two dozen states cover chiropractic treatment under Medicaid.

If you have health insurance, check whether chiropractic care is covered before you seek treatment. Your plan may require care to be approved in advance, limit the number of visits covered, and/or require that you use chiropractors within its network.

What has scientific research found out about whether chiropractic works for low-back pain?

For this report, the results of individual clinical trials and reviews of groups of clinical trials were examined. Sources were drawn from the National Library of Medicine's PubMed? database; were published in English; and studied chiropractic techniques that were identified as such (e.g., "chiropractic manipulation") rather than some other forms of "manipulation" or "spinal manipulation therapy"--which, as noted above, may be delivered by certain other health care providers.

So far, the scientific research on chiropractic and low-back pain has focused on if, and how well, chiropractic care helps in relieving pain and other symptoms that people have with low-back pain. This research often compares chiropractic to other treatments.