Research

1.   Status and Recognition of Chiropractic Care
2.   Neck Pain
3.   Headaches
4.   Back Pain (Acute, Chronic, and General)
5.   Carpal Tunnel Syndrome
6.   Fibromyalgia
7.   Infantile Colic
8.   Childhood Ear Infections
9.   Elderly
10.    Pregnancy
11.    Sports
12.    Rehabilitation
13.    Wellness
14.    Safety and Effectiveness
15.    Patient Satisfaction
16.    Cost-Effectiveness
17.    Chiropractic Education

Status and Recognition of Chiropractic Care

Chiropractic is now firmly rooted in the public consciousness as a primary agent of health care management. According to a 1990 study published in the New England Journal of Medicine, the number of visits to non-medical health care providers in 1990 totaled 425 million, 9.5% more than the total number of visits to all family physicians (Eisenberg et al.1993). A follow-up study determined that, in 1997, total visits to non-medical providers amounted to 629 million, exceeding the total projected visits to all primary care physicians by 63% (Eisenberg et al. 1998). Moreover, a 1998 study published in the New England Journal of Medicine reported chiropractic as the most used non-medical treatment (15.7%) (Astin 1998).

The change in consumer preferences for health care is reflected in health insurance coverage. Specifically, a 1999 study found that coverage of chiropractic care is "offered by nearly two-thirds of all HMOs (65%)" (Landmark 1999, 14). When surveyed concerning their policies toward alternative therapies, 43% of HMO representatives reported that they "do not regard chiropractic as an alternative therapy" but as a form of mainstream health care (11).

RAND , a prestigious nonprofit research organization and "think tank," has conducted several studies of chiropractic. Dr. Paul Shekelle, a medical doctor and a researcher for RAND , stated: "Instead of thinking of chiropractic as an alternative or some kind of therapy separate from other health care, we really should consider it equivalent" (Qtd. in Brin 1998).

Widespread consumer use of chiropractic care and its documented effectiveness have stimulated major studies by governments and other organizations throughout the United States , Canada , Europe , and other areas of the world. Some of the significant studies and other inquiries are reported below.

In consideration of these data and because chiropractors represent the third largest primary health care profession (surpassed in numbers only by medical and dental practitioners), the chiropractic community and those served by the profession do not generally apply the terms "alternative" or "unconventional" as descriptors of chiropractic care. Where these terms do appear in this research, it refers only to options other than medication.

Astin, John A. 1998. "Why Patients Use Alternative Medicine." Journal of the American Medical Association 279, no. 19: 1548-1553.
Brin, Dinah Wisenberg, July 2 1998 , "Study Credits Chiropractors with Right Procedures," The Scranton Times , 14+.
Cherkin, Daniel C., and Frederick A. MacCornack. 1989. "Patient Evaluations of Low Back Pain Care from Family Physicians and Chiropractors." Western Journal of Medicine 150 (March): 351-355.
"Chiropractors File Supreme Court Response to AMA's Requests for Review." 1990. Press Release. November 5. Chicago , Illinois .
DiFabio, R.P. 1992. "Efficacy of Manual Therapy." Physical Therapy 72, no. 12: 853-864.
Eisenberg, David M., Roger B. Davis, Susan L. Ettner, Scott Appel, Sonja Wilkey, Maria Van Rompay, and Ronald C. Kessler. 1998. "Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-up National Survey." Journal of the American Medical Association 280, no. 18: 1569-1575.
Eisenberg, David M., Ronald C. Kessler, Cindy Foster, Francis E. Norlock, Dav R. Calkins, and Thomas L. Delbanco. 1993. "Unconventional Medicine in the United States ." New England Journal of Medicine 328, no. 4: 246-252.
Landmark Healthcare, Inc. 1998. The Landmark Report on Public Perceptions of Alternative Care. Sacramento , CA : Landmark Healthcare, Inc.
Landmark Healthcare, Inc. 1999. The Landmark Report II on HMOs and Alternative Care. Sacramento , CA :Landmark Healthcare, Inc.
Ottenbacher et al. 1985. "Efficacy of Spinal Manipulation/Mobilization Therapy: A Meta-analysis. Spine 10, no. 9: 833-837.

Neck Pain

Hurwitz et al. (1996), a doctor of medicine and doctors of chiropractic from RAND and several academic institutions, conducted a review of literature on treatments for neck pain. The authors found manipulation to be more effective than mobilization or physical therapy in treating some subacute or chronic neck pain and noted that "all 3 treatments are probably superior to usual medical care" (1755).

Hurwitz, Eric L., Peter D. Aker, Alan H. Adams, William C. Meeker, and Paul G. Shekelle. 1996. "Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature." Spine 21, no. 15: 1746-1760.
Aker, Peter D., Anita R. Gross, Charles H. Goldsmith, and Paul Peloso. 1996. "Conservative Management of Mechanical Neck Pain: Systematic Overview and Meta-analysis." British Medical Journal 313 (23 November): 1291-129

Doctors of medicine and other professionals from the Netherlands conducted two randomized clinical trials comparing the outcomes of various treatments of chronic back and neck complaints. Spinal manipulative therapy was compared to physiotherapy, treatment by a general practitioner, and a placebo. The authors found faster and greater improvement in the spinal manipulation groups (Koes et al. 1992; Koes et al. 1992a).

Koes, Bart W., Lex M. Bouter, Henk van Mameren, et al. 1992. "A Blinded Randomized Clinical Trial of Manual Therapy and Physiotherapy for Chronic Back and Neck Complaints: Physical Outcome Measures." Journal of Manipulative and Physiological Therapeutics 15, no. 1: 16-23.
Koes, Bart W., Lex M. Bouter, Henk van Mameren, et al. 1992a. "Randomised Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up." British Medical Journal 304 (7 March): 601-605.

Several studies (Howe, Newcombe, and Wade 1983; Verhoef, Page, & Waddell 1997) have found spinal manipulation to improve neck mobility and decrease neck pain. As Verhoef, Page, and Waddell (1997) concluded, "patients suffering from back and/or neck complaints experience chiropractic care as an effective means of resolving or ameliorating pain and functional impairments" (240).

Howe, D. H., R. G. Newcombe, and M. T. Wade. 1983. "Manipulation of the Cervical Spine-A Pilot Study." Journal of the Royal College of General Practitioners 33: 574-579.
Verhoef, Maria J., Stacy A. Page, and Stephen C. Waddell. 1997. "The Chiropractic Outcome Study: Pain, Functional Ability and Satisfaction with Care." Journal of Manipulative and Physiological Therapeutics 20, no. 4: 235-240.

Headache Pain

A randomized controlled trial reported by medical doctors and doctors of chiropractic in Denmark found manipulation to have "a significant positive effect" on intensity and duration of cervicogenic headaches compared to "soft-tissue" therapy (Nilsson, Christensen, and Hartrigsen 1997).

Nilsson, Niels, Henrik Wulff Christensen, and Jan Hartvigsen. 1997. "The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache." Journal of Manipulative and Physiological Therapeutics 20, no. 5: 326-330.

Boline et al. (1995) conducted a study comparing manipulation to pain medication (amitriptyline) in the treatment of tension headaches. The authors found that pain medication had short-term effectiveness--although with side effects--while "four weeks after the end of intervention, the spinal manipulation group showed a 32% reduction in headache intensity, 42% [reduction] in headache frequency, 30% [reduction] in over-the-counter medication usage, and a 16% improvement in functional health status... The amitriptyline therapy group showed no improvement or slight worsening" (150).

Boline, Patrick D., Kassem Kassak, Gert Bronfort, Craig Nelson, and Alfred V. Anderson. 1995. "Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-Type Headaches: A Randomized Clinical Trial." Journal of Manipulative and Physiological Therapeutics 18, no. 3: 148-154.

In 1998, Hack et al. reported a new anatomical discovery: bridges of connective tissue establish a direct connection between neck muscles and the protective covering of the brain and spinal cord. This is a probable cause-and-effect connection between headaches and cervical spine dysfunction. The authors hypothesized that chiropractic treatment of muscle tension headaches is effective because it can "decrease muscle tension and thereby reduce or eliminate pain by reducing the potential forces exerted on the dura via the muscle-dura connection" (22).

Hack, D.G., G. Dunn et al. 1998. "The Anatomist's New Tools." 1998 Medical and Health Annual. Chicago : Encyclopaedia Brittanica, Inc.

In 1998, Mitchell, Humphreys, and O'Sullivan described previously unreported ligaments of the neck attached to the base of the skull. This discovery has implications for manual therapy and the treatment of cervicogenic headaches caused by damaged ligaments, mainly in cases of moderate to severe whiplash.

Mitchell, Barry S., B. Kim Humphreys, and Elizabeth O'Sullivan. 1998. "Attachments of the Ligamentum Nuchae to Cervical Posterior Spinal Dura and the Lateral Part of the Occipital Bone." Journal of Manipulative and Physiological Therapeutics 21, no. 3: 145-48.

Back Pain

Acute Low-Back Pain

U.S. Government Agency Report. In 1994, the Agency for Health Care Policy and Research published Clinical Practice Guideline 14-Acute Low Back Problems in Adults (Bigos et al. 1994). The guideline defined acute low-back pain, evaluated various treatments, and made recommendations concerning the efficacy of those treatments. According to the Guideline, spinal manipulation is one of the most safe and effective treatments for most cases of acute low-back pain. Regarding the guideline, the following editorial comments appeared in the Annals of Internal Medicine: "The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that ... spinal manipulation hastens recovery from acute low back pain and recommended that this therapy be used in combination with or as an alternative to nonsteroidal anti-inflammatory drugs... Perhaps most significantly, the guidelines state that... spinal manipulation offers both pain relief and functional improvement" (Micozzi 1998, 65).

Bigos, Stanley J., O. Richard Bowyer, G. Richard Braen, et a1. 1994. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville , MD : Agency for Health Care Policy and Research, Public Health Service , U.S. Department of Health and Human Services.
Micozzi, Mark. 1998. "Complementary Care: When is it Appropriate? Who Will Provide It?" Annals of Internal Medicine 129: 65-66.

Shekelle et al. (1992): doctors of medicine and doctors of chiropractic from RAND , UCLA Schools of Medicine and Public Health, and other research organizations, conducted a literature review of 25 controlled trials and a meta-analysis of nine studies addressing chiropractic treatment of low-back pain. The literature review was published in the Annals of Internal Medicine and concluded, "spinal manipulation hastens recovery from acute uncomplicated low-back pain" (594).

Shekelle, Paul. G., Alan H. Adams, Mark R. Chassin, Eric L. Hurwitz, and Robot H. Brook. 1992. "Spinal Manipulation for Low-Back Pain." Annals of Internal Medicine 117, no. 7: 590-598.

Chronic Low-Back Pain

Van Tulder, Koes, and Bouter (1997), researchers in the Netherlands funded by the Dutch Health Insurance Board, retrieved and evaluated evidence from 48 randomized controlled trials conducted worldwide that addressed the treatment of acute and chronic low-back pain. Researchers found "strong evidence" for the effectiveness of spinal manipulation in the treatment of chronic low-back pain.

Van Tulder, Maurits W., Bart W. Koes, and Lex M. Boater. 1997. "Conservative Treatment of Acute and Chronic Nonspecific Low Back Pain: A Systematic Review of Randomized Controlled Trials of the Most Common Interventions." Spine 22, no. 18: 2128-2156.

General Low-Back Pain

Bronfort (1999) conducted a systematic review of literature concerning the efficacy of chiropractic treatment of low-back pain. The author found evidence "of short-term efficacy for SMT [spinal manipulative therapy] in the treatment of acute LBP [low-back pain]" (107). Additionally, the author found a combination of spinal manipulation and mobilization to be effective for chronic low-back pain "compared with placebo and commonly used therapies such as general medical practitioner management" (98).

Bronfort, Gert. 1999. "Spinal Manipulation: Current State of Research and Its Indications." Neurologic Clinics of North America 17, no. 1: 91-111.

In a study reported in 1992, Anderson et al. conducted a meta-analysis of twenty-three randomized controlled clinical trials of the effectiveness of spinal manipulation in the treatment of back pain. The researchers stated, "the trend for spinal manipulation to produce better results than any form of treatment to which it was compared was consistent and strong" (193). For 86% of the outcomes, spinal manipulation was more effective than any other treatment.

Anderson, Robert, William C. Meeker, Brian E. Wirick, Robert D. Mootz, Diana H. Kirk, and Alan Adams. 1992. "A Meta-Analysis of Clinical Trials of Spinal Manipulation." Journal of Manipulative and Physiological Therapeutics 15, no. 3: 181-194.

In a study conducted for the Ontario Ministry of Health, Manga et al. (1993) reported that spinal manipulation is the most effective treatment for low-back pain and that spinal manipulation is "safer than medical management of low-back pain" (11).

Manga, Pran, Doug Angus, Costa Papadopoulos, and William Swan. 1993. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Ottawa : University of Ottawa .

Following a 1993 study, researchers Cassidy, Thiel, and Kirkaldy-Willis of the Back Pain Clinic at the Royal University Hospital in Saskatchewan concluded that "the treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective" (102).

Cassidy, J. David, Haymo W. Thiel, and William H. Kirkaldy-Willis. 1993. "Side Posture Manipulation for Lumbar Intervertebral Disk Herniation." Journal of Manipulative and Physiological Therapeutics 16, no. 2: 96-103.

A study conducted by T.W. Meade, a medical doctor, and reported in the British Medical Journal concluded, after two years of patient monitoring, that "for patients with low-back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management" (Meade 1990, 1431).

Meade, T. W., S. Dyer, W. Browne, J. Townsend, and A. O. Frank. 1990. "Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment." British Medical Journal 300, no. 6737: 1431-1437.

A 1988 study of 10,652 Florida workers' compensation cases was conducted by Wolk and reported by the Foundation for Chiropractic Education and Research. According to Wolk, back injury patients treated by chiropractors versus medical doctors or osteopaths were less likely to develop compensable injuries (injuries resulting in time lost from work and therefore requiring compensation) and less likely to require hospitalization. The author explained that chiropractors are more effective in treating low-back injuries because "chiropractic treatment, in providing more services to the patient at the outset of injury, may produce more immediate therapeutic results and may reduce the amount of time lost from work" (56).

Wolk, Steve. 1988. "An Analysis of Workers' Compensation Medical Claims for Back-Related Injuries." ACA Journal of Chiropractic (July): 50-59.

“Of 1,996 low-back pain cases studied, patients receiving chiropractic treatment averaged 6.26 compensation days compared to th25.56 compensation days for medical patients.”

Ebrall, P. Mechanical Low-Back Pain: A comparison of Medical and Chiropractic Management Within Victorian WorkCare Scheme. Chiropractic Journal of Australia 1992; 22(2): 47-53.

Carpal Tunnel Syndrome

Davis et al. (1998) compared chiropractic treatment of carpal tunnel syndrome (CTS) to nonsurgical medical treatment. The chiropractic group used manipulation, ultrasound, and wrist supports while the medical group used wrist supports and ibuprofen. While both treatment groups improved significantly, the authors noted that chiropractic represents an alternative conservative treatment for CTS, especially for patients "who are unable to tolerate ibuprofen" (322).

Davis, P. Thomas, James R. Hulbert, Kassem M. Kassak, and John J. Meyer. 1998. "Comparative Efficacy of Conservative Medical and Chiropractic Treatments for Carpal Tunnel Syndrome: A Randomized Clinical Trial." Journal of Manipulative and Physiological Therapeutics 21, no. 5: 317-326.

Fibromyalgia

Blunt, Rajwani, and Guerriero (1997) concluded that chiropractic treatment of fibromyalgia resulted in clinically significant improvement in flexibility and pain levels. The authors recommended that chiropractic treatment be included in a multidisciplinary treatment regimen for fibromyalgia.

Blunt, Kelli L., Moez H. Rajwani, and Rocco C. Guerriero. 1997. "The Effectiveness of Chiropractic Management of Fibromyalgia Patients: A Pilot Study." Journal of Manipulative and Physiological Therapeutics 20, no. 6: 389-399.

Infantile Colic

Klougart, Nilsson, and Jacobsen (1989) reported a prospective study of 316 cases of infantile colic. The authors found that 94% of the infants appeared to be helped by chiropractic treatment "within 14 days from the start of treatment" (287). The infants included in the study had moderate to severe infantile colic and were otherwise healthy, averaged two weeks of age at the outset of colic, and averaged 5.7 weeks of age at the start of treatment.

The authors found that chiropractic treatment resulted in "both a reduction of the daily length of the colic periods and a reduction of the number of colic periods per day" (287). Because recovery began between 5.7 and 7.7 weeks of age, the authors maintained that this provided substantial evidence that the improvement could not be attributed strictly to "natural cessation of colic symptoms" (286).

Klougart, Niels, Niels Nilsson, and Jens Jacobsen. 1989. "Infantile Colic Treated by Chiropractors: A Prospective Study of 316 Cases." Journal of Manipulative and Physiological Therapeutics 12, no. 4: 281-288.

In a 1999 study similar to the 1989 colic study noted above, Wiberg, Nordsteen, and Nilsson found that "spinal manipulation has a positive short-term effect on infantile colic" (520). Researchers randomly placed otherwise healthy, colicky infants into one of two treatment groups: chiropractic treatment and dimethicone medication. Parents kept a diary of symptoms and behaviors before the trial to establish baseline data and continued to keep a diary of symptoms during the trial. Both groups received two weeks of treatment. The infants in the chiropractic group exhibited "a reduction of 67% on day 12" of daily hours with colic, which was nearly identical to the results of the first study. The "dimethicone group only had a reduction in daily hours with colic of 38% by day 12" (520).

The dimethicone group had several subjects drop out of the study because their symptoms worsened. These subjects and their corresponding data were excluded from the results, creating better overall improvement statistics for the dimethicone group than actually occurred. Yet, the chiropractic subjects still exhibited twice as much improvement at the end of the trials when compared to the dimethicone group.

The authors noted that "spinal manipulation is normally used in the treatment of musculoskeletal disorders, and the results of this trial leave open 2 possible interpretations. Either spinal manipulation is effective in the treatment of the visceral disorder infantile colic or infantile colic is, in fact, a musculoskeletal disorder, and not, as normally assumed, visceral" (520).

Wiberg, Jesper M. M., Jan Nordsteen, and Niels Nilsson. 1999. "The Short-term Effect of Spinal Manipulation in the Treatment of Infantile Colic: A Randomized Controlled Clinical Trial with a Blinded Observer." Journal of Manipulative and Physiological Therapeutics 22, no. 1: 13-16.

Childhood Ear Infections

Children age 5 or younger with reoccurring middle ear infections were treated with chiropractic adjustments to the upper cervical (neck) region. The results were favorable with 93% of all episodes improved, 75% in 10 days or fewer and 43% with only one or two treatments. …This study's data indicates that limitation of medical intervention (antibiotics) and the addition of chiropractic care may decrease the symptoms of ear infection in young children.

Froehle RM. Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors. J Manipulative Physiol Ther. 1996 Mar-Apr;19(3):169-77.

Otitis media is a common disorder that results in numerous visits to the physician each year. This article suggests that by using some forms of manipulation, the eustachian tube is made to open and close in a “pumping action” that allows the ear to drain accumulated fluid more effectively.

Pratt-Harrington D. Galbreath technique: a manipulative treatment for otitis media revisited. J Am Osteopath Assoc . 2000 Oct;100(10):635-9.

Elderly Coulter, et al. demonstrated that “[Elderly] chiropractic users were less likely to have been hospitalized, less likely to have used a nursing home, more likely to report a better health status, more likely to exercise vigorously, and more likely to be mobile in the community. In addition, they were less likely to us prescription drugs.”

Coulter I, Hurwitz E, Aronow H, Cassata D, Beck J. Chiropractic Patients in a Comprehensive Home-Based Geriatric Assessment, Follow-up and Health Promotion. Topics in Clinic Chiropractic 1996; 3(2): 46-55.

Several studies indicate that elderly persons who utilize chiropractic care spend less money on health care those who do not. Data compiled from the Centers for Medicare and Medicaid Services (CMS) in 1999 demonstrated that health care payments for beneficiaries receiving chiropractic care was on average $3,677 less per year than those payments made on beneficiaries not receiving chiropractic care. Other studies have found that this monetary discrepancy may be even more.

Muse & Associates. Utilization, Cost, and Effects of Chiropractic Care on Medicare Program Costs. July 2001.

According to a recent study reported in Fundamentals of Chiropractic, patients over the age of 65 who received maintenance care (minimum of four visits per year for five years) averaged health care expenditures of $3,106 per year. This compared to $10,041 per year for patients over the age of 65 who were not receiving chiropractic care, a difference of $6,935.

Redwood, D. Fundamentals of Chiropractic. Mosby. August 1, 2003 .

Pregnancy A study done jointly by a chiropractor and a medial doctor revealed that 75% of pregnant women who received adjustments during their pregnancies stated they found relief from pain symptoms.

Mantero E, Crispini L. Static Alterations of the Pelvic, Sacral, and Lumbar Area due to Pregnancy. Chiropractic Interprofessional Research. Torino : Edizioni Minerva Medica, 1982: 59-68.

Structural adaptations…place excessive demands on the musculoskeletal system…resulting directly from postural changes, hormonal secretions and increased abdominal girth (that allows for the) development of back pain during pregnancy and labor. Non-invasive chiropractic adjustments can play an important role in treating back pain in both the pregnant and postpartum patients.

Benizzi-DiMarco, D. The Female Patient: Enhancing and Broadening the Chiropractic Encounter with Pregnant and Postpartum Patients. Journal of the American Chiropractic Association. November 2003; 18-24.

Researchers found that a reduction of labor time is associated with chiropractic care.

Fallon JM. Chiropractic and Pregnancy. Int. Rev. Chiro. 1990; 46(6): 39-42.

Sports Football

There is significant chiropractic participation in US professional football. Certified athletic trainers see a role for the sport chiropractor in the NFL, primarily as a spinal specialist treating low back and other musculoskeletal injuries. A substantial majority of NFL trainers have developed cooperative relationships with chiropractors, with 77% having referred a player to a chiropractor. Thirty-one percent of NFL teams have a chiropractor officially on staff, and an additional 12% of teams refer players to chiropractors but do not directly retain these chiropractors.

Stump JL, Redwood D. The use and role of sport chiropractors in the national football league: a short report. J Manipulative Physiol Ther. 2002 Mar-Apr;25(3):E2.

Running

Chiropractic care can improve running injuries by identifying the underlying dysfunction and implementing a multilevel treatment protocol that involves manipulative therapy, restoration of faulty biomechanics, strengthening of weakened muscle groups, and motor pattern re-education.

Conway PJ. Chiropractic approach to running injuries. Clin Podiatr Med Surg. 2001 Apr;18(2):351-62.

Golf

This study was an initial investigation evaluating the effects of orthotic intervention on club-head velocity (CHV) among a group of experienced golfers before and after 9 holes of simulated golf. After 6 weeks of use, there was an approximate increase in CHV of between 3 and 5 mph, or a relative increase in CHV by up to 7%, after subjects had worn custom-made, weight-bearing, flexible orthotics daily for 6 weeks. A 5-mph increase in CHV is equivalent to an approximate increase in golf ball travel distance of 15 yards, a significant increase for the tour player for whom small increases in performance can reflect large position changes on the roster board. In addition, the use of these custom of those eliminated the effects of fatigue associated with playing 9 holes of golf (relative to CHV) and therefore may improve the likelihood for more consistent golf performance.

Stude DE , Gullickson J. Effects of orthotic intervention and nine holes of simulated golf on club-head velocity in experienced golfers. J Manipulative Physiol Ther. 2000 Mar-Apr;23(3):168-74.

Ankle Injury

The purpose of this study was to determine the efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains. Patients in the treatment group received the ankle adjustment. This study appears to indicate that ankle adjustment may be superior to (other therapies) in the management of subacute and chronic grade I and grade II inversion ankle sprains.

Pellow JE, Brantingham JW. The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains. J Manipulative Physiol Ther. 2001 Jan;24(1):17-24.

Rehabilitation In an opinion article by respected researchers on the use of chiropractic manipulation in lumbar rehabilitation, Triano, McGregor, and Skogsbergh (1997) stated that the symptom relief and improved flexibility provided by chiropractic care make it a "valuable tool," assisting and easing patients into necessary rehabilitative programs. According to the authors, not only can chiropractic treatment relieve symptoms that interrupt therapy, but it restores patients' confidence in movement, discourages chronicity, and encourages patients to continue rehabilitation.

Triano, John J., Marion McGregor, and Dennis R. Skogsbergh. 1997. "Use of Chiropractic Manipulation in Lumbar Rehabilitation." Journal of Rehabilitative Research and Development 34, no. 4: . 394-404.

Wellness

Coulter, et al. demonstrated that “[Elderly] chiropractic users were less likely to have been hospitalized, less likely to have used a nursing home, more likely to report a better health status, more likely to exercise vigorously, and more likely to be mobile in the community. In addition, they were less likely to us prescription drugs.”

Coulter I, Hurwitz E, Aronow H, Cassata D, Beck J. Chiropractic Patients in a Comprehensive Home-Based Geriatric Assessment, Follow-up and Health Promotion. Topics in Clinic Chiropractic 1996; 3(2): 46-55.

Redwood, D. Fundamentals of Chiropractic. Mosby. August 1, 2003 .

Safety and Effectiveness Usage Nearly 30% of the U.S. population, aged 18 and older, have used chiropractic, and 9 out of 10 chiropractic users thought their treatment was effective.

Alhstrand S. National Opinion of Chiropractic Users/Nonusers Study. The Gallup Organization, Inc., Princeton , NJ . March 1991.

Court Evidence of Effectiveness

Validation of chiropractic treatment through evidence presented in the legal system evolved from an antitrust suit filed by four members of the chiropractic profession against the American Medical Association (AMA) and a number of other health care organizations in the U.S. (Wilk et al. v. AMA et al. 1990).

Following eleven years of litigation, a federal appellate court judge upheld a U.S. District Court ruling that the AMA had engaged in a boycott designed to restrict cooperation between MDs and chiropractors in order to eliminate the profession of chiropractic as a competitor in the U.S. health care system.

The U.S. District Court Judge rejected the AMA's patient care defense and cited specific studies which showed that "chiropractors are twice as effective as medical physicians and physical therapists in the care and alleviation of neuro-mechanical problems" ("Chiropractors File Supreme Court Response" 1990, 1). The court determined that chiropractic care was therapeutic based on evidence that "chiropractors are particularly effective in relieving long term chronic and severe pain syndromes, headaches, and stress and strain problems associated with pregnancy" (1-2).

Wilk et al. vs. American Medical Association et al., U.S. District Court (Northern District of Illinois Eastern Division) No. 76 C 3777, Getzendanner J, Opinion dated August 27, 1987.

Research Evidence of Effectiveness

In a comparison study of low-back pain patients treated with various types of treatment, this study found that patients were more satisfied with chiropractic care than with physical therapy after 6 weeks. Results also indicated that back pain patients are more satisfied with chiropractic care than with medical care after 4 weeks of treatment.

Hertzman-Miller, RP, et al. Comparing the Satisfaction of Low Back Pain Patients Radomized to Recive Medical or Chiropractic Care: Results from the UCLA Low-Back Pain Study. American Journal of Public Health October 2002 92(10) 1628-1633.

“Of 1,996 low-back pain cases studied, patients receiving chiropractic treatment averaged 6.26 compensation days compared to the 25.56 compensation days for medical patients.”

Ebrall, P. Mechanical Low-Back Pain: A comparison of Medical and Chiropractic Management Within Victorian WorkCare Scheme. Chiropractic Journal of Australia 1992; 22(2): 47-53.

Patient Satisfaction “Overall, respondents were very satisfied with the chiropractic care they received. Global satisfaction was 6.17 (on a 7-point scale), that is within the range of ‘very satisfied’ to ‘completely satisfied’.”

Goertz CMH , Whitmer BL, Hegetschweiler K, Elton D, Allenberg T. The Chiropractic Report Card: Patient Satisfaction Study. Journal of the American Chiropractic Association 1997; 34(10): 40-47.

Patients who saw chiropractors reported a significantly higher degree of satisfaction than those who saw practitioners in the four other strata, [including primary care, orthopedic, or HMO provider].”

Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. North Carolina Back Pain Project. The Outcomes and Costs for Acute Low-Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors and Orthopedic Surgeons. New England Journal of Medicine. 1996; 333(14): 913-917.

“Compared to those who sought care from medical doctors, those who sought care from chiropractors were more likely to feel that treatment was helpful, more likely to be satisfied with their care, and less likely to seek care from another provider to that same episode of pain.”

Carey TS, Evans AT, Hadler NM, Lieberman G, Kalsbeek WD, Jackman AM, Fryer JG, McNutt RA. Acute Severe Low Back Pain. A Population-based Study of Prevalence and Care-seeking. Spine 1996; 21(3): 339-344.

Those who sought care from a chiropractor were more likely to be very satisfied (63%) with their care than those who were treated by a physical therapist (56%), medical doctor (52%) or osteopathic doctor (50%).”

American Chiropractic Association. Americans’ Perceptions of Practitioners and Treatment for Back Problems: A Comprehensive Summary of Survey Findings. 1995.

“…A significant percentage (84%) felt that the care they received was ‘just about perfect’ and 97% either strongly agreed or agreed with the statement, ‘I would recommend this doctor to a friend or relative’.”

Sawyer CE, Kassak K. Patient Satisfaction with Chiropractic Care. Journal of Manipulative and Physiological Therapeutics 1993; 16(1): 25-32.

Cost-Effectiveness of Chiropractic Care

For some conditions, evidence of the cost effectiveness of chiropractic is mixed; however, most studies on the cost effectiveness of chiropractic clearly indicate that chiropractic is more cost effective than other treatment options. Some discrepancy naturally results from the various strategies researchers use to evaluate costs. Managed care trends and outcome-based treatment protocols will encourage further study in this area.

A comparison of over 1.7 million insured patients seeking care for back pain showed that when chiropractic care was utilized the cost of treatment was reduced by 28%, hospitalizations were reduced by 41%, back surgery was reduced by 32%, and the cost of medical imaging (x-ray, MRI) was reduced by 37%. Additionally, 95% of those receiving chiropractic care stated they were satisfied with their treatment. The authors of this study estimated that utilizing chiropractic care as a first treatment option for back pain may reduce annual U.S. health care costs by more than $28 billion.

Legorreta, A.P. "Comparative Analysis of Individuals With and Without Chiropractic Coverage." Archives of Internal Medicine, Oct. 11, 2004; vol. 164: pp 1985-1992.

Mosley, Cohen, and Arnold (1996) concluded that for patients who had back or neck pain, "chiropractic care was substantially more cost effective than conventional care" (281).

Mosley, Carrie D., Ilana G. Cohen, and Roy M. Arnold. 1996. "Cost-Effectiveness of Chiropractic Care in a Managed Care Setting." American Journal of Managed Care 2, no. 3: 280-282.

Stano and Smith (1996) found that "[for both total payments and total outpatient payments, the mean cost of chiropractic first episodes ($518 and $477 respectively) is substantially and significantly lower than medical episodes ($1,020 and $598) with much of the difference in total costs because of inpatient costs" (198).

Stano, Miron, and Monica Smith. 1996. "Chiropractic and Medical Costs of Low Back Care." Medical Care 34, no. 3: 191-204.

An earlier cost comparison study by Stano (1993) involved 395,641 patients with neuromusculoskeletal conditions. Results over a two-year period showed that patients who received chiropractic care incurred significantly lower health care costs than did patients treated solely by medical or osteopathic physicians.

Stano, Miron. 1993. "A Comparison of Health Care Costs for Chiropractic and Medical Patients." Journal of Manipulative and Physiological Therapeutics 16, no. 5: 291-299.

In a 1998 study, Manga and Angus urged the Ontario government to lower chiropractic co-payments, which would grant access to more proper and prompt care for those who need it most yet can least afford it: poor and elderly patients. Once the government improves public access to chiropractic care, "direct savings to Ontario 's health care system may be as much as $770 million, will very likely be $548 million, and will be at least $380 million. The corresponding savings in indirect costs--made up of the short and long term costs of disability--are $3.775 billion, $1.849 billion and $1.225 billion".

Manga, Pran, and Doug Angus. 1998. Enhanced Chiropractic Coverage under OHIP as a Means of Reducing Health Care Costs, Attaining Better Health Outcomes and Achieving Equitable Access to Health Services. [online]. <http://www.chiropractic.on.ca>.

In a study of work-related back pain claims in Australia, Ebrall (1992) found that the percentage of cases managed by chiropractors that required compensation days was half that of cases managed by medical doctors. The likelihood of a claim progressing to 90-day, or chronic, status was three times more likely with medical management than with chiropractic management.

Ebrall, Phillip S. 1992. "Mechanical Low-Back Pain: A Comparison of Medical and Chiropractic Management within the Victorian WorkCare Scheme." Chiropractic Journal of Australia 22, no. 2: 47-53.

A 1992 review of data from over 2,000,000 users of chiropractic care in the U.S., reported in the Journal of American Health Policy, stated that "chiropractic users tend to have substantially lower total health care costs," and "chiropractic care reduces the use of both physician and hospital care" (Stano, Ehrhart, and Allenburg 1992, 43).

Stano, Miron, Jack Ehrhart, and Thomas J. Allenburg. 1992. "The Growing Role of Chiropractic in Health Care Delivery." Journal of American Health Policy (November/December): 39-45.

Chiropractor’s Education

In order to become a licensed doctor of chiropractic, an individual must meet stringent academic and professional requirements, which generally include passing nationally standardized examinations. Currently, an individual must complete the following four major steps in order to become a licensed chiropractor:

complete two or more years of general college-level studies (Bachelor's degree required by some states)
obtain a Doctor of Chiropractic degree and complete a clinical externship through an accredited four-year chiropractic college program
pass the National Board of Chiropractic Examiners' and/or other state-required examinations
satisfy any other individual state-specific requirements for licensure

Chiropractic Training

Government inquiries, as well as independent investigations, have affirmed that today's chiropractic academic training is of equivalent standard to medical training in all pre-clinical subjects. The Council on Chiropractic Education (CCE) and its Commission on Accreditation, as recognized by the U.S. Department of Education, maintain high standards in chiropractic education.

Postdoctoral training in a variety of clinical disciplines and specialties is available through accredited colleges and specialty councils. Postgraduate programs include:

Applied Chiropractic Sciences
Family Practice
Industrial Consulting
Neurology
Nutrition
Orthopedics
Pediatrics
Radiology
Rehabilitation

Chiropractic Licensing

Chiropractic is one of many occupations that are regulated by state licensing agencies. The requirements for chiropractic licensure vary from state to state (and country to country). Some states require a Bachelor's degree as a prerequisite for licensure.

To assist the various regulatory agencies in assessing candidates for licensure, the National Board of Chiropractic Examiners (NBCE) develops and administers examinations to individuals currently in the chiropractic educational system or who have completed a chiropractic education program. The NBCE also offers an examination designed for previously licensed individuals. A candidate for licensure may request that transcripts of scores from NBCE examinations be forwarded to licensing agencies that assess eligibility for licensure.

Scores from NBCE examinations are made available to licensing agencies throughout the U.S. and to many licensing authorities outside the U.S.

Comparison of Medical and Chiropractic Educations

A general opinion exists that chiropractors are less educated than medical doctors. However, research suggests that when comparing the education of medical schools to that of chiropractic schools, chiropractors receive more education in basic and clinical sciences than their medically-educated colleagues.

These researchers point out that the number of hours of education that chiropractors undergo is greater than that of medical doctors in the areas of anatomy, biochemistry, physiology, and pathology. Medical education does exceed chiropractic education in the subject of public health, and both educations have a similar number of educational hours in microbiology.

When comparing chiropractic educational hours to medical educational hours, the chiropractic student will complete a total of 4800 hours compared to the 4668 hours completed by the medical student. The researchers are quick to point out that when comparing these educations, “they are more similar than dissimilar.”

Also noted by the researchers was a trend that while chiropractic students are familiar with medical therapies, medical students are not familiar with chiropractic. This is directly related to a void of chiropractic education in medical classrooms. It is also noted that medical students spend little time studying the neuromusculoskeletal system, which is the basis of the chiropractic education. This may explain why medical doctors are less likely to refer patients for chiropractic care.

This research goes on to state that because of the increasing amount of scientific evidence suggesting that spinal manipulation has clinical efficacy, medical doctors will have an increasing number of patients pursuing chiropractic care, and “If evidence-based medicine is to have any real meaning in education, ignoring the evidence presented by manipulation becomes increasingly (unacceptable).”

A review of the chiropractic education curriculum, and its comparison to that of the medical curriculum supports the role of the chiropractic physician as a highly educated and important member of the health care delivery system.

Coulter, I. et al. A Comparative Study of Chiropractic and Medical Education. Alternative Therapies, September 1998, 4(5): 64-75.