A chiropractor performs an adjustment on a patient. Spinal manipulation, which chiropractors call "spinal adjustment" or<unk>  adjustment", is the most common treatment used in<unk>  care. Spinal manipulation is a passive manual maneuver during which a three-joint complex is taken past the normal range of movement, but not so far as to dislocate or damage the joint. Its defining factor is a dynamic thrust, which is a sudden force that causes an audible release and attempts to increase a joint's range of motion. High-velocity, low-amplitude spinal manipulation (HVLA-SM) thrusts have physiological effects that signal neural discharge from paraspinal muscle tissues, depending on duration and amplitude of the thrust are factors of the degree in paraspinal muscle spindles activation. Clinical skill in employing HVLA-SM thrusts depends on the ability of the practitioner to handle the duration and magnitude of the load. More generally, spinal manipulative therapy (SMT) describes techniques where the hands are used to manipulate, massage, mobilize, adjust, stimulate, apply traction to, or otherwise influence the spine and related tissues. There are several schools of<unk>  adjustive techniques, although most chiropractors mix techniques from several schools. The following adjustive procedures were received by more than 10% of patients of licensed US chiropractors in a 2003 survey: Diversified technique (full-spine manipulation, employing various techniques), extremity adjusting, Activator technique (which uses a spring-loaded tool to deliver precise adjustments to the spine), Thompson Technique (which relies on a drop table and detailed procedural protocols), Gonstead (which emphasizes evaluating the spine along with specific adjustment that avoids rotational vectors), Cox/flexion-distraction (a gentle, low-force adjusting procedure which mixes<unk>  with osteopathic principles and utilizes specialized adjusting tables with movable parts), adjustive instrument, Sacro-Occipital Technique (which models the spine as a torsion bar), Nimmo Receptor-Tonus Technique, applied kinesiology (which emphasises "muscle testing" as a diagnostic tool), and cranial.<unk>  biophysics technique uses inverse functions of rotations during spinal manipulation. Koren Specific Technique (KST) may use their hands, or they may use an electric device known as an "ArthroStim" for assessment and spinal manipulations. Insurers in the US and UK that cover other<unk>  techniques exclude KST from coverage because they consider it to be "experimental and investigational". Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain. Lumbar, cervical and thoracic<unk>  spinal manipulation Many other procedures are used by chiropractors for treating the spine, other joints and tissues, and general health issues. The following procedures were received by more than one-third of patients of licensed US chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), physical fitness/exercise promotion, corrective or therapeutic exercise, ergonomic/postural advice, self-care strategies, activities of daily living, changing risky/unhealthy behaviors, nutritional/dietary recommendations, relaxation/stress reduction recommendations, ice pack/cryotherapy, extremity adjusting (also mentioned in previous paragraph), trigger point therapy, and disease prevention/early screening advice. A 2010 study describing Belgian chiropractors and their patients found chiropractors in Belgium mostly focus on neuromusculoskeletal complaints in adult patients, with emphasis on the spine. The diversified technique is the most often applied technique at 93%, followed by the Activator mechanical-assisted technique at 41%. A 2009 study assessing<unk>  students giving or receiving spinal manipulations while attending a United States<unk>  college found Diversified, Gonstead, and upper cervical manipulations are frequently used methods. Practice guidelines Reviews of research studies within the<unk>  community have been used to generate practice guidelines outlining standards that specify which<unk>  treatments are legitimate (i.e. supported by evidence) and conceivably reimbursable under managed care health payment systems. Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs antiscientific reasoning and makes unsubstantiated claims.<unk>  remains at a crossroads, and that in order to progress it would need to embrace science; the promotion by some for it to be a cure-all was both "misguided and irrational". A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice, which may have resulted from a lack of research education and skills. Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain are inconsistent between countries. Effectiveness Numerous controlled clinical studies of treatments used by chiropractors have been conducted, with varied results. There is no conclusive evidence that<unk>  manipulative treatment is effective for the treatment of any medical condition, except perhaps for certain kinds of back pain. Generally, the research carried out into the effectiveness of<unk>  has been of poor quality. Research published by chiropractors is distinctly biased: reviews of SM for back pain tended to find positive conclusions when authored by chiropractors, while reviews by mainstream authors did not. There is a wide range of ways to measure treatment outcomes.<unk>  care benefits from the placebo response, but it is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT). The efficacy of maintenance care in<unk>  is unknown. Available evidence covers the following conditions: * Low back pain. A 2013 Cochrane review found very low to moderate evidence that SMT was no more effective than inert interventions, sham SMT or as an adjunct therapy for acute low back pain. The same review found that SMT appears to be no better than other recommended therapies. A 2012 overview of systematic reviews found that collectively, SM failed to show it is an effective intervention for pain. A 2011 Cochrane review found strong evidence that suggests there is no clinically meaningful difference between SMT and other treatments for reducing pain and improving function for chronic low back pain. A 2010 Cochrane review found no difference between the effects of combined<unk>  treatments and other treatments for chronic or mixed duration low back pain. A 2010 systematic review found that most studies suggest SMT achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up. * Radiculopathy. A 2013 systematic review and meta-analysis found a statistically significant improvement in overall recovery from sciatica following SM, when compared to usual care, and suggested that SM may be considered. There is moderate quality evidence to support the use of SM for the treatment of acute lumbar radiculopathy and acute lumbar disc herniation with associated radiculopathy. There is low or very low evidence supporting SM for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration and no evidence exists for the treatment of thoracic radiculopathy. * Whiplash and other neck pain. There is no consensus on the effectiveness of manual therapies for neck pain. A 2013 systematic review found that the data suggests that there are minimal short- and long-term treatment differences when comparing manipulation or mobilization of the cervical spine to physical therapy or exercise for neck pain improvement. A 2013 systematic review found that although there is insufficient evidence that thoracic SM is more effective than other treatments, it is a suitable intervention to treat some patients with non-specific neck pain. A 2011 systematic review found that thoracic SM may offer short-term improvement for the treatment of acute or subacute mechanical neck pain; although the body of literature is still weak. A 2010 Cochrane review found low quality evidence that suggests cervical manipulation may offer better short-term pain relief than a control for neck pain, and moderate evidence that cervical manipulation and mobilization produced similar effects on pain, function and patient satisfaction. A 2010 systematic review found low level evidence that suggests<unk>  care improves cervical range of motion and pain in the management of whiplash. * Headache. There is conflicting evidence surrounding the use of<unk>  SMT for the treatment and prevention of migraine headaches. A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache. A 2005 review found that the evidence was weak for effectiveness of<unk>  manipulation for tension headache, and that it was probably more effective for tension headache than for migraine. * Extremity conditions. A 2011 systematic review and meta-analysis concluded that the addition of manual mobilizations to an exercise program for the treatment of knee osteoarthritis resulted in better pain relief than a supervised exercise program alone and suggested that manual therapists consider adding manual mobilization to optimize supervised active exercise programs. There is silver level evidence that manual therapy is more effective than exercise for the treatment of hip osteoarthritis, however this evidence could be considered to be inconclusive. There is a small amount of research into the efficacy of<unk>  treatment for upper limbs, limited to low level evidence supporting<unk>  management of shoulder pain and limited or fair evidence supporting<unk>  management of leg conditions. * Other. A 2012 systematic review found insufficient low bias evidence to support the use of spinal manipulation as a therapy for the treatment of hypertension. A 2011 systematic review found moderate evidence to support the use of
Chiropractic
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BackCare
Paramedic
Arthrology
Orthotist
Kinaesthetics
Neuromuscular medicine