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 offer.
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) . 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.
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 . Thus people with frequent tension headaches might want to first try massage rather than risk injury from cervical manipulation.
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 .
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 techniques.
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 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 Directory.
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 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 Inside Chiropractic: A Patient’s Guide (Prometheus Books, June 1999).
- Cherkin DC and others. 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.
- Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: A randomized controlled trial. JAMA 280:1576-1579, 1998.
- Bigos S and others. Acute Low Back Problems in Adults. Rockville, MD: Agency for Health Care Policy and Research, 1994. AHCPR publication 95-0642.
This article was revised on May 19, 1999.