Guidelines for Considering Chiropractic Care
Chiropractic care is primarily recommended for acute and chronic low back pain, but is strongly contraindicated in patients with spinal fusion or advanced spinal osteoporosis due to risk of serious complications. 1
Appropriate Conditions for Chiropractic Referral
Low Back Pain
- Chiropractic manipulation shows moderate effectiveness for:
- Chronic low back pain: Superior to sham manipulation and ineffective therapies 1
- Subacute or chronic low back pain: Slightly superior to usual care (approximately 5 points improvement on 100-point scales for pain and disability) 1
- Acute back pain with disc protrusion: More effective than simulated manipulation for pain relief 2
Not Recommended For
- Rheumatoid arthritis: The American College of Rheumatology conditionally recommends against chiropractic therapy for RA management due to potential cervical spine complications 1
- Ankylosing spondylitis with spinal fusion or advanced spinal osteoporosis: Strongly recommended against due to risk of spine fractures, spinal cord injury, and paraplegia 1
Safety Considerations
Risk Assessment
- Serious adverse events after spinal manipulation are very rare:
Absolute Contraindications
- Spinal fusion
- Advanced spinal osteoporosis
- Recent vertebral fracture
- Unstable spondylolisthesis
Relative Contraindications
- Osteoporosis
- Inflammatory arthropathies
- Malignancy affecting the spine
- Anticoagulant therapy
Effectiveness Comparison
Similar Effectiveness To:
- General practitioner care or analgesics
- Physical therapy or exercises
- Back school programs 1
More Effective Than:
- Sham manipulation
- Therapies considered ineffective (traction, bed rest, no treatment) 1
Patient Selection Factors
Predictors of Better Response
- Patients meeting at least 4 of 5 predefined criteria have higher likelihood of >50% improvement with spinal manipulation:
- Duration of current episode <16 days
- No symptoms distal to the knee
- At least one hypomobile segment in the lumbar spine
- At least one hip with >35° internal rotation
- FABQW score <19 1
Treatment Approach
Recommended Protocol
- Initial assessment to rule out contraindications
- Short course of treatment (typically 6-12 sessions)
- Regular reassessment of response
- Discontinuation if no improvement after 4-6 sessions
- Combination with exercise therapy when appropriate 1, 3
Limitations and Considerations
Scientific Evidence
- Evidence is stronger for spinal pain conditions than for non-musculoskeletal conditions
- Many studies have methodological limitations
- Long-term effectiveness data is limited 4
Cost Considerations
- Generally cost-effective for back and neck pain when compared to usual medical care
- May reduce the need for medication and invasive procedures 5
In conclusion, chiropractic care should be considered primarily for patients with acute or chronic low back pain without contraindications such as spinal fusion or advanced osteoporosis. The evidence supports its use as part of a comprehensive approach that may include exercise and other conservative treatments.