Chiropractic Clinical Practice

Why Do People Go To Chiropractors?

What Are the Clinical Assessments,
Clinical Goals, and Clinical Applications
of a Typical Chiropractic Office Visit?

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Why Do People go to Chiropractors?

The most recent authoritative assessment of the chiropractic profession appeared in the December 2017 issue of the prestigious orthopedic medical journal Spine, and was titled (1):

The Prevalence, Patterns, and Predictors of
Chiropractic Use Among US Adults:
Results From the 2012 National Health Interview Survey

The data for this study was from the National Health Interview Survey (NHIS), which is the principle and reliable source of comprehensive health care information in the United States. The NHIS dataset provides a large-scale nationally representative sample regarding chiropractic use.

The authors note that 93% of patients go to chiropractors for low back pain (63%) and/or neck pain (30%). They found that:

65% of the patients reported that chiropractic care helped their condition “a great deal.”

26% of the patients reported that chiropractic care helped their condition “somewhat.”

Only 3% reported that the chiropractic care did not help them.

The authors also made the following points pertaining to the chiropractic profession:

“Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being.”

“Back pain or back problems (63.2%) and neck pain or neck problems (30.2%) were by far the top specific health problems for which people consulted a chiropractor in the past 12 months, followed by joint pain/stiffness (13.6%) and other pain conditions. Around two in three users (64.5%) reported that chiropractic had helped a great deal to address these health problems.”

“Our analyses show that, among the US adult population, spinal pain and problems - specifically for back pain and neck pain - have positive associations with the use of chiropractic.”

“The most common complaints encountered by a chiropractor are back pain and neck pain and is in line with systematic reviews identifying emerging evidence on the efficacy of chiropractic for back pain and neck pain.”

“Chiropractic services are an important component of the healthcare provision for patients affected by musculoskeletal disorders (especially for back pain and neck pain) and/or for maintaining their overall well-being.”

What Are the Chiropractic Clinical Assessments?

Nerve signals can be broadly divided into two groups:

Efferents, which are nerve signals that leave the brain and spinal cord and are transmitted into the peripheral tissues, such as the muscles and the viscera. These are also known as motor nerve signals.

Afferents, which are nerve signals that begin in the peripheral tissues and are transmitted into the spinal cord and the brain. These are also known as sensory nerve signals.

Pain is a sensory nerve signal. For more than fifty years it has been understood that pain is a sensory electrical signal sent to the brain.

Importantly, there are other sensory electrical signals that are sent to the spinal cord. These other sensory signals are not painful. Examples would be touch, vibration hot and cold. The most important and abundant of these other sensory signals is proprioception.

Proprioceptive signals to the spinal cord and brain transmit mechanical information, especially mechanical factors such as position and movement. This concept is well-stated by attorney Chris Crowley and physician Henry Lodge, MD, in their book Younger Next Year, in a section they refer to as:

“The Balancing Act”

“Now it’s time to think about your brain and a concept called proprioception—the deceptively simple notion that you have to know where the different parts of your body are at all times.”

“Your body is aware of exactly where each limb is in space every second, because each muscle, tendon, ligament and joint sends thousands of nerve fibers back to the brain through the spinal cord. Those fibers signal every nuance gradation of contraction, strength, muscular tone, orientation, position and movement at every moment of the day.”

“Your brain keeps careful track of the location of every muscle and joint in you body every second, all day, every day, waiting for you to need the information.”

In 1965, pain researchers became aware that the proprioceptive signal to the brain could block the pain signal to the brain. This concept was originally proposed by pain researchers Ronald Melzack and Patrick Wall (3). Their theory is known as the Gate Control Theory of Pain. Ronald Melzack, PhD, is a Canadian psychologist. Patrick Wall, MD (d. 2001), was a British neuroscientist and pain expert, as well as the first editor of the journal Pain.

In 2002, the British Journal of Anaesthesia published a study reaffirming the validity of the Gate Theory of Pain in an article titled (4):

Gate Control Theory of Pain Stands the Test of Time

An oversimplified explanation of their Gate Control Theory of Pain is that the pain electrical signal to the brain can be blocked by non-painful electrical signals arising from other sensory afferents, especially from joint proprioceptors. Practically, this would mean that if a person’s posture became abnormal and static, and/or if a person’s joints lost or reduced their normal movement arc, there would be a proportionate reduction of the proprioceptive sensory input into the spinal cord and brain. This would allow pain signals to enter the brain because the pain gate would be open.

For more than a century, chiropractors, patients, government, insurance companies, and scientists have realized that chiropractic spinal adjusting (specific manipulation) helps people with pain syndromes. As noted in the Adams study (1):

“Chiropractic is one of the largest manual therapy professions in the United States and internationally.”

“Chiropractic is one of the commonly used complementary health approaches in the United States and internationally.”

“There is a growing trend of chiropractic use among US adults from 2002 to 2012.”

Chiropractic:

• Uses manual therapy to treat musculoskeletal and neurological disorders.
• Is covered by Medicare and Medicaid for all adults in the United States.
• Is included in the workers’ compensation systems in most US States.
• Has more than 70,000 practicing providers in the United States.
• Total costs for US visits in 2013 is estimated to be more than $10 billion.

The application of chiropractic spinal adjusting for pain control using Melzack and Wall’s Gate Control Theory of Pain was first done by Canadian orthopedic surgeon Kirkaldy-Willis in 1985 (5). Dr. Kirkaldy-Willis’ study was impressive. It presented the results of chiropractic spinal manipulation on 283 patients with chronic low back and leg pain. All 283 patients had failed prior conservative and/or operative treatment, and they were all totally disabled. (“Constant severe pain; disability unaffected by treatment”)

These patients were given a two or three week regimen of daily spinal manipulations by an experienced chiropractor. Essentially 81% of the patients who did not have compressive neuropathology had their signs and symptoms resolved and were no longer disabled. Dr. Kirkaldy-Willis notes:

“No patients were made worse by the manipulation, yet many experienced an increase in pain during the first week of treatment. Patients undergoing manipulative treatment must therefore be reassured that the initial discomfort is only temporary.”

Dr. Kirkaldy-Willis presented the following observations pertaining to chiropractic spinal manipulation and the Gate Theory of Pain:

Melzack and Wall proposed the Gate Theory of Pain in 1965, and this theory has “withstood rigorous scientific scrutiny.”

“The central transmission of pain can be blocked by increased proprioceptive input.” Pain is facilitated by “lack of proprioceptive input.” This is why it is important for “early mobilization to control pain after musculoskeletal injury.”

The facet capsules are densely populated with mechanoreceptors. “Increased proprioceptive input in the form of spinal mobility tends to decrease the central transmission of pain from adjacent spinal structures by closing the gate. Any therapy which induces motion into articular structures will help inhibit pain transmission by this means.”

Returning to the initial question, “What Are the Chiropractic Clinical Assessments?” Some spinal pain syndromes can be serious. These usually involve compressive neuropathology. Common examples of compressive neuropathology include disc herniations, lateral recess stenosis, and central canal stenosis. Although each of these can be successfully managed by chiropractors, they often need advanced diagnostics (MRIs, etc.), and rarely require a surgical intervention. Chiropractors are well trained to examine and recognize cases of compressive neuropathology and to make appropriate referrals when necessary. Statistically, compressive neuropathology is quite rare, constituting only 1-2% of chiropractic clinical practice.

In addition to the standard orthopedic and neurological tests used to determine if a patient has compressive neuropathology, chiropractic clinical assessments include posture analysis and joint range of motion. These assessments are windows into a patient’s proprioceptive integrity. The large majority of chiropractic pain patients have lack of proprioception, opening their pain gate.

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A representative supportive study was published by the Institute of Occupational Health, Helsinki, Finland, in 1987, by physician T. Viderman, MD. His study was published in the journal Clinical Biomechanics, and titled (6):

Experimental Models of Osteoarthritis:
The Role of Immobilization

Dr. Viderman notes that when there is a lack of joint motion for any reason, the periarticular tissues adapt to the shortest distance between its origin and insertion. This profoundly and significant alters musculoskeletal function, including proprioceptive signals. He makes the following points:

“Whenever the periarticular shrinkage stems from immobilization, the process does not affect articular cartilage only; instead the whole joint is involved.”

“Immobilization, for whatever reason, is one of the pathogenic factors in musculoskeletal degeneration.”

“With respect to patients, it can be postulated that immobilization, for whatever cause, will initiate a pathogenic chain of musculoskeletal degenerative changes.”

Dr. Viderman also discusses the value of mobilization to prevent and reverse the pathological consequences of immobilization. He notes:

“If immobilization, irrespective of its cause, cannot be avoided, it would be therapeutically logical to take every possible step to limit its extent and duration.”

“When the adverse effects of immobilization have already become apparent, the earlier they are treated the better.”

“The evidence reviewed shows very clearly that early mobilization is essential.”

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Numerous studies and publications, spanning nearly eight decades, indicate that the mobilization of injured and/or stiff tissues enhance healing and reduce pain (7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27).

If mobilization of injured and stiff tissues are so critical to the healing process and in preventing/treating pain, it is logical that exercising these tissues would be an important aspect of treatment, and indeed it is. However, it has been understood for decades that exercise alone is limited in its ability to optimize improvement of joint tissues. This is because exercise, although beneficial, only affects the tissues in the most narrow range, the Range of Active Motion.

In contrast, maximum tissue mobilization benefit can only be achieved by manipulation, which moves the tissues into the Periarticular Paraphysiological Range of Motion. Importantly, this can be done without any risk of injury as the motion never exceeds the limit of anatomic integrity. A number of well-respected references explain this distinction in detail (28, 29, 30, 31). The procedure is described by Dr. Kirkaldy-Willis as follows (5):

“Spinal manipulation is essentially an assisted passive motion applied to the spinal apophyseal and sacroiliac joints.”

There are three categories of joint motion:

1) Active exercise range of motion.

2) “Beyond the end of the active range of motion of any synovial joint, there is a small buffer zone of passive mobility.” A joint can only move into this zone with passive assistance, and going into this passive range of motion “constitutes mobilization.”

3) “At the end of the passive range of motion, an elastic barrier of resistance is encountered. This barrier has a spring-like end-feel.”

“If the separation of the articular surfaces is forced beyond this elastic barrier, the joint surfaces suddenly move apart with a cracking noise.”

“This additional separation can only be achieved after cracking the joint and has been labeled the paraphysiological range of motion.”

“This constitutes manipulation.”

Joint manipulation [adjusting] “requires precise positioning of the joint at the end of the passive range of motion and the proper degree of force to overcome joint coaptation” [to overcome the resistance of the joint surfaces in contact].

“With experience, the manipulator can be very specific in selecting the spinal level to be manipulated.”

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Darlene Hertling, RPT, and Randolph Kessler, MD note in their authoritative book, Management of Common Musculoskeletal Disorders, that exercise in the presence of altered joint biomechanical function can damage the joint (32).

They review the case of a boy who continued to use his knee in the absence of normal external rotation of the tibia on the femur during knee extension. One and a half years later, at surgery, dimpling of the articular cartilage of the medial femoral condyle was observable with the naked eye, presumably owing to continued abnormal compression of this portion of the articular surface from loss of normal arthrokinematic movement. They state:

“The traditional approach to management of patients presenting with loss of pain-free movement at a joint usually involves active and passive measures to improve osteokinematic movement, and encouragement of normal use of the part.”

“It should be clear that this approach is inadequate and perhaps dangerous. It ignores the basic problem, which is often loss of normal arthrokinematics. It involves considerable forcing of osteokinematic movements in the absence of normal arthrokinematic movement, which may only occur at the expense of the articular cartilage.”

“A more logical approach to the management of these patients emphasizes the restoration of joint play to allow free movement between bones. This can be achieved only by  deciding if joint mobilization is indicated, choosing the appropriate techniques based on the direction and extent of restrictions, and skillfully applying techniques of specific mobilization.”

“Some movement should be encouraged in the cardinal planes, but only as normal kinematics are restored.”

“To a certain extent, functional use of the part should be restricted through careful instructions to the patient until normal joint mechanics are restored. This approach minimizes the possible danger of undue stresses to the articular cartilage during attempts to restore movement. It also minimizes the possibility of discharging a patient who has relatively pain-free functional use of the joint, but who may have some residual kinematic disturbance sufficient to cause cartilage fatigue over time and perhaps osteoarthrosis in later years.”

Hertling and Kessler are indicating that it is important to first restore normal joint motion before beginning exercise of the muscles that cross that joint. Failure to do this can result in the acceleration of joint arthritis. The goal of chiropractic manipulation is to restore normal joint motion.

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SUMMARY

Chiropractors primarily treat and manage spinal pain syndromes.

Initially, chiropractors rule out or confirm the presence of compressive neuropathology. This involves a series of orthopedic and neurological tests, and perhaps some imaging, such as x-rays or possibly an MRI. If compressive neuropathology is present, depending upon the uniqueness of the individual case and examination findings, the chiropractor may decide to treat the condition, refer the patient to another provider, or co-treat the patient with another provider.

Very few spinal pain syndromes are the result of compressive neuropathology. Once compressive neuropathology is ruled out, the chiropractor will assess the status of the proprioceptive signals that close the pain gate. This classically involves three interrelated mechanical assessments:

1. Postural alignment
2. Regional spinal range of motion (cervical, thoracic, and lumbar)
3. Segmental range of motion (joint motion integrity)

Discovered mechanical problems are dealt with mechanically, including ergonomically, exercise, traction, tissue work, and spinal adjusting.

When spinal joints do not have optimum movement, the pain gate at that level is open. Chiropractic adjusting (specific manipulation) increases the firing of the proprioceptors, creating a neurological sequence of events that closes the pain gate. The reduction in pain is often immediate, depending on levels of concomitant inflammation.

The quality of proprioception is a significant factor in the state of the pain gate. Improved proprioception closes the pain gate. Chiropractic adjusting improves proprioception. Consequently, chiropractors are noted for their treatment and management of pain syndromes, especially for spinal pain syndromes.

REFERENCES

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
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5. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
6. Viderman T; Experimental Models of Osteoarthritis: The Role of Immobilization; Clinical Biomechanics; November 1987; Vol. 2; No. 4; pp. 223-229.
7. Stearns ML; Studies on development of connective tissue in transparent chambers in rabbit’s ear; American Journal of Anatomy; Vol. 67; 1940; p. 55.
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27. Hauser RA, Dolan EE, Phillips HJ, Newlin AC, Moore RE, Woldin BA; Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics; The Open Rehabilitation Journal; 2013; No. 6; pp. 1-20.
28. Haldeman S; Modern Developments in the Principles and Practice of Chiropractic; Appleton-Century-Crofts; New York; 1980.
29. Kirkaldy-Willis WH, Managing Low Back Pain; Churchill Livingston; (1983 and 1988).
30. Kirkaldy-Willis WH, Cassidy D; Spinal Manipulation in the Treatment of Low-Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-40.
31. Fischgrund JS; Neck Pain; Monograph 27; American Academy of Orthopaedic Surgeons; 2004.
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“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”