Chiropractic

Getting It All into Alignment

Crossing a street in Jersey City one wintry afternoon, Mary Lou Zubel was hit by a van and wound up with serious back, neck and leg injuries and severe pain that wouldn't quit.

"My orthopedist recommended surgery on my neck and knee," says Zubel, a former purchasing director in her mid-forties. "But I'm trying to avoid that."

So, twice a week for a couple of months, she lets chiropractor Frank Zolli, D.C., adjust her spine.

Dr. Zolli, dean of the University of Bridgeport College of Chiropractic in Connecticut, starts each session with a series of orthopedic and neurologic tests to evaluate Zubel's coordination, flexibility and pain: Does the pain worsen when he bends her legs this way? How about when he moves her neck that way? This morning, Zubel says that her lower back really hurts when he bends her legs at the knee.

So Dr. Zolli asks Zubel to lie on a padded examination table and begins massaging her back. Once she's relaxed, he palpates or feels the bones and muscles along her spine, looking for subluxations--chiropractic jargon for skeletal misalignments.

Having located the problem spots on Zubel's back, Dr. Zolli adjusts her spine by delivering a few quick thrusts along the length of her back. He then asks her to lie on her side, with her top leg bent at a right angle. Pushing her hip in one direction while gently pulling her shoulder the opposite way, he adjusts her pelvic bones.

Though a few of the procedures look like they might cause some pain, Zubel says otherwise. (Some chiropractic manipulations are accompanied by unsettling popping sounds, but the noises, caused by gas escaping from spaces surrounding the newly manipulated joints, aren't cause for concern, practitioners say.)

"Chiropractic is the route that's helped me the most with the pain," Zubel says. "Before, the pain was so bad that I couldn't walk or sit."

In addition to Zubel's twice weekly adjustments, Dr. Zolli recommends sessions with a physical therapist three times a week. Like most chiropractors, he also prescribes at-home exercises and recommends dietary changes. To enhance the effect of adjustments, chiropractors sometimes use gentle techniques like massage, ultrasound and heat. Chiropractic, he says, requires full patient participation. "That's why women tend to do particularly well with chiropractic--because they take better care of themselves than men do."

ONE IN THREE AMERICANS HAS TRIED IT

According to chiropractic theory, skeletal and joint misalignments--caused by accidents, strains, poor posture and stress--are responsible for many types of pain and disease. The aim of chiropractic manipulation is to correct subluxations.

These days, only the most traditional chiropractors believe that all illness is the result of subluxations and rely on manipulation alone to treat all health problems. Less traditional practitioners treat mostly muscular and skeletal problems such as head, neck and back pain and menstrual cramps and refer patients with other types of health problems to physicians for treatment. Research suggests that this is the better way to go. While studies confirm that chiropractic gets results with lower-back problems, its track record with other ailments is spotty.

Despite opposition from mainstream medical organizations such as the American Medical Association, chiropractic is thriving a century after its founding. According to one poll, 30 percent of American adults have seen a chiropractor. An estimated 15 to 20 million of us visit chiropractors yearly--primarily for back pain, neck pain and headaches.

Once chilly toward chiropractors, many physicians are now referring patients with muscular and skeletal problems to D.C.'s and are even setting up joint practices with them.

"I don't see how a physician can work without a chiropractor," says David Edelberg, M.D., director of the Chicago-based American Holistic Centers. "A number of my patients have managed to avoid major surgery by taking this combined approach--seeing a physician and a chiropractor," says Dr. Edelberg, who sends patients to chiropractors for head, neck and back pain.

Most insurance plans, including Medicare and many state Medicaid programs, cover chiropractic care. A significant body of research, in fact, confirms that spinal manipulation can help alleviate lower-back pain.

Other benefits, however, aren't as well documented. Research is needed to determine if spinal manipulation helps relieve menstrual pain and treat borderline high blood pressure, at least temporarily. Chiropractors claim success with treating other health problems, like ulcers, carpal tunnel syndrome and asthma, but evidence of those benefits is mostly word-of-mouth.

Why chiropractic seems to relieve symptoms--particularly symptoms of problems other than back pain--is a matter of debate.

"There are a lot of chiropractors who believe the traditional theory--that subluxations cause most diseases and disorders. Many others don't believe that, but they do believe that the correction of these misalignments increases the potential of the body to heal itself," says Patricia Brennan, Ph.D., dean of research at National College of Chiropractic in Lombard, Illinois. "I believe spinal-manipulative therapeutic intervention can affect organ systems, but I'm not sure what the mechanism is. No one is."

THE SCIENTIFIC EVIDENCE

Controlled scientific studies have found spinal manipulation to be at least as good as, if not better than, conventional care for treating back pain. When researchers analyzed data from nine published trials, they found that men and women suffering uncomplicated, acute lower-back pain were 17 percent more likely to recover after three weeks if they had spinal manipulation. A British study that tracked more than 700 men and women with lower-back pain over the course of three years concluded that those who had spinal manipulation fared better than those who got traditional hospital care.

"Chiropractic is ideal for lower-back pain," says Willard Dean, M.D., medical director of the Center for Self Healing in Santa Fe, New Mexico, who refers patients to D.C.'s for neck pain and backaches.

A small pilot study has found that women who get manipulation on the first day of their menstrual periods report relief from severe menstrual cramps. And a number of preliminary studies suggest that spinal adjustments may reduce blood pressure temporarily, says Christine Goertz, D.C., vice-president of research and policy at the American Chiropractic Association in Arlington, Virginia.

Though chiropractors report success with treating ear infections, fibromyalgia (painful "trigger points" in the muscles), asthma, carpal tunnel syndrome, ulcers and colic, so far, there is no scientific evidence beyond case reports to back up those claims, says Scott Haldeman, D.C., M.D., Ph.D., associate clinical professor in the Department of Neurology at the University of California at Irvine and editor of Principles and Practice of Chiropractic.

WHY IT WORKS--THE THEORIES

Chiropractic traces its unlikely origins to a summer day in 1895 when a deaf janitor stopped at the Davenport, Iowa, offices of a self-taught healer named Daniel David Palmer. The janitor had lost his hearing 17 years earlier. It happened suddenly, he told Palmer, after he felt something "give" in his back. Palmer examined the man, examined what he thought to be a misplaced vertebra in his spine, concluded that this was the problem and then pushed the bone back into place. "And soon the man could hear as before," Palmer wrote in his autobiography, published in 1910.

Palmer's experience with the janitor and a subsequent success treating a patient with heart trouble, convinced him that 95 percent of all diseases stemmed from spinal misalignments. Knocked out of place, vertebrae pinched surrounding nerves, interfering with the proper function of the nervous system, Palmer reasoned. Since the nervous system influenced all other bodily systems, these misalignments gave rise to diseases--everything from diabetes to strep throat. The way to cure virtually all disease was to press, push and pull the spine, pelvis and other bones back into their proper places, Palmer concluded.

Though traditionalists still share Palmer's view--and his opposition to drug treatment, surgery and immunization--many do not. "The concept that somehow misalignments cause the pinching of nerves and that that causes organs not to work properly has virtually been thrown out of aca-
demic circles because no one has been able to establish that this, in fact, occurs," says Dr. Haldeman.

Abnormal spinal mechanics can cause back, neck and head pain, he continues, but the mechanism doesn't appear to be as simple as Palmer believed. Misaligned bones may pinch surrounding nerves. But they also appear to lead to abnormal muscle contractions that hamper mobility and circulation and contribute to pain, Dr. Haldeman says. Manipulation probably helps relieve pain by relaxing the muscles, increasing mobility and improving circulation.

At least one study suggests that manipulation may also ease pain by prompting the body to release endorphins--the feel-good nerve chemicals responsible for "runner's high," he notes. Neurochemical activity may also explain why manipulation seems to offer at least temporary relief from menstrual cramps and other disorders that are neither muscular nor skeletal, Dr. Brennan says. In a preliminary study with women suffering menstrual pain, manipulation altered the blood levels of neurochemicals that can cause pain at high concentrations. Manipulation also appeared to trigger a drop in the levels of prostaglandin, a hormonelike chemical that contributes to pain. In women with dysmenorrhea (painful menstrual
periods), Dr. Brennan notes, levels of prostaglandin are very high on the first day of menstruation. So it's possible that manipulation releases a compound that blocks prostaglandin synthesis, she adds.

Spinal manipulation--a tool used by both chiropractors and osteopathic physicians--may also help reprogram the nervous system,
correcting glitches that cause pain and other symptoms, says Philip Greenman, D.O., associate dean and professor in the Department of Osteopathic Manipulative Medicine at Michigan State University College of Osteopathic Medicine in East Lansing.

Nerves that govern involuntary actions, such as breathing and digestion, run in the spinal cord and are linked to the function of the spine. So it's possible, for instance, that you could help ease stomach problems by manipulating the back in related segments of the spine to influence the nerves that run to the stomach, Dr. Greenman says.

In the end, research is likely to find that manipulation affects the body in a variety of ways, and all of these effects contribute to symptom relief under certain circumstances and to varying degrees, Dr. Brennan predicts. "I don't think that there's going to be any simple explanation."

A Chiropractic Guide to the Spine Many chiropractors believe that manipulating misaligned bones of the spine can improve health by influencing nerves associated with other parts of the body.

WHEN TO SEE A PHYSICIAN FIRST

In light of the available evidence, when should you consider seeing a chiropractor?

For serious health problems--like cancer, diabetes, heart trouble or severe trauma--you should see a physician immediately. "I don't think chiropractors are equipped to deal with those problems," says Dr. Haldeman. If you're suffering simple back, neck or head pain, on the other hand, a visit to a D.C. makes a lot of sense, he says.

Dr. Edelberg suggests seeing a physician for a diagnosis first if you have unexplained, chronic back pain. However, "if you know you injured your back by lifting something, a visit to a physician isn't necessary," he says.

While orthopedists have better success rates treating progressive curvature of the spine than chiropractors do, a D.C. can help relieve the discomfort associated with mild spinal curvature. So seeing one for help with mild curvature also makes sense, Dr. Edelberg adds.

For carpal tunnel syndrome, Dr. Haldeman suggests that you see your chiropractor before surgery. "I always think that surgery is a last resort, and I like to try virtually everything else before surgery--taking anti-inflammatory drugs such as aspirin or ibuprofen, maybe going to a chiropractor or physical therapist or wearing wrist splints for awhile."

If you do go, be sure to give your chiropractor a complete medical history. You shouldn't undergo manipulation if you've had symptoms of a stroke or blood clot or have a condition that causes bone softening--such as cancers or infections that have spread to the bone, severe osteoporosis or severe rheumatoid arthritis, Dr. Haldeman says. But you can still see a chiropractor for physical therapy, nutritional and lifestyle advice and massage, ultrasound, heat or low-voltage electric current treatments to ease muscle tension.

Try five to ten treatments before making up your mind about chiropractic, advises Dr. Haldeman. If there's no change at all after ten treatments, discuss other treatment options with your physician. (As with other therapies, the frequency and duration of treatment varies with each condition.) "Patients who have problems as a result of a bad fall or a car crash have more damage and require more intensive care than the person who was reaching for something and felt a pop in her neck," explains Dr. Zolli.

You may want to ask your chiropractor at the outset how long therapy will take. One criticism of chiropractic care, Dr. Edelberg notes, is that D.C.'s drag it out.

A University of North Carolina study suggests that they might, indeed. According to the study, patients who saw chiropractors for acute back pain spent more for care than those who saw primary care physicians. Though the chiropractors charged less per visit, they scheduled many more sessions.

Some chiropractors will tell you to keep coming in for regular "preventive health" adjustments after you're back on your feet and feeling fine again. But you shouldn't, says Dr. Edelberg.

"Certain chiropractors earnestly believe that you should come in regularly for adjustments--until your next incarnation," he says. "But there's no reason to go for regular adjustments if you feel fine. Regular adjustments won't do anything except loosen up your ligaments, which isn't good."