Essentials of Complementary and Alternative Medicine (June 1999)

PROVIDER-PATIENT INTERACTION
Patient Assessment Procedures
The chiropractic physician uses the same standard diagnostic approach as that of the medical or osteopathic physician, but adds a number of special procedures 
unique to the chiropractic profession as described.
H
ISTORY
-T
AKING AND
 P
HYSICAL
 D
IAGNOSIS
A visit to the chiropractor starts with a history (anamnesis) and a standard physical examination, the latter driven by the specific presentation of the patient. A 
standard systems review (e.g., cardiovascular system, genitourinary system, gastrointestinal system) is part of the examination, as is neurological examination, 
orthopedic examination, radiological examination, and so on as required by the specific nature of the patient's case.
O
THER
 D
IAGNOSTIC
 M
ETHODS
:S
PINAL
 E
XAMINATION
Bergmann has succinctly noted that the chiropractor views the human body as a dynamic, integrated, and complex living system which, having innate intelligence, 
therefore has a remarkable capacity for self-healing (
27
). Chiropractors can serve as a gatekeeper for entry into the health care system and as a potential primary 
care practitioner. (Chiropractors are primary care practitioners in the eyes of many, but not in the eyes of some.) The chiropractic physician must by necessity be able 
to use the findings from a standard physical examination, integrate them with the findings from chiropractic procedures, and then use the combined information to 
fashion both an appropriate diagnosis and management plan for the patient.
Given that spinal adjustment is the primary therapeutic tool used by a chiropractor, spinal examination becomes a paramount part of the patient evaluation process. 
Spinal examination allows the chiropractor to determine the nature of the lesion, whether subluxation or spinal dysfunction. There are a number of procedures used to 
evaluate the spine. Bergmann has coined the term  PARTS to help define the diagnostic criteria for identifying spinal dysfunction (
Table 15.3
) (
28
). Within the 
parameters formed by these components are a number of specific procedures, including postural analysis (via plumb line examination or via more sophisticated 
computer systems), gait analysis, static articular palpation, motion palpation, muscle strength testing, spinal percussion, and motion analysis.
Table 15.3. PARTS: Diagnostic Criteria for Identifying Spinal Dysfunction(
28
)
Palpation, in general terms, is the art of feeling by hand to determine a variety of parameters governing the health and mobility of the tissues on or near the surface of 
the body. Static palpation is used to help analyze the bony or soft tissue structures of the body in a fixed position (e.g., palpation of the location of the spinous 
process). Motion palpation, which was originally developed by the Belgian chiropractor Henri Gillet (
29
), is designed to help assess the dynamic motion of the 
vertebrae and extravertebral joints. Specifically, it assesses the presence or absence of joint play, an accessory joint motion not under direct control of the voluntary 
muscles. Postural analysis helps determine the presence of gross (i.e., directly observable) physical abnormalities. This may be accomplished through visual 
observation using a plumb line or through computerized systems such as the Metrecom device.
Differential Diagnosis
D
ISEASE
 C
LASSIFICATION AND
 T
AXONOMY
Chiropractors use standard medical diagnostic and disease classifications, but differ in the manner in which they assess involvement of the human nervous system in 
disease processes. The key concept undergirding the chiropractic profession is that of  subluxation, which should not be interpreted in the medical sense of “less than 
a luxation.” The concept of subluxation has undergone continual evolution and controversy. There is no single, agreed-on definition, although a recent consensus 
panel defined subluxation as “a motion segment in which alignment, movement integrity, and/or physiologic function are altered although contact between joint 
surfaces remains intact” (
30
) The role of subluxation in health and disease is considered a significant area for chiropractic research. The presence of subluxation, 
however defined, and its related neurological sequelae are seen as important concomitants of disease states or other conditions.
D
ETERMINING
 T
REATMENT
Treatment is determined by combining the results of the standard physical examination with the results of specialized chiropractic examination procedures. For 
example, a patient who has suffered a bout of back pain will undergo a standard physical examination, which might determine that the problem is essentially an 
uncomplicated strain. The chiropractic examination will then determine which specific areas of the spine are involved as well as which areas are to be adjusted and 
how they are to be adjusted.
THERAPY AND OUTCOMES
Treatment Options
The basic therapeutic tool used by a chiropractic physician is the chiropractic adjustment, which is applied to the articulations of the body, particularly to those located 
in the spine. Chiropractors also use a host of other interventions, including physiotherapeutic tools and devices, exercise, nutrition, and orthotics. In addition, when 
the patient's condition warrants, the best tool may be referral to a medical practitioner.
The chiropractic adjustment helps restore proper motion between articular surfaces, which then has potentially beneficial effects on the nervous system. Within the 
chiropractic profession, many schools exist, each with a specified body of technique to offer. Included in these are the Activator technique, diversified technique, Cox 
flexion/extension technique, sacro-occipital technique, Gonstead technique, Thompson terminal point technique, Logan basic technique, and upper cervical 
technique.
Description of Treatments
The chiropractic adjustment is delivered to joints in the spine or extraspinal regions of the body. The adjustment entails placement of the doctor's hands onto contact 
points on the body, followed by positioning of the joint and, most often, a high-velocity short-amplitude thrust to that joint. Force is introduced by the doctor for that to 
occur, although the actual maneuver is gentle.

For example, a patient with a mild strain of the low back musculature may receive the following approach to therapy (obviously there is some variability in the 
approach selected by any individual doctor): Assuming that the patient's problem is uncomplicated low back pain, the course of therapy may begin with the use of hot 
moist packs followed by gentle soft tissue massage, such as a petrissage procedure. Some chiropractors may follow this with trigger point therapy to deactivate any 
active trigger points, followed perhaps by an electrical modality, such as high-volt galvanism or interferential current; other chiropractors might not use these 
procedures at all. Finally, the patient will receive the adjustment.
Before the adjustment, the doctor would have already assessed the patient's spine, likely using a palpatory procedure, such as motion palpation. Areas of decreased 
mobility or static malposition would be noted, and adjustments would then be directed to those regions. For purposes of example, assume that there is a rotational 
restriction noted at the fourth lumbar vertebra on the right. The patient would then be placed on his or her side, with the side of restriction placed up. The patient's 
lower arm would be placed under the head; the upper arm would be placed on the side of the body. The up leg would be bent so that the foot can be placed near the 
knee of the lower leg. The doctor would then position him or herself so that the cephalad arm is placed on the patient's arm, and his or her body would be placed so 
that it comes over the patient's body. The caudal hand would have its pisiform placed on the spinous process of the fourth lumbar vertebra. After removing tissue 
tension by rotating the patient gently, the thrust is gently but quickly delivered in a posterior to anterior direction.
The profession has designed a multitude of such procedures for all areas of the human body.
Treatment Evaluation
A number of outcomes may be used to monitor patient progress:
Changes in scales, such as the visual analogue scale or the Oswestry instrument
Changes in function, as may be assessed by a variety of parameters: EMG, Oswestry scale, Roland-Morris scale, neck disability index, headache diary
Changes in spinal mobility, as may be assessed by motion palpation
Patient response to therapy
Thus, it is possible to look for either decreases in pain (or other symptomatology) or increases in function (e.g., muscle strength, spinal mobility).
Pain may be assessed through visual analogue scales or pain drawings. Function may also be assessed through manual palpation of the spine to determine mobility 
of individual spinal motion segments.
Research has indicated that spinal manipulation is most useful in the short term for patients suffering a variety of low back and cervical problems (
31
). Thus, such 
improvements in pain and function occur within a relatively short period of time (i.e., within about two weeks). However, there is a growing body of evidence to show 
that these improvements may extend over longer amounts of time (
32
, 
33
).
As in most forms of medical care, treatment is altered when care fails to provide expected results, the patient does not respond, or the situation worsens.
USE OF THE SYSTEM FOR TREATMENT
Major Indications
C
HIROPRACTIC AS A
 P
RIMARY
 A
PPROACH
Most people associate chiropractic with treatment for low back pain, and indeed that is where the greatest amount of scientific support exists. There is strength of 
evidence for the use of manipulation in patients suffering from low back pain without radiculopathy when used in the first month of problems (
34
).
In general, chiropractic finds its greatest usefulness in managing conditions affecting the neuromusculoskeletal system, such as strains, sprains, disk disease or 
herniation, tendinitis, bursitis, headache, spondylolisthesis, whiplash injury, osteoarthritis, myofascial pain, disorders of the cervical, thoracic, and lumbar spine and 
pelvis, and so forth. These conditions comprise the so-called Type M disorders. There are also visceral conditions that have spinal overlays and that are managed by 
chiropractors (e.g., hypertension [35]). Bergmann, Peterson, and Lawrence provide a more complete discussion of this topic (
28
).
C
HIROPRACTIC AS A
 C
OMPLEMENTARY
 A
PPROACH
The use of chiropractic care in specific visceral conditions, such as hypertension or ulcer, is complementary rather than primary. The chiropractic physician works 
alongside another medical or osteopathic physician in managing the musculoskeletal manifestations that accompany the disease process.
Contraindications
Chiropractic management is less useful or not recommended in managing infectious disease and other Type O conditions. Risks for complications caused by 
manipulation, though, are quite low (
36
). Manipulation is contraindicated in situations in which vertebral artery narrowing is present, when aneurysm is present, and 
with tumor, bone infection, and fracture. Gatterman lists these conditions as absolute contraindications (
37
). This list is not comprehensive; common sense should 
rule.
Preventive Value
Hawk and Dusio (
38
) surveyed 753 randomly selected chiropractors to assess their attitudes towards prevention-related training, especially those that pertain to 
primary care practice. Although this study did not assess actual knowledge or training in prevention-related topics, it did provide an overview of the attitudes that drive 
these issues. Of the 65% who did respond, the majority (greater than 90%) considered themselves primary care practitioners, although less than 80% thought they 
had received adequate training in primary care during their chiropractic education. The more recent graduates reported greater amounts of such training. Hawk and 
Dusio concluded that there is an apparent need for greater training in matters pertaining to preventive and primary care.
Scope of Practice
Scope of practice is dictated by state law, and therefore varies from state to state. Some states are more liberal in what they allow, whereas others are restrictive (the 
so-called 10 finger states). Lamm (
39
) has shown that greater than 50% of those state licensing boards that responded to a questionnaire (90% response rate; 54 of 
60 questionnaires returned) allow the following procedures:
Ordering or performing clinical laboratory procedures
Routine physical examination
Female pelvic examination
Rectal examination
Electromyography
Nerve conduction velocity studies
Greater than 80% of the states that answered the questionnaire allow x-ray examination, Doppler studies, and either computed tomography or magnetic resonance 
imaging. And greater than 90% allow chiropractors to employ physiotherapy, adjust soft tissue or extremities, provide vitamin supplements, and perform impairment 
ratings (
39
). A full state-by-state breakdown of allowable procedures can be found in Lamm's article.

ORGANIZATION
Training
G
ENERAL
 R
EQUIREMENTS
In general, chiropractic colleges in the United States require the following criteria for matriculation (
40
):
High school diploma
A minimum of 2 years of 60 semester credit hours (90 quarter hours) leading to a bachelor's degree in the arts or sciences
—Those credits must be earned in an accredited institution (as listed in the United States Office of Education's Directory of Colleges and Universities)
—Those courses must be from appropriate areas of study, such as the biological sciences, general or inorganic chemistry, organic chemistry, physics, 
psychology, English, humanities, social sciences, or communication skills
The College Level Examination Program (CLEP) is accepted
For people from foreign countries who desire entry into United States chiropractic colleges, the entry requirements are the same as those for a native citizen. 
Transcripts from foreign countries may be evaluated by outside agencies, depending upon the country of origin. Recently, several chiropractic colleges have 
announced efforts to raise entry requirements, so that both higher grade-point averages and more college course work are necessary. Advanced standing credit may 
be awarded if previous college course work matches that of the specific curriculum, although no credit can be awarded for clinical course work.
B
ASIC
 C
URRICULUM OF
 C
HIROPRACTIC
 E
DUCATION
There are three basic components to chiropractic education: basic science course work, clinical science course work, and clinical internship.
Basic science course work tends to fall in the earlier semesters of the curriculum. Topics covered in detail include anatomy, biochemistry, histology, microbiology, 
physiology, genetics, embryology, and so on. The mid to latter semesters, before the final internship, are generally composed of the clinical science courses. These 
include general diagnosis, biomechanics, all chiropractic technique classes, radiological diagnosis, orthopedic diagnosis, neuromusculoskeletal diagnosis, neurology, 
cardiology, nutrition, rehabilitation and exercise, physiological therapeutics, and so on. These courses combine standard medical diagnostic and therapeutic 
procedures (excluding invasive procedures, pharmacology, and surgery) with specific chiropractic diagnostic and therapeutic procedures, such as motion palpation, 
radiographic mensuration, and various types of chiropractic manipulative procedures. The final internship involves application of the didactic portion of the program in 
a controlled clinical setting and under the supervision of licensed chiropractic physicians.
The typical course of study is 5 academic years; this can be completed, if a student takes summer courses, in a little less than four complete years. Basic science 
course work generally occurs during the first 4 (of 
10
) semesters of the curriculum. Clinical science courses are then taken in the next 4 semesters, and the full 
internship program then takes place in the final 2 semesters. A semester lasts approximately 4 months. The total number of hours over the entire course is 
approximately 5000.
A movement within the chiropractic educational community toward problem-based education is introducing students to clinical matters far earlier in the chiropractic 
program than was traditional. It has also allowed for a potentially more effective integration of basic and clinical science courses than in the past. This is rather new, 
with only two colleges (National and Los Angeles) moving toward full problem-based learning programs, although many others have initiated smaller changes in their 
curriculum.
Most colleges, and some state and professional organizations, also offer full postgraduate and continuing education programs, some of which offer a variety of 
specialty certifications.
Quality Assurance
L
ICENSURE AND
 C
ERTIFICATION
In the United States, licensure requires the student to have (
1
) passed all courses in the chiropractic curriculum with a passing grade average per department, (
2
) 
pass all elements of the National Board of Chiropractic Examiners examinations, and (
3
) pass the licensure test for the specific state in which the chiropractor desires 
to practice. All applicants for licensure must also have attended a chiropractic college accredited by the Council on Chiropractic Education (CCE), or one that meets 
equivalent standards. The CCE has developed educational standards for chiropractic education. This specialized accrediting body focuses its attention on the 
particular program that the chiropractic college uses. There is also institutional accreditation within chiropractic, such as might be conferred by the North Central 
Association of Schools and Colleges or the Western Association of Schools and Colleges; this examines the entire institution rather than just its program.
McNamee notes that “the accreditation of an institution by an institutional accrediting body certifies to the general public that the institution: (a) has appropriate 
purposes; (b) has the resources needed to accomplish its purposes; (c) can demonstrate that it is accomplishing its purposes; and (d) gives reason to believe that it 
will continue to accomplish its purposes” (
39
). Other countries have their own accreditation process: for example, the Australasian Council on Chiropractic Education, 
the Council on Chiropractic Education (Canada), and the European Council on Chiropractic Education.
All 50 states and the District of Columbia have their own chiropractic licensing boards, as do the provinces of Canada. There are also licensing boards in other 
countries, including Australia, Belgium, Denmark, France, Great Britain, Italy, Japan, Netherlands, Norway, Puerto Rico, South Africa, Sweden, Switzerland, and other 
European and Asian countries.
P
ROFESSIONAL
 S
OCIETIES
The profession is served by a multitude of professional societies, ranging from American national organizations, such as the American Chiropractic Association (the 
largest association in the profession) and the International Chiropractic Association, to national foreign organizations (e.g., the Japanese Chiropractic Association or 
the Canadian Chiropractic Association), to state and provincial organizations, and to research organizations such as the Foundation for Chiropractic Education and 
Research. In the United States, each state is served by at least one chiropractic organization, and some have more than one (including Pennsylvania, Illinois, and 
Michigan). States in which there are more than one organization reflect the different philosophies regarding the practice of chiropractic.
C
ONTINUING
 E
DUCATION
Postgraduate and continuing education is regulated by statute and differs from state to state or from country to country. In general, each state requires a certain 
number of continuing education hours yearly; these hours may be earned by attending postgraduate classes offered by the colleges or state and professional 
organizations. These courses may cover the gamut from orthopedics to nutrition, from chiropractic technique to neurology, to sports therapy and radiology. Some 
hours may be earned by reading professional scientific publications. In addition, the majority of chiropractic colleges offer residency postgraduate programs. Current 
residency programs include orthopedics, radiology, neurology, family practice, research, rehabilitation, sports and recreational injuries, ergonomics, physiological 
therapeutics, meridian therapy/acupuncture, and pediatrics. These programs require 2 years of on-campus training beyond initial degree status.
Reimbursement Status
Chiropractic is covered under most insurance policies and is involved in managed care networks.
Relations with Conventional Medicine
Although the two professions have a history characterized by rancor and ill will, this has changed substantially in the last decade as chiropractic research and practice 

has grown. The Wilk trial (
41
) may have been the impetus for some of this change in that it finally made organized medicine take stock of the positions it had held for 
so long. Wilk and some other chiropractors brought suit against the AMA, AOA, and 10 other medical organizations, charging that they had conspired to unreasonably 
restrain the practice of chiropractic; a permanent injunction against the AMA was entered in 1987. Today, chiropractors can be found on staff at many hospitals, 
chiropractic research is respected and important, and chiropractors are playing significant roles in both legislative and research matters. As a result, the cooperation 
between the two professions is growing, and the traditional opposition to chiropractors has decreased. It is not, however, absent.
Most medical professionals recognize that chiropractors refer patients when appropriate, and good working relationships between the two professions exist 
everywhere. Referrals are also made from medical physicians to chiropractors. This is perhaps the best recognition of the diagnostic and therapeutic acumen that 
chiropractors possess. Indeed, perhaps the greatest challenge for the profession today comes not from medical opposition, but from within the profession itself as it 
tries to communicate to policy makers charged with reforming health care. The profession's move toward evidence-based practice will be of significant aid in this 
regard.