CARE 2000 SYMPOSIUM
CLINIC MAR30, 2000
S. Burton, DC CCN
Chiropractic Management of Low Back Pain.
HISTORICAL APPLICATION OF
Recorded history of manipulative therapy extends back to
the days of Hippocrates. Orthodox
and folk practitioners in Europe and the Middle East wrote on the
usefulness of manipulation for treatment of acute low back pain
and spinal curvatures. Early
manipulation involved Succession from a ladder while hanging by
the patients feet. According
to Elizabeth Lomax in (1) Hippocrates disapproved of this approach
due to its overuse and instead preferred extension with pressure
exerted in the prone position on a wooden table.
Sometimes wood was applied as a lever to aid in the
In the mid 1700s Nicholas Andry
founded the term orthopaedia from the Greek roots orthos
(meaning straight) and paidos (child) was termed with the
implication that many of the deformities of adolescence and adult
life originate in childhood. His use however along with his contemporaries included rest,
corsets, exercise and posture.
He was not an advocate of manipulation.
Percival Pott (1) stated that spinal problems were more
common than suspected. Treatment
was by rest and local discharge by the use of issues.
Manipulation and extension was considered useless and
Dr. Edward Harrison in the late 18th century became a big proponent of
manipulation after spending a couple of decades in Lincolnshire
a county known for its numerous bonesetters. In 1821 he
wrote a series of articles title observations respecting the
nature and origin of the common species of disorders of the spine:
with critical remarks on the opinions of former writers on the
attacked the views of Pott and expressed his own opinion, which
was that the true cause of spinal complaints is in the connecting
ligaments which seem to have lost part of their power of
holding the bones together. His treatment consisted of
manipulation (and probably friction based upon other treatments at
that time). One
account was daily manipulations for 3 weeks.
There was some discourse since the
doctrine of vertebral luxation and use of manipulation was
considered taboo. The
Medico-Chirurgical Review was
very critical of Dr. Harrison.
He ended up being charged with practicing medicine without
a license. In court, he defended himself by saying was actually
practicing surgery instead. Even though untrue the jury found in
his favor. He
continued to practice until his death in 1838.
Other supporters of Harrison advocated
manipulation, such as Andrew Dods in 1824 and W. J. Little in
1868. Wharton Hood of Lancet in 1871 stated I was most
astonished, and often no less mortified at the number and variety
of instances in which the manipulations I have endeavored to
describe were followed by almost immediate cure.
Spinal irritation became a new clinical
entity and became more popular noted in 1871 Treatise on
Diseases of the Nervous system These spinal irritations were
thought to manifest as mania, vertigo, amblyopia, nervous
fevers, cough dyspnoea, pleuritis, colic, vomiting, disorders of
menstruation, hysteria, asthma, and diabetes.
Diagnosis was based on tenderness of appropriate vertebra.
Treatment consisted of application of irritants, such as
blisters, leeches, and cauteries to the tender dorsal points
(Note: the area they denote is along the bladder acupuncture
meridian which, today, is stimulated by needles, electricity,
microcurrent, heat, and lasers in acupuncture, and chiropractic
adjustments which supply the mechanical force.)
There seems to be much historical
controversy in the orthopedic profession.
Watson-Jones has written there is no place for manipulation
in orthopedic practice. Wiles
has published that manipulation should always be tried before any
operation is undertaken. According to John Mennell (1) Recently I asked an
orthopedic surgeon in charge of a large residency training program
what he really thought about manipulation.
I did not say spinal manipulation yet that is how he
heard my question. Paraphrasing
his reply he said I use it. I twist people around and I really
dont know what I am doing, but it is surprising how often it
Few of you will enter into practice
today without having the so-called bone-setter as a
. Learn then to imitate what is good and avoid what
is bad in the practice of bone-setters
It is advisable to learn
from ones opponent. Sir
James Paget late 19th century.
From this comment, it appears that
historically there has not just been controversy, but an
adversarial relationship between manipulators and the medical
Chiropractic is the 2nd
largest health care profession in the US and the only one whose
focus is on spinal manipulation.
My goal is to demonstrate that we are capable of a high
level of visceral diagnosis, able to determine when to refer, very
qualified in neuromuscular problems, able to determine
contraindication to adjustments, able to pick an approach to
treating the spine which is the most effective and least risky. We
typically see the patient more often so we are able be more
accurate in our diagnosis.
To be a good chiropractor is a lifelong pursuit of
History of Chiropractic:
Chiropractic is 105 years old.
The history of Chiropractic requires mention of
Dr. D.D. Palmer the founder,
Dr. B.J Palmer, the developer, Dr. Logan, Dr. Dejarnette,
Dr. Gonstead, Dr. Arlan Fuhr, Dr. George Goodheart. Dr. Grostic.
Dr Gillet, Dr. Thompson, Dr. Cox, and the hundreds of
Chiropractors who perform and performed clinical research in their
practices to evolve a methods of treatment which consists of
100s of different techniques* designed to restore joint and
nerve function and whose ultimate goal is to optimize health.
From its early inception, nutrition played an integral
part, and we have been on the forefront of clinical nutrition.
*(A technique is the method of
determining when an adjustment is needed, how to treat it, and
when you are finished.)
Definition: (Fla. Statute 460.403.
a) Practice of chiropractic means
a noncombative principle and practice consisting of the science of
the adjustment, manipulation, and treatment of the human body in
which vertebral subluxations and other malpositioned articulations
and structures that are interfering with the normal generation,
transmission, and expression of nerve impulse between the brain,
organs, and tissue cells of the body, thereby causing disease, and
adjusted, manipulated, or treated, thus restoring the normal flow
of nerve impulse which produces normal function and consequent
b) Any chiropractic physician who has
complied with the provisions of this chapter may examine, analyze,
and diagnose the human living body and its diseases by the use of
any physical, chemical, electrical, or thermal method; use the
X-ray for diagnosing; phlebotomize in compliance with paragraph
(f); and analysis taught in any school of chiropractic.
c) Chiropractic physicians my adjust
manipulate, or treat the human body by manual, mechanical,
electrical, or natural methods; by the use of physical means or
physiotherapy, including light, heat, water, or exercise; by the
use of acupuncture; or by the administration of foods, food
concentrates, food extracts, and proprietary drugs and may apply
first aid and hygiene, but chiropractic physicians are expressly
prohibited from prescribing or administering to any person any
legend drug, from performing any surgery except as stated herein,
or from practicing obstetrics.
The subluxation is the clinical entity
associated with chiropractic.
The antiquated premise has been termed the Garden
Hose theory or nerve compression hypothesis.
More elaborate descriptions have been described in the
literature (1). The
most recent and most complete definition is that of the
Subluxation Complex (2), noted below.
tends to Pathophysiology, which tends to Pathology.
Axiom Correction of a subluxation
restores normal physiologic processes and the reversible pathology
Subluxation A complex clinical
entity comprising one or more of the following.
The Chiropractic curriculum is accredited by the CCE
(Council on Chiropractic Education) typically consists of 5
academic years. Courses consist of classroom and laboratory work
in basic sciences such as anatomy, physiology, and biochemistry;
chiropractic courses on theory, treatment, and diagnostic
procedures; and chiropractic clinic for practical experience.
Like allopathic physicians, when a
patient presents into our offices, the primary focus is on
differential diagnosis to determine if this patient requires
immediate referral to an appropriate physician, co-managed with an
appropriate physician, or treated in-house.
The initial visit includes, elaboration
of chief complaint, a thorough history of present illness, past
medical history, review of systems, past family social history,
A typical examination can include,
visceral examination (if necessary), vital signs, extremity
examination always includes an orthopedic, neurologic, and
chiropractic exams. The orthopedic exam includes inspection, palpation,
percussion, range of motion, posture analysis, and orthopedic
tests. A neurologic
exam consists of
mental status, cranial nerves, motor
function, muscle testing, reflexes, cerebellar function, and
Diagnostic imaging may be necessary
which can include plain film X-ray, (usually weight bearing),
videoflouroscopy ( for joint movement), MRI for soft tissue, disc
problems or fractures if software enhancements are employed.
CT and bone scans are recommended, if necessary.
Laboratory testing may also be prescribed. It is important to note that on many of these more
complicated cases the average chiropractor would prefer to
co-manage if the proper referral system were in order.
Range of Motion
X-ray for mensuration and
Referral vs. Treat
Purpose of Diagnosis:
Whatever the health field, the diagnosis
determines the course of treatment.
In medicine, cervicalgia and lumbalgia which means neck and
low back pain, would, by their definition, be treated with pain
chiropractic, lumbalgia may be caused by; misalignment of L5 on
S1, hypermobile SI joints, fixation of a lumbar vertebra, or
piriformis involvement. The
chiropractic diagnosis may be: body right L5, CAT II Right, L3-L4
fixation, or piriformis syndrome.
Therefore without a functional diagnosis a treatment
approach is difficult. Given below are examples of Medical
Diagnoses and Chiropractic Diagnoses.
Sciatica, Facet syndrome, sacroiliitis,
lumbar discitis, piriformis syndrome, bursitis, tendonitis, Tumor
(Benign + Malignant), infection, arthritis (OA, rheumatoid,
nonrheumatoid variants, enteropathic) Referred pain from viscera
are examples of a medical diagnosis.
Chiropractic Diagnoses for low back
pain are based upon function, examples are:
Ligamentous: Fixation of L5 - C1 in any
of the up to 8 joints per vertebra, fixation of sacroiliac joints,
symphysis pubis, aberrant movement of any of the above,
subluxation, sacral segment subluxation, sacral misalignment,
pelvic misalignment, hypermobility of sacroiliac joint, Category
II, & III in SOT, and iliolumbar ligament contacture.
Muscular: weakness of quadratus
lumborum, piriformis-contracted or elongated, gluteus maximus,
minimus, psoas, hamstrings, abdominals,
Misaligment, weakness or functional
problem distal to pain:
Hip, knee, ankle, foot, either side and
spinal lesion and thoracic, cervical, or cranial regions.
Treatment may consist of:
1) Manipulation varying velocity, force, direction,
torque, directly to the lesion or distal through reflex points or
along muscular attachments, traction and distraction.
approaches such as trigger point and strain-counter strain.
3) Energy approaches such as
approaches specific to the complaint (symptom approach) or to the
organ system (holistic approach)
Physical therapy modalities such as EMS, US, Trigger point
US, Microcurrent, Cryotherapy, and heat
use of Physiotherapy
Frequently physiotherapy is applied with the
chiropractic treatment. PT
was firmly established at the National College of Chiropractic
1914. A chiropractic
traction couch patented in 1914. (5) The table below shows the
Modalities related to the Physiologic Stages involved in
Stage of Hyperemia or Active Congestion
packs: vasoconstrictive effects
vasoconstrictive, hardening of tissue effects.
Ultrasound: dispersing effects; increased membrane permeability
with possible support; prevents irritation and further injury.
Stage of Passive Congestion
hot and cold applications, preferably in a 3:1 ratio every few
hours: revulsive effects
massage, particularly effleurage: revulsive effects
manipulation: effects of revulsion, maintenance of muscle tone,
freeing of coagulates and possibly early adhesions.
range of motion exercise: effects same as 3.
current stimulation, of a surging nature: effects same as 3.
increase in gaseous exchange, dispersion of fluids, liquefaction
of gels, and increased membrane permeability effects.
Stage of Consolidation and/or Formation
of Fibrinous Coagulant
moderate heat, preferably of a moist nature: mild vasodilation,
increased membrane permeability effect.
active exercise: revulsive effects, freeing of coagulant and early
adhesions, maintenance of tone, and ligamentous and muscular
alternating traction: effects same as 2.
range of motion manipulation: effects same as 2.
hyperemia, liquefaction of gels, dispersion of gases and fluids,
increased membrane permeability, and tissue-softening effects.
current, surging or pulsating: effects same as 2.
Stage of Fibroblastic Activity and
heat, prolonged (e.g., diathermy): prolonged vasodilation,
increased membrane permeability, increased chemical activity
massage (e.g., petrissage or other soft-tissue manipulation):
tends to break down fibrotic tissue and create more elasticity.
active exercise, preferably with slight traction or at lease
without weight bearing: maintains muscle and ligamentous
integrity, stretches fibrotic tissues, breaks adhesions, and
creates greater elasticity.
alternating traction: effects same as 3.
galvanism, particularly with an antisclerotic (e.g., potassium
iodine): vasodilation, softening, liquefaction, and antisclerotic
effects causing softening of tissues as previously mentioned.
joint manipulation: reduction of muscular spasm, breaking of
adhesions and fibrotic tissue, and restoration of physiologic
TO MANIPULATION (4)
According to the Mercy Guidelines which
was an initial united effort by the chiropractic profession to
establish practice guidelines using accepted consensus methods in
Jan 25-30, 1992.
The contraindication ratings for the
below conditions had the highest level of consensus amongst the
Mercy participants. Note
: there are no contraindications for low force adjusting in areas
distant to the lesion.
contraindicated for high velocity thrust procedures in areas of
Acute rheumatoid, rheumatoid-like and nonspecific
arthropathies including acute AS
Acute fractures and dislocations; or healed fractures with
signs of ligamentous rupture or instability.
Unstable os odontiodium
Bone Weakening Destructive
Active juvenile avascular necrosis, specifically (Perthes
Infection of bone and joint
Acute Myelopathy or Acute Cauda Equina Syndrome.
to Absolute contraindicated for high velocity thrust procedures in
areas of involvement
Spondylolysis and Spondylolisthesis with progressive
Articular hypermobility, and circumstances where the
stability of a joint is uncertain.
Bone Weakening Destructive
Demineralization of bone warrants caution
Benign bone tumors may result in pathological fractures
Circulatory and Cardiovascular
Anticoagulant therapy or certain blood dyscrasias has
bleeding as a potential complication.
contraindicated for high velocity thrust procedures in areas of
Subacute or chronic AS and other chronic
spondyloarthropathies with no signs of ligamentous integrity,
anatomic subluxation, or ankylosis.
DJD, OA, degenerative discopathy, and spondyloarthrosis.
Spondylolysis and Spondylolisthesis without progressive
Post surgical joints or segments with no evidence of
Acute injuries of osseous and soft tissue may require
modification of treatment
The chiropractic approach is
multifaceted and has developed somewhat independently from the
medical profession; this has led to ignorance and mistrust between
the professions. The Journal of the American Medical Association has estimated
that 40% of Americans have turned away from traditional drug usage
in favor of incorporating natural alternatives. Establishing
relationships between us will benefit the patient first and then
U.S. Department of Health, Education, and Welfare.: The research
status of Spinal manipulative Therapy NINCDS Monograph No. 15,
1975. Pgs. 3-47
Faye and the Motion Palpation Institute. 1986 .: Motion Palpation
and Chiropractic Technic 2nd edition. R.C. Schafer, DC,
FICC, and L.J. Faye, DC, FCCSS © Hon.
Homewood A.E.; The Neurodynamics of the Vertebral
Proceedings of the Mercy Center Consensus Conference.;
Guidelines for Chiropractic Quality Assurance and Practice
5) Jaskoviak, P.A ; DC, FICC, R.C.
Schafer, DC, FICC; Applied Physiotherapy, Practical Clinical
Applications with Emphasis on the Management of Pain and Related
Syndromes.; First Edition 1986. Pgs 3-14.