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Introduction
The diagnosis of an ailment is determined by the chosen or recommended therapy that may have an efficacious result. The treatment modalities are often intertwined with practices or disciplines since ages. As such, they have come into existence and become rampant in the society. Man has ever changing scientific atmosphere around him. So, apart from well known therapies, a new mode of treatment has gained popularity which is Chiropractics. It is considered as one of the health care disciplines. This area stresses on the diagnosis, treatment and reduction of ailments of disorders origin, especially the spine, based on the hypothesis that these disorders affect the whole body through the nervous system (Nelson et al., 2005). This disorder is usually regarded as alternative and complementary medicine inspite of few discrepancies.
The important treatment under chiropractics is based on a strategy of manual therapy like soft tissues, joints, and the most important spine manipulations (Mootz, et al., 1997). The therapy is accompanied by exercises and health and lifestyle counseling (Mootz, et al., 1997). There is a need to emphasize much on ‘Spinal manipulation’ as it was been in use since 2500 years with regard to its therapeutic effects (DeVocht, 2006). There is a limited data on the effective utility of Chiropractics in the area of spinal manipulation. The thesis is “spinal manipulation therapy offers better health because an upright, rigid spinal column contributes to the development of physical carriage, smooth breath taking ability, and a well coordinated neuromusculoskeletal system”. Hence the purpose of the article is to explore the data in this context and shed light on its efficacy and certain limitations. The scope of this article furnishes better insights on the manipulation therapy surrounding neuromuscular disorders. In detail, Chiropractics started a century before and later turned into a well recognized discipline that led to the establishment of educational institutions globally (DeVocht, 2006).
It has gained popularity from the patients who have received the therapy. As a result, independent cases studies have opened a new pathway towards many studies in the area of basic and clinical sciences with regard to the low back pain (DeVocht, 2006). There were reports that Chiropractics has significantly contributed to many clinical trials of spinal manipulation to lessen low back pain when compared to other modes of treatment that were of low reliable (DeVocht,2006). It is less expensive and has prolonged patient interest for the condition to be managed or treated with other practices (DeVocht, 2006).
Review
In countries like United States, Chiropractics is a reputed health care profession. It has relatively transformed from a naïve, unexplored area to a stage where it has drawn the attention for consideration as the best source of alternative and mainstream medicine (Meeker & Haldeman, 2002). Chiropractic is a profession improved gradually and also acquired licenses and shares in the business in the earlier two decades. This led to its improvement in the public and private health care financing systems and thus of the general opinion as a reliable specialty by experts in the medical profession (Meeker & Haldeman, 2002).
From the positive perspective, chiropractic has evolved its influence from a quarter century-long research effort in the area of neuromuscular system especially with regard to spinal manipulation.
However, Chiropractic theory remained in a debate, as the medical establishment has no properly acceptable records on chiropractic as a mainstream form of care. This demands further investigations (Meeker & Haldeman, 2002). The mainly considered reasons that pulled Chiropractic spinal care into controversy is its classical definition lacked lucidity, credibility and scientific coherence (Nelson et al., 2005).
This drawback has prevented this field from becoming a firm establishment in its authority and dominance over other domains of health care(Nelson et al., 2005). There were attempts to turn chiropractics into a model for the chiropractic profession to bring recognition and enhance market share of the society which is in the need of chiropractic care(Nelson et al., 2005).
There were three specific features of the Chiropractics profession that are recognized as blocks to the generation of believable aspects of chiropractics (Nelson et al., 2005). These are professional ethics related accepted standards with their departures, trustworthiness on outdated principles of chiropractic philosophy and the promotion of chiropractors as primary care providers (Nelson et al., 2005). The recognition of chiropractics profession needs to depend on spinal care with regard to the clinical definition and utility, partial integration of the main stream healthcare system, putting accepted standards of professional ethics into applications, enabling chiropractors as portal-of-entry providers, and the approval and endorsement of evidence-based health care, and a move toward traditional clinical science (Nelson et al., 2005).
Chiropractors are not being identified as professional practitioners in the United States (Red wood et al., 2008). In a survey, an investigation was done to determine the opinions of faculty and practitioners of Chiropractics with regard to the precise classification of their discipline based on the terms of complementary and alternative medicine (CAM) versus mainstream(Red wood et al., 2008). The sample population consisted of Doctorates i.e., who possess Doctor of Chiropractic (D.C.) degrees at chiropractic colleges and the practitioners are of 108 participants, located in various states in the US in a chiropractic practice-based research network(Red wood et al., 2008).
The findings revealed that a significant portion (69%) negated to accept that chiropractics should be categorized as CAM. Only a low proportion (27%) were of the notion that chiropractors need to be classified as IM and relatively few practitioners and faculty members accepted chiropractics as mainstream medicine(Red wood et al., 2008). It indicated that the educated professionals are not readily deciding on the Chripractics related medical applications. This may indicate that the area of chiropractic still needs extensive surveys to determine whether or not t it should be identified professional discipline. This suggests that the faculty members should communicate their clinical findings as it could rapidly enable the identification of Chiropractics in an evidence based approach. Students pursuing this course should keep reliance and strive to modulate the area to a much needed health care strategy.
It was described that the concepts of chiropractic were focused mainly on spinal manipulation and subluxation in view of the safety, reliability and cost effectiveness (Ernst, 2008). There are nearly 60,000 chiropractors who presently involve in practice in North America, and, globally and billions of amount are incurred for their services (Ernst, 2008).
Chiropractors belong to two categories those readily accept and liberal to change and those who follow religious guidelines and stay tuned to the gospel of the foundation (Ernst, 2008). Spinal manipulation considered as the main concept of chiropractics, is not thought to be based on sound science (Ernst, 2008). Although back and neck pains are the areas to be concentrated, most chiropractors provide therapy to different musculoskeletal problems (Ernst, 2008). Chiropractic spinal manipulation was not completely shown to be reliable for medical conditions mostly (Ernst, 2008).
This could be because manipulation is very often connected to mild adverse effects and with potential consequences of unknown prevalence (Ernst, 2008) Hence, this led to belief that chiropractics is not adhering firmly to the science concepts accompanied with its non effective therapeutic potential (Ernst, 2008). This could indicate that Chiropractic spinal manipulation therapy needs further clinical evidence for its efficacy and cost effective applications.
Earlier, spinal manipulation for low back pain and neck pain received much debate. Studies were undertaken frequently to assess the quality of spinal manipulative therapy (SMT) and mobilization (MOB) for the control of neck pain (NP) and low back pain (LBP) with much emphasis on its utility keeping in view of the facts and for sorting out the efficacy of SMT(Bronfort et al., 2004). For this purpose, clinical trials were carried out randomly on patients receiving SMT or MOB keeping in view of the convalescence, worldwide enhancement, disability and overall patient feedback (Bronfort et al., 2004). The study revealed that SMT induced much short period pain relief compared to MOB. With regard to the LBP, there was low response on faster recovery compared to a routinely used physical therapy treatment strategy (Bronfort et al., 2004). With regard to the Chronic LBP, it was shown that SMT has an equivalent result comparable to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy (Bronfort et al., 2004).
There is less support than SMT is effective than physical therapy and home back exercise in during lengthy and small periods (Bronfort et al., 2004). But, less support is also favored on MOB which is inferior to back exercise after disc herniation surgery (Bronfort et al., 2004).
Further, with regard to the combination of acute and chronic LBP, SMT/MOB yielded significant pain outcomes during lengthy and short periods when compared to other therapies like medical care, back school, soft tissue treatment, and management by physical therapists (Bronfort et al., 2004). Hence, the chiropractors could suggest with some credibility that use of SMT and/or MOB is a reliable approach for the treatment of both low back pain and N (Bronfort et al., 2004). Although, certain good quality trials differentiate chronic and acute subjects, majority are confined to only short follow up period (Bronfort et al., 2004).
There is a need of critical evaluation of well characterized patient sub groups, and study the efficacy SMT and MOB for acute patients, to guarantee the quantity of treatment visits and take into a account the cost-effectiveness (Bronfort et al., 2004). This was strengthened by another report.
It was reported that NP and LBP are frequent old age conditions which lead to decreased independence and altered functional ability (Maiers et al., 2007).
Although common exercise and manual therapies are common for the NP and LBP patients, they have not yet proven to be effective in a research based manner for aged NP and LBP patient groups (Maiers et al., 2007). Hence, a strategy was devised to determine their clinical efficacy that is a combination of home exercise and manual therapy and monitor combination of home exercise, and rehabilitative exercise and independent home exercise with regard to the patient-rated pain, for senior NP and LBP sufferers (Maiers et al., 2007). The findings obtained from the three treatment approaches would be utilized for a comparative study with regard to the treatment utility,
patient satisfaction and their health status and trunk strength and endurance as well as objective outcomes of spinal motion (Maiers et al., 2007). The study revealed that clinical trials undertaken randomly could furnish better information on, and patients’ opinions clinical efficacy and, cost-effectiveness with regard to the commonly used treatments for and NP and aged LBP sufferers (Maiers et al., 2007).
Lawrence described that SMT lessens the patient complaints and enhances the performance ability of chronic LBP in conditions of acute and sub acute LBP (Lawrence et al., 2008). The utility of exercise in combination with manipulation may accelerate and enhance the outcomes and lessen the recurrence (Lawrence et al., 2008). Low support exists for the patients with LBP and leg pain diversions who depend on manipulation (Lawrence et al., 2008).
This was revealed when literature was retrieved from medical databases (Lawrence et al., 2008). Here, relevant articles were chosen in a professional format based on largely spread professional news and the relevant media (Lawrence et al., 2008). In addition, a Scientific Commission on Chiropractic Guidelines was reported to be equipped with a gradual accumulation of the literature, managed by anatomy to assess and describe on chiropractic care. Here, nearly 887 source documents were retrieved (Lawrence et al., 2008). The results were categorized into related topics. outcome and cohort studies, psychosocial issues and cognitive therapy, methods, diagnostic based articles, basic science, meta-analyses and systematic reviews guidelines, randomized clinical trials of different interventions for LBP and its manipulation(Lawrence et al., 2008). This study ensured team members obtain nearly equal numbers of literature from each group, for to be selected for random distribution (Lawrence et al., 2008).
This study would help the investigators to gain insights n the methodology to be followed for a effective implementation of chiropractic for spinal manipulation (Lawrence et al., 2008). In one of the case studies it was revealed that an old managed 77 years who had lower-back pain was recommended for lower spine manipulation related to chiropractics (Solheim, Jorgensen, Nygaard, 2007). He had chronic atrial fibrillation. Followed by a manipulation period, he acquired temporarily a condition where urinary retention and lower extremity paresis developed, known as cauda equina syndrome (Solheim, Jorgensen, Nygaard, 2007). This case was also subjected to brain scanning which showed an L3 level. epidural hematoma. In view of the clinical history this patient was recommended surgical evacuation of the hematoma via L3 and L4 region laminectomy (Solheim, Jorgensen, Nygaard, 2007).
He was followed up and there was gradual improvement in his motor, but the bladder dysfunction remained. This has made the chiropractics into a side effect induced therapies as it contributed to lumbar epidural hematoma. Hence, serious complications to spinal manipulation are mostly reported to be observed in the cervical region (Solheim, Jorgensen, Nygaard, 2007). Therefore, the case of lumbar epidural hematoma after chiropractic manipulation could make this concept of chiropractics into hard to believe discipline (Solheim, Jorgensen, Nygaard, 2007).
Very often adverse effects of rare occurrence followed by chiropractic manipulation of the spine need to be considered against relatively good effects of the treatment (Solheim, Jorgensen, Nygaard, 2007). It could also raise a precautionary measure to be shown in patients who would be recommended antithrombotic therapy (Solheim, Jorgensen, Nygaard, 2007). This case study had indicated that chiropractics have some potential and detrimental effects.
The chiropractic discipline needs a thorough evaluation of the suspected side effects to overcome the associated complications at the earliest. It was reported that nearly chiropractic patients are children and adolescents and they both constitute 5- 10%. These patient groups have complaints related to spinal pain and other musculoskeletal conditions (Hestbaek and Stochkendahl, 2010). These problems initiate in the early childhood stage and continue till the adult life thus affecting the quality of life (Hestbaek and Stochkendahl, 2010). A study was carried out to determine the efficacy of manual therapy of musculoskeletal disorders in children and adolescents in an evidence based approach. The inclusion was based keeping in view of studies carried out in a non-randomized, quasi-randomized manner (Hestbaek and Stochkendahl, 2010).
So far three studies made an effort to determine the manual therapy efficacy for children or adolescents complaining of spinal problems, but there were no controlled clinical trials on random scale (Hestbaek and Stochkendahl, 2010). It was revealed that there are relatively few studies in the area of chiropractic spinal care although there is rationale to visit a chiropractor is spinal pain in children (Hestbaek and Stochkendahl, 2010). Hence, this research suggests that there is a need to explore the reliability of joint manipulation of problems with regard to the musculoskeletal system that requires development (Hestbaek and Stochkendahl, 2010). There is also a need to consider conditions other than spinal disorder induced low back pain. Fibromyalgia syndrome (FMS) is considered as the frequently diagnosed nonarticular soft tissue conditions throughout the specialization of musculoskeletal medicine domain, together with chiropractics (Schneider et al., 2009).The findings were based on review reports from consensus document, published guidelines, meta-analyses and systematic reviews (Schneider et al., 2009). They revealed good support for nonpharmaceutical treatments like cognitive behavioral therapy and aerobic exercise (Schneider et al., 2009).
Medium support existed for spa therapy (balneotherapy), acupuncture, muscle strength training, and massage. Some degree of evidence also favored dietary modification, knowledge about movement/body spinal manipulation, herbs and vitamins (Schneider et al., 2009). This study indicated the significant role of nonpharmacologic treatments and manual-type therapies in the treatment of FMS (Schneider et al., 2009). This study suggests that chiropractic spinal manipulation could improve if a similar study is undertaken by the investigators.
Summary
The profession of Chiropractics can be considered as one of the good areas of Health care to be recommended. Especially, spinal manipulation therapy has received much emphasis keeping in view of growing evidence from the accumulated literature. Pain related complications continue to trouble children, adolescents and the age old. This has suggested the need for urgent chiropractic manipulation with central interest on random clinical trials. Initially, the chiropractic spinal care has received much criticism as inadequate data persisted.
But with the complaints escalating in the area of neuromusculoskeletal system, interventions have begun to provide a remedy to the sufferers at the earliest. Some of these include cognitive and nutrition therapy and fitness related exercise. Although, there is good number of Doctorate holders in the area of Chiropractics, discrepancies still exist as it is not professionally being accepted as a mainstream and alternative medicine. Awareness is still less among the population and this needs to be counteracted with the increased number of professionals of Chiropractics at the earliest. This will have implications for the evidence based therapeutic interventions on a large patient population. Health care authorities should take precautionary measure to monitor any adverse side effects resulting from the Chiropractic spinal manipulations will have good implications to overcome the unnecessary criticisms that could retard the progress of this much needed health care discipline.
References
Nelson, C, F., Lawrence, D, J., Triano, J, J, Perle, S,M., Metz, R,D., Hegetschweiler, K., LaBrot, T. (2005).Chiropractic as spine care: a model for the profession. Chiropr Osteopat, 13,9.
Nelson and his co associates have described a model for the chiropractic discipline to deeply root its cultural authority and enhance market share of the society in need of chiropractic care. Their model could help associate chiropractic with the mainstream delivery system without disturbing the uniqueness of the profession.
Redwood, D., Hawk, C., Cambron, J., Vinjamury, S, P., Bedard, J.(2008). Do chiropractors identify with complementary and alternative medicine? Results of a survey. J Altern Complement Med, 4(4),361-8.
An article was written on the opinions of chiropractic practitioners regarding the classification of Chiropractics in terms of complementary and alternative medicine (CAM) versus mainstream. Most practitioners did not accept themselves to be recognized as CAM practitioners but have favored integrated medicine (IM), to some extent.
Mootz, R,D., Shekelle, P,G. (1997). “Content of practice”. in Cherkin, D,C., Mootz, R,D (eds.). Chiropractic in the United States: Training, Practice, and Research. Rockville, MD: Agency for Health Care Policy and Research. pp. 67–91. OCLC 39856366.
An article was written to highlight the application of manual therapy that focuses on soft tissues, joints, and the most important spine manipulations. The article has given the significance of exercises and health and lifestyle counseling in the area of manual therapy
DeVocht, J, W. (2006). History and overview of theories and methods of chiropractic: a counterpoint. Clin Orthop Relat Res, 444, 243-9.
DeVocht had shed light on the Chiropractic Spinal care from historical perspective The area of spinal manipulation is having a history of 2500 years with good educational institutions spread across the world. Nearly, 43 clinical trials carried out on random basis have resulted in the improvement of Chiropractic Spinal care indicating well accepted public and professional feed backs on chiropractics.
Meeker, W, C., & Haldeman, S. (2002). Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med,136(3), 216-27.
These two authors have written how the chiropractics has transformed from the initial unexplored stage to a state where it is present on the crossroads of alternative and mainstream medicine. Spinal manipulation was given prior importance in the relevant investigations thus leaving the opinion about its adoption into all health care systems in the near future
Ernst, E. (2008). Chiropractic: a critical evaluation. J Pain Symptom Manage. 35(5), 544-62.
Ernst commented on the chiropractics with regard to the strength of current practitioners world wide. Conflicts were highlighted due to two different types of chiropractors, and low efficacy against any medical condition. The connection between spinal manipulation and frequent side effects is a matter of debate accompanied by its feeble adherence to solid science.
Bronfort, G., Haas, M., Evans, R, L., Bouter, L, M. (2004). Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J, 4(3),335-56.
An article was written to highlight the existing controversy despite the presence of good number published randomized clinical trials (RCTs), reviews and national clinical guidelines. The article has recommended the use of spinal manipulation therapy (SMT) a reliable approach for treating both low back pain and NP.
Maiers, M,J., Hartvigsen, J., Schulz, C., Schulz, K., Evans, R,L., Bronfort, G. (2007). Chiropractic and exercise for seniors with low back pain or neck pain: the design of two randomized clinical trials. BMC Musculoskelet Disord,18, 8:94.
Maiers and his team members have written an article on the efficacy of clinical trials to solve the issues related to cost-effectiveness, clinical efficacy, and patients opinions on the frequently used treatments for elderly low back pain (LBP) and neck pain (NP) sufferers. Since these conditions are common in aged people, the study has given insights on the utility of various therapies used independently and in combination.
Lawrence, D, J., Meeker, W., Branson, R., Bronfort, G., Cates, J, R., Haas, M., Haneline, M., Micozzi, M., Updyke, W., Mootz, R., Triano, J, J., Hawk, C. (2008). Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. J Manipulative Physiol Ther, 31, 659-74.
An article was written to highlight the awareness on the evidence of spinal manipulations to lessen the symptoms and enhance function in patients with chronic, acute and subacute LBP. The article emphasized on the combination approach of exercise with manipulation is to produce significant result and lessen recurrence.
Solheim, O., Jorgensen, J, V., Nygaard, O, P. (2007). Lumbar epidural hematoma after chiropractic manipulation for lower-back pain: case report. Neurosurgery, 61(1),E170-1,discussion E171.
A case report of 77 year old man was written to highlight the adverse outcome Lumbar epidural hematoma followed after chiropractic manipulation in a patient with low back pain. Although spinal manipulation therapy has accepted applications for treatment of lower-back pain, this case had seemed to provide a cautionary notice inspite of beneficial effects of spinal manipulation therapy.
Hestbaek, L & Stochkendahl, M, J. (2010). The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: The emperor’s new suit? Chiropr Osteopat, 2, 18,15.
An article was written by Hestbaek and Stochkendahl to provide an insightful picture on the susceptible population to spinal pain and other musculoskeletal conditions. These are children and adults. Spinal problems could begin in the early life and continue till the adult hood stage which is the matter of concern. A careful evaluation of the developing musculoskeletal system is suggestive.
Schneider, M., Vernon, H., Ko, G, Lawson, G., Perera, J. (2009). Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther 32 (1),25-40.
An article was written to highlight the evidence based approaches for the management of fibromyalgia syndrome (FMS). This disorder is a nonarticular soft tissue condition related to musculoskeletal medicine and also chiropractics. Various non pharmaceutical therapies were reported to be effective that are having strong to limited evidence. Literature reviews have proven to provide evidence based ratings on the therapies and the related procedures.
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