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Date Posted:

January 2014

Study Title:

Chiropractic care and public health: answering difficult questions about safety, care through the lifespan and community action


Johnson C, Rubinstein SM, Cote P et al.

Author's Affiliations:

National University of Health Sciences, Lombard, IL; Department of Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), Oshawa, Ontario, Canada; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, Ontario, Canada.

Publication Information:

Journal of Manipulative & Physiological Therapeutics 2012; 35: 493-513.

Background Information:

Chiropractic, as a healing profession addressing the body’s systems and all aspects of care, is aligned closely with the World Health Organization’s definition of health, which states that health is “…a state of complete physical, mental and social well-being, and not merely the absence of disease” (1). The chiropractic profession, indeed, embraced this approach to health prior to the WHO adopting its definition in 1946. The role, then, of chiropractic in public health is an important consideration for the profession as a whole moving forward. When considering this, it is important to take account of the recent activities in this field.

The authors of this editorial article developed, through a concerted effort, to address public health questions that are relevant to the chiropractic profession and the public. Experts in various fields were invited to contribute to the discussion. The materials were meant to be informative and thought-provoking and the authors hope that it will stimulate further discussion. This summary will present each contribution, focusing on the area of interest and the author’s recommendations on the future role of chiropractic in that aspect of public health.


Is Spinal Manipulative Therapy for Neck and Low Back Pain a Public Health Problem?
Experts: Rubenstein SM, Cote P

As a treatment modality, spinal manipulative therapy (SMT) is widely practiced and is supported by a significant body of evidence. High quality evidence such as systematic reviews and large-scale randomized, controlled trials have demonstrated its effectiveness (2-6). The central consideration with SMT, as with any treatment, is its safety.

Much is known about the adverse events associated with SMT. In general, adverse events range from mild to moderate, are self-limiting and last only a few days in most cases. These complaints typically include musculoskeletal soreness and, less frequently, nausea or dizziness. Serious adverse events are extremely rare and therefore less well understood. The most significant serious adverse event is the vertebrobasilar artery injury (VBAI) which, in a recent population-based study of 100 million life-years, indicated that only 14 cases of VBAI have been verified (7).

Evaluating the true risk of VBAI secondary to cervical manipulation is difficult, due to the rarity of the event but also due to the difficulty in designing high-level trials to determine the risk of these serious adverse events. Randomized, controlled trials are prohibitive due to sample size requirements. Thus, case-control studies are the design of choice to evaluate the risk of VBAI. Four such studies (7-10) have examined the risk and determined that there is an association; however, concerns regarding the time between the event (SMT) and the adverse reaction make acceptance of the findings marginal. The preponderance of evidence should be considered when recommending treatment to patients and discussing the possible adverse effects of those treatments. The best evidence currently suggests that SMT is a safe therapy whose benefits outweigh the risks.

What is the Role of Chiropractic Care in Prevention or Reduction of Musculoskeletal Injuries in Children?
Expert: Hestbaek L

Back and neck pain are prevalent conditions among children, with estimates ranging from 5 to 74% (11, 12). Children and adolescents with a history of musculoskeletal complaints have a higher risk of having these problems as an adult, with the long-lasting effects of pain including a decreased pain threshold. The initiation of this process in childhood is thought to induce a lifelong cascade of negative health events, resulting in general poorer health and lower quality of life. Likewise, the presence of pain in the adolescent or younger patient is a potential barrier to physical activity, which can have significant health impacts over the course of a lifetime.

With the potential for the chiropractic profession to play a prominent and important role in the promotion of health and activity in children, the following 3 suggestions for action are recommended:
  1. Raise public awareness about the importance of musculoskeletal health in the youth population,
  2. Establish an evidence base for the best treatment strategies for pediatric musculoskeletal conditions, and
  3. Develop screening procedures to identify children at risk for musculoskeletal injuries to implement targeted primary prevention.
While the paucity of evidence reflects the historical lack of interest in this area of practice, the potential exists for the chiropractic profession to play an integral role in contributing to healthy and active children which can contribute positively to improved overall public health in the long term.

What Ways Can DCs Stay Updated on Evidence-based Information about Vaccines and Immunization Throughout the Lifespan?
Experts: Injeyan S, Puhl A

The use of vaccination in children has been associated with a decrease, or near elimination, of many previously serious diseases such as polio, smallpox and whooping cough. The use of vaccination in adults, including the influenza vaccine, HPV vaccine and vaccines for travelers has grown of late. As primary contact practitioners, chiropractors often receive enquiries regarding these vaccinations from their patients. While vaccines represent an area of public health in which a small percentage of chiropractors oppose the consensus view of public health officials regarding vaccination, the evidence suggests a change in the personal and professional attitudes of DCs towards vaccination (13, 14). Currently, chiropractic users are no less likely to be vaccinated for influenza than non-chiropractic users (15, 16).

The chiropractic profession is positioned to make a positive influence on immunization by providing sound advice consistent with the current evidence and public health policies. Chiropractic education provides a basis for this advice, and chiropractors should seek out evidence-based information and avoid misinformed rhetoric. Through evidence and education, chiropractic can make an important contribution to improving public health and attitudes towards vaccination.

Can Smoking Cessation be a Prevention Strategy for Back Pain?
Expert: Green B

The physical and economic impacts of back pain are well known. While much energy has been invested into determining effective treatment options, surprisingly little is known about preventing low back pain. Many clinicians and researchers have taken the view that back pain will spontaneously resolve – a false assumption, as the majority of patients who suffer a bout of acute back pain will have their pain recur within the year (17).

From a prevention point of view, an important and often overlooked risk factor for back pain is tobacco smoking. Patients who are current or former smokers are more likely to have back pain than those who have never smoked (18). While patients may express surprise that smoking can be associated with back pain, addressing smoking habits with back pain patients is a form of secondary prevention that may have direct implications for each patient's back pain experience. While more study is needed to determine the link between smoking and back pain, should smoking be definitively identified as a risk factor for back pain, initiating aggressive public health campaigns for smoking cessation as a form of primary prevention for back pain may be revolutionary in reducing the incidence, prevalence, costs, and suffering associated with back pain.

Does Chiropractic have Relevance within the VA Health Care System for Chronic Pain and Comorbid Disorders?
Experts: Napuli JG, Dunn AS

Musculoskeletal (MSK) conditions have become an increasingly burdensome condition for veterans returning from combat. As compared with prior wars (World War I, II and the Korean War), mortality rates among active service members injured in combat have decreased, while the rate of diagnosis with mental disorders such as post-traumatic stress disorder have increased, with some estimates suggesting that over two-thirds of returning veterans suffer from this condition (19). Musculoskeletal disorders are the most common physical complaint of returning veterans, with low back pain leading the list of conditions. Recent findings suggest that returning veterans with mental health diagnoses are at risk for receiving opioids for pain, demonstrating high-risk opioid use and adverse clinical outcomes. The management of MSK conditions among this group cannot take place without consideration of these comorbid conditions.

As front-line practitioners in the treatment of MSK disorders, the onus is on the chiropractic profession to explore how we can best address chronic pain in the presence of comorbid behavioral health disorders, an increasingly important public health issue. By improving our understanding of how chronic pain and comorbid conditions interact, the chiropractic profession can better define its role in caring for this complex cohort of patients and those outside of the veteran community with similar conditions and comorbidities.

How Can Chiropractic Use Cognitive Behavioral Therapy to Address Chronic Low Back Pain as a Public Health Problem?
Expert: Dougherty P

Chronic low back pain (CLBP) is a significant public health issue, with a lifetime prevalence of 80% and an annual incidence of 10-15% (20). Back pain costs continue to increase and, while numerous treatments are employed to address CLBP, none has been identified as the definitive treatment option. In keeping with the holistic approach to care that is represented by chiropractors, the biopsychosocial (BPS) model of care proposes that to truly understand and respond to a patient’s condition, clinicians must address the biological, psychological and social dimensions of illness. Proponents of this approach argue that the pathoanatomic model of CLBP fails to fully explain this condition. Recent studies have shown that depression and fear avoidance behaviors do play an important role in prognosis in patients with CLBP (21).

The treatment most often applied by practitioners subscribing to the BPS model is cognitive behavioral therapy (CBT), which is based on the idea that our thoughts cause our feelings and behaviors, not external factors. CBT has been shown in one study to be as effective as surgery in treating low back pain (22) and a recent study found that combining behavioral treatment with physical therapy was more effective than physical therapy alone (23). Chiropractors may want to consider introducing CBT to their treatment protocols, in an attempt to provide an enhanced treatment that may be better able to address the cormorbid psychological factors associated with poor prognosis in many cases of CLBP.

What Opportunities Exist for DCs to More Effectively Serve the Aging Population?
Expert: Killinger LZ

For the first time in human history, the fastest growing subset of the population is the group that is 85 years of age and older (24). This “graying” of the population is a world-wide phenomenon, with most industrialized countries observing the same demographic changes. In Japan and much of Europe, over 20% of the population is over age 60 (25). As a result, all health care professionals, regardless of discipline, must prepare themselves to care for an aging patient base.

The health care challenges associated with treating this aging population will be most profound if the health care system continues on a symptom-based path, waiting for chronic diseases to disable patients and then trying to “fix” these patients after years of poor care and bad health habits. As a result, the proactive approach taken by chiropractors becomes a potentially important factor in the ongoing care of an aging population. The simple approach of addressing not only the presenting complaint, but providing preventative strategies including fall prevention, nutritional counselling and physical activity has the potential to have a profound impact on our aging world.

What is the Role of Ethics and the Contribution of the Chiropractic Profession to Public Health?
Expert: Page SA

Professionalism plays out in practice through a commitment to an ethic of care, defined professional codes of ethics and conduct. The fundamental underlying ethical principles in the healing professions are respect for others, doing good and avoiding harm. The application of ethical principles vary when applied in either clinical or public (i.e. population) environments, with clinical settings attempting to promote health in the individual, while in public settings, ethics is applied in a greater context through disease and injury reduction. The application of ethical principles in the public health realm can conflict with that of the individual patient, but is done so for the public good. Seat belts and mandatory vaccinations are examples of initiatives where individual freedoms have been limited in the interest of the public good.

The chiropractic profession encourages its members’ responsibilities to public health promotion as an important part of practice. The delivery of evidence-based public health initiatives intended to promote wellness is consistent with the profession’s fundamental commitment to wellness and health promotion.

What Public Health Roles can Chiropractic Interns Perform for Underserved Communities in a Collaborative Environment?
Experts: Stites J, Ramcharan M

The focus of chiropractic education remains clinical, with little attention paid to public health issues. The transition from the didactic classroom setting to clinical practice is not conducive to promoting the implementation of public health initiatives. It is important for chiropractic educators to instill in students the value and applicability of public health initiatives. Two factors are proposed to be instrumental in increasing the importance of public health considerations in chiropractic trainees: the expanding population of under- and uninsured patients in the United States (and other countries) and the increasing awareness of the massive public health impact of musculoskeletal disorders.

A number of chiropractic colleges have clinical training programs that provide care for at-risk populations (26, 27). These patients provide chiropractic trainees with examples of the value of public health initiatives such as smoking cessation, weight management and nutritional education. These clinical opportunities provide an excellent springboard upon which chiropractic trainees can grow their appreciation for public health initiatives and their impact on both the practitioner’s own practice and public health in general.

Can the Chiropractic Profession Contribute to Community Health?
Expert: Leach RA

Chiropractors have a unique potential to act as significant contributors to overall community health. With the increase in access to health care in the United States provided by the Affordable Care Act and an aging patient population, chiropractors are positioned to play an important role in furthering community health goals. Chiropractors can act as agents of change within their local communities, through simple acts such as referral of patients to smoking cessation programs or alcohol dependence programs. Similarly, chiropractors have an opportunity to collaborate with other health care practitioners and local stakeholders to garner support for ordinances or legislation, such as promoting non-smoking areas or bicycle helmet laws. By utilizing evidence-based methods to engage stakeholders, chiropractors can play a potentially influential role in promoting community health.

What Opportunities do DCs have to be Involved in Health Care Reform in the Areas of Prevention and Public Health?
Expert: Byrd L

The Affordable Care Act (ACA), in an effort to promote prevention as a means of improving health, provides funding for prevention, wellness and public health initiatives. With prevention a cornerstone of the chiropractic profession, we are uniquely positioned to play an important role in the promotion of disease prevention. The most effective way to accomplish this is through advocacy. Chiropractors should keep abreast of health reform issues and advocate for prevention as a matter of public health. Whether at the individual level (doctor-to-patient) or on a larger scale (community involvement), chiropractors have numerous opportunities to promote a preventive lifestyle. With continuing cutbacks in health services in most jurisdictions, the role of chiropractors is underscored, as a knowledgeable, motivated group who are able to reach large portions of the population and help to promote the role of disease prevention in public health.

What Role do Citizen-DCs have in Organizing Community Action on Health-Related Matters?
Expert: Redwood D

In addition to their role as health care practitioners and collaborators with other providers, chiropractors have an important role as citizen-doctors who, through their actions, demonstrate that they care not only about the health of their patients, but the overall health of their community. The issue in which to engage is dependent entirely upon what motivates that particular chiropractor. Whether advocating for the elimination of junk food from school cafeterias, promoting environmental programs or volunteering with local charities such as the Red Cross, chiropractors can continue the long tradition of citizen activism alive in the United States, Canada and other countries.

An example of successful activism is an Alabama chiropractor who successfully lobbied to ban smoking in all public places that serve minors and to increase the minimum number of non-smoking rooms maintained by local hotels.

The lessons to be learned and applied from successful stories are: become a health resource person in your local community; serve on a local community or philanthropic board; and support local public health initiatives such as promoting removal of soda vending machines from schools.

How can our Future Chiropractic Graduates Become Socially Responsible Agents of Change?
Expert: Kopansky-Giles D

Health inequity and health disparity have been identified as the most important influencers of underperforming health systems. These terms refer respectively to unequal distribution of health determinants (disparity) and circumstances where these disparities result from injustice or systematic discrimination towards vulnerable groups (inequity). Despite advances in health care over the past 100 years, these advances have not been effectively shared between countries, a failure that has had a tremendous negative impact on vulnerable populations (e.g. Aboriginal, remote/rural). A major contributing factor to this problem was a lack of professional education programs to “keep pace” and adequately evolve their programs.

Recommendations have been made regarding changes to healthcare education programs, with a goal to assure that health service becomes universally available, resulting in improvements in health equity within and between countries. Educational reforms should accompany these changes, guided by 2 prioritized outcomes: transformative learning (developing leadership attributes) and interdependence in education (interprofessional education). The latter of these concepts remains foreign and has not yet gained traction in chiropractic education.

Increased social responsibility and accountability have grown in importance in mainstream healthcare education. The goal is to produce practitioners who are committed to both the individual patient and to meet international responsibilities to a global community (28). Unfortunately, chiropractic educational programs have lagged behind in this respect. The younger generation of practitioners will need to enter their respective fields committed to working together and addressing individual, community and population needs. This imperative must become a priority for the chiropractic profession and its educators.

Clinical Application & Conclusions:

From humble beginnings, the chiropractic profession has evolved into an important contributor to the healthcare systems of many developed and developing countries. Legitimization and professionalization have, however, been a struggle over the years. One of the traits of a profession, along with specialized knowledge, autonomy and authority, is altruism. Practicing in such a way as to serve individual patients and the public as a whole, instead of taking a business-first approach where money trumps the best interests of the patient ensures that chiropractic will gain and maintain the public’s trust. With the projected growth of chronic disease over the coming decades, and the ability of chiropractic to treat, minimize and prevent these conditions, chiropractors are well-positioned to grow their role in public health system. Many would say that they have a duty as a profession to address these issues.

Study Strengths / Weaknesses:

This paper was written from a primarily American perspective (healthcare system structure, VA affairs etc.). This does not reduce the wide applicability and relevance of the discussion points, however.

Additional References:

  1. Preamble to the constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (official records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Available from: http://www.who.int/about/definition/en/print.html. Accessed September 5, 2012.
  2. Bronfort G, Evans R, Anderson AV et al. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Intern Med 2012; 156: 1-10.
  3. Gross A, Miller J, D'Sylva J et al. Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther 2010; 15: 315-33.
  4. Rubinstein SM, van MM, Assendelft WJ et al. Spinal manipulative therapy for chronic low back pain. Cochrane Database Syst Rev 2011; 1: CD008112.
  5. Leaver AM, Refshauge KM, Maher CG, McAuley JH. Conservative interventions provide short-term relief for nonspecific neck pain: a systematic review. J Physiother 2010; 56: 73-85.
  6. Guzman J, Haldeman S, Carroll LJ et al. Clinical practice implications of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. Spine 2008; 33: S199-213.
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  8. Dittrich R, Rohsbach D, Heidbreder A et al. Mild mechanical traumas are possible risk factors for cervical artery dissection. Cerebrovasc Dis 2007; 23: 275-81.
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  13. Russell M, Vehoef MJ, Injeyan HS. Are chiropractors interested in participating in immunization awareness and promotion activities? Can J Public Health 2005; 96: 194-6.
  14. Rose KA, Ayad S. Factors associated with changes in knowledge and attitude towards public health concepts among chiropractic college students enrolled in a community health class. J Chiropr Educ 2008; 22: 127-37.
  15. Davis MA, Smith M, Weeks WB. Influenza vaccination among chiropractic patients and other users of complementary and alternative medicine: are chiropractic patients really different? Prev Med 2012; 54: 5-8.
  16. Smith M, Davis MA. Immunization status of adult chiropractic patients in analyses of national health interview survey. J Manipulative Physiol Ther 2011; 34: 602-8.
  17. Itz CJ, Geurts JW, van Kleef M, Nelemans P. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain 2013; 17(1): 5-15.
  18. Shiri R, Karppinen J, Leino-Arjas P et al. The association between smoking and low back pain: a meta-analysis. Am J Med 2010; 123: 87e7-87e35.
  19. Lew HL, Otis JD, Tun C et al. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev 2009; 46: 697-702.
  20. Fourney DR, Andersson G, Arnold PM et al. Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach. Spine 2011; 36(21 Suppl): S1-9.
  21. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain?. JAMA 2010; 303: 1295-302.
  22. Brox JI, Reikerås O, Nygaard Ø et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006; 122: 145-55.
  23. Vong SK, Cheing GL, Chan F et al. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Phys Med Rehabil 2011; 92: 176-83.
  24. U.S. Census Bureau. An older and more diverse population by mid-century. Washington, DC: U.S. Census Bureau; 2008. Available from: http://www.census.gov/newsroom/releases/archives/population/cb08-123.html.
  25. Kinsella K, Phillips D. Global aging; the challenge of success. Population Bulletin 2005; 60: 7.
  26. Kopansky-Giles H, Vernon I, Steiman A et al. Collaborative community-based teaching clinics at the Canadian Memorial Chiropractic College: addressing the needs of local poor communities. J Manipulative Physiol Ther 2007; 30: 558-65.
  27. Johnson C. Poverty and human development: contributions from and callings to the chiropractic profession. J Manipulative Physiol Ther 2007; 30: 551-6.
  28. Jamieson J, Snadden D, Dobson S et al. Health Disparities, Social Accountability and Postgraduate Medical Education. Members of the FMEC PG consortium; 2011. Available from: http://www.afmc.ca/pdf/fmec/01_Jamieson_Health%20Disparity.pdf.

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