PrefaceBack pain is the most common cause of disability in adults ofworking age throughout the developed world, and involves hugecosts to individuals and society. The World Health Organisation'scurrent Low Back Pain Initiative, which is bringing togetherchiropractic and medical experts, seeks to foster better under-standing in interdisciplinary management of back pain, which is“a major clinical and public health problem” that continues togrow and “has reached epidemic proportions”.

For chiropractors and physicians to work together in managing patients with back pain and a variety of other com-plaints commonly seen in chiropractic practice, it is importantthat they understand each other. This places an onus on the chiropractic profession to present information on chiropracticeducation, principles and practice in a format and language suitable for physicians.

Recently the Norwegian Chiropractic Association (NCA) metthis challenge in Norway in its very impressive booklet titled Disorders of the Neuromusculoskeletal System: An Introductionto Chiropractic Management. This was distributed to physiciansthroughout Norway, was favourably reviewed in the NorwegianMedical Journal, and has led to much greater co-operation between the two professions in clinical practice in that country.

The NCA has now completed this English translation of theoriginal booklet in Norwegian, and is making it available to chiropractors worldwide. Although some of the data and com-ment are specific to Norway, the great majority of the text and illustrations – including the key sections on education, exami-nation and diagnosis, treatment, scope of practice and the roleand effects of manipulation – is of relevance and strong value everywhere.

On behalf of the World Federation of Chiropractic and its 70member national associations, I recommend this introduction tochiropractic to all physicians and health care managers, and offerwarm congratulations to the NCA for making this fine publica-tion available in the English language.

Bruce Vaughan DCPresidentWorld Federation of Chiropractic, www.wfc.org

Editorial committee: Øistein H. Haagensen (Editor),Jakob Lothe, Kyrre Myhrvold

Table of contents

Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

EExxaammiinnaattiioonn aanndd ddiiaaggnnoossiiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

TTrreeaattmmeenntt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

SSccooppee ooff pprraaccttiiccee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

FFrroomm ssttrruuccttuurree ttoo ffuunnccttiioonn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

FFuunnccttiioonnaall SSppiinnaall LLeessiioonn ((FFSSLL)) . . . . . . . . . . . . . . . . . . . . . . . . 11

FFrroomm ppaassssiivvee ttoo aaccttiivvee ttrreeaattmmeenntt . . . . . . . . . . . . . . . . . . . . . 14

TThhee eeffffeecctt ooff mmaanniippuullaattiioonn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

SSiiddee--eeffffeeccttss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

DDeeggeenneerraattiivvee cchhaannggeess ooff tthhee ssppiinnee . . . . . . . . . . . . . . . . . 17

IInn bbrriieeff:: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Disc prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Sciatica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Segmental instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Hypermobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Pelvic pain and pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 19

Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Whiplash injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Dizziness and disturbed postural control . . . 21

curriculum of university level . . . . . . . . . . . . . . . . . . 22

4

The practice of chiropracticinvolves the diagnosis, treat-ment and prevention of dis-orders in the neuro-musculo-skeletal system, particularlyconditions involving the spinalcolumn.

Chiropractic is a comple-mentary discipline to traditio-nal medicine; it must not beregarded as an alternative to it.A chiropractor is someonewho has been authorised topractise chiropractic by theNorwegian Board of Health.The chiropractor has the sta-tus of a primary contact, andhas an independent treatmentliability like that of a medicalpractitioner, dentist or psycho-logist.

TrainingChiropractic education is stan-dardised at minimum five yearsat university level. Up to now,Norwegian chiropractors havereceived their training from col-leges and universities in Austra-lia, the USA, the UK, SouthAfrica and Canada that are ap-proved by the Norwegian aut-horities. On the initiative of theNordic Council, a Nordic trai-ning scheme has recently been established atSyddansk University in Odense,Denmark. Some places are as-signed each year to Norwegianapplicants. Nordic medical andchiropractic students share, to a large extent, a common syllabus and instruction duringthe pre-clinical part of their

courses. A curriculum map isgiven at the back of this booklet.

Licence to practiseTo practice as a Chiropractorone must graduate from an ap-proved academic programme inchiropractic, followed by a one-year internship in Norway as inmost other European countries.

Clinical experienceIn 1995, publicly licensed chiropractors in Norway carried out around one millionpatient consultations. In thecourse of one year, the averagechiropractor holds 5,000 con-sultations (data from the Nor-wegian Chiropractic Associati-on). In Norway, manipulativetherapy is mainly performed bypublicly licensed chiropractors(Norwegian Board of Health1988).

The number of patients visiting chiropractors is steadilyrising. A Danish survey showsthat 37% of those sufferingfrom back complaints haveseen a professional therapistover the past year; 24% a medical practitioner, 11% achiropractor and 10% aphysiotherapist (some patientsconsulted therapists in morethan one profession). On average, a chiropractor dealt with 18 times as manyback patients as a general practitioner and nine times asmany as a physiotherapist(Lønnberg 1997).

HistoryThe word chiropractic is Greek and means done byhand. The history of chiro-practic started over 100 yearsago in the USA when the founder of chiropractic, D.D.Palmer (1845–1914), postula-ted the first chiropractic theo-ry of illness by relating thefunction of the spinal columnto the integrity of the nervoussystem.

Over the years, chiropractichas developed through scienti-fic studies and research. It isnow a profession that dealswith those illnesses on whichexperience has shown chiro-practic treatment has the besteffect: back pain and othermusculoskeletal disorders (Pedersen P 1994, Breen AC1996).

Norway got its first chiro-practor in 1922; the Norwe-gian Chiropractic Associationwas founded in 1935. In 1988the Storting, Norway’s parlia-ment, voted to institute publicauthorisation of chiropractors.

The role of the chiropractorWith a public authorisationarrangement in place, chiro-practors became the fourthgroup of health professionalsin Norway with independentresponsibility for the treat-ment they provide. Up tothen, only medical practitio-ners, psychologists and den-tists had the right to be the

primary patient contact. However, it is still the case thatonly patients who have beenreferred by their doctor are entitled to a partial reimburse-ment of chiropractor fees fromthe social security system. Surveys have shown thataround a third of chiro-practors’ patients are referredby their doctors, while the other two-thirds make appointments with chiro-practors directly (Kilvær A etal. 1992, 1997).

A medical practitioner whorefers a patient to a chiro-practor is liable for his or herown diagnosis. Relevant symptoms, findings and anyX-ray results must be stated onthe referral. According to theNorwegian Board of Health(1989), the chiropractor is legally liable for his or her ownexamination, diagnosis andtreatment, irrespective ofwhether the patient has beenreferred by a medical practitio-ner or not. Under present-dayrules, chiropractors cannot re-fer a patient to a specialist,write a doctor’s note in case ofillness, or prescribe medi-cation.

Where are chiropractorsto be found?There are presently around200 publicly authorised chiro-practors in Norway. Theypractise mainly in large townsand densely populated areas.A list of publicly authorised

Chiropractic

5

The disorders treated by a chi-ropractor have a multifactorialaetiology. Developments inmodern society have led to great changes in the use of, andstrains on, our bodies andmind. In order to make a diag-nosis, the chiropractor needsinformation about the patient’swork situation, psychosocialconditions, level of physical activity and lifestyle in general.

Clinical examinationThe chiropractor analyses thefunction of the neuromuscu-loskeletal system and assesseswhether any dysfunctions re-late to the patient’s symptoms.In addition to orthopaedic andneurological diagnostic tests,the clinical examination con-sists of special palpatory tech-niques by which the chiro-

practor notes changes in muscle tone and joint move-ment patterns. The patient’sreports of pain during the clinical examination are im-portant. Chiropractors carryout an examination both before and after the treatmentin order to evaluate its efficacy.

X-ray examinationsoften supplement the clinicalexamination. Chiropractors aretrained to carry out and inter-pret X-ray examinations of theskeleton. Many have their ownX-ray equipment, equipmentwhich is subject to public regu-lations.

In Norway chiropractors canalso request X-ray and CT exa-minations from institutes andhospitals. These are paid for bythe social security services as if

the patient had been referred by a medicalpractitioner.

X-rays are used by thechiropractor mainly toexclude any contraindica-tions to treatment. In addition, emphasis is placed on anomalies anddegenerative changes thatmay be significant to thechiropractor in his or herchoice of treatment tech-nique. In order to evalua-te alignment, the chiro-practor often prefers totake X-rays with the pati-ent standing up insteadof lying down.

DiagnosisTo the chiropractor, a so-calledpathoanatomical (disease or in-jury causing anatomical changes)(Norwegian Board of Health1995) diagnosis is only part ofa wider, functional diagnosis.Such a diagnosis is based on anintegrated understanding offindings at several levels:a) Identify functional spinal

lesions (FSL – see separatesection)

b) Localise any pathoanatomi-cal sources of pain

c) Assess any pain and othersymptoms in relation to a) and b)

A diagnosis that purely descri-bes the symptoms, such as“low back pain (LBP) (withradiating pain)” may thereforerepresent several different di-agnoses or combinations ofthese depending on clinicalfindings, such as:a) Acute LBP with or without

radiation/leg pain due toFSL at level L5/S1 and/or

b) Acute LBP with or withoutradiation/leg pain due tosymptoms from a disc lesionL4/5 affecting the fifthlumbar nerve root and/or

c) Acute LBP with or withoutradiation/leg pain due to adysfunction of the sacroi-liac joint

Case recordsChiropractors keep case re-cords of each consultation.Exact notes show the develop-ment of symptoms and clini-cal findings compared withthe treatment. The diagnosiswill often be a working diag-nosis at first, to be reassessedin relation to the response tothe treatment. Hence responseto specific treatment can behelpful in localising pain sour-ces in a way similar to the useof diagnostic injections.

Examination and diagnosis

6

TractionChiropractic traction treatment is slightly different from thatused standard physical medicine. The chiropractor uses an adjus-table special treatment table that can move in several planes during the traction treatment, in order to achieve a pumping mobilisation of the discs and joints below the segment that is stabilised.

The most important chiro-practic method of treatment ismanipulation of the spinal co-lumn, but a number of othertreatment techniques are alsoused (Pedersen P 1994, BreenAC 1996).

Both the intensity of thetreatment and the choice of

technique are continuously assessed during the course oftreatment. The cause of thedisorder is often revealed byhow the patient reacts to treat-ment, both physically andmentally, so that the diagnosisand treatment together form adynamic process.

Manipulative therapycan be described as a fast, passive stretch of the structures arounda joint. This usually causes a clicking sound as the joint surfacesseparate. A number of neurophysiological effects are associatedwith this phenomenon. These are discussed in further detail in a separate section.

Mechanical aidsAs an alternative to tradi-tional manipulation, severalparticularly gentle techniqueshave been developed, wherethe patient is given a mani-pulation-like impulse with a controlled depth and power. This is administeredeither by using a handheldinstrument or on a purpose-built bench with an adjusta-ble, mechanical drop.

Case records of the treatment of 1,013 patients(Data from the “A survey of chiropractic practice in Europe”, Pedersen P 1994.)

100

90

80

70

60

50

40

30

20

10

0Manipulative

therapyOther

therapeutictechniques

Other treatment

Ergonomicadvice/

exercises

Guidance General advice on

health

Explanationof

symptoms

First visit

Second visit

Fifth visit

Treatment

Modes of chiropractic treatment

Per

cent

age

of p

atie

nts

7

Soft-tissue treatmentChiropractic soft-tissue techniques existin many different forms and are mainlyused to affect muscle tone. Manual trigger-point treatment is frequentlyused, often in combination with passivestretching. Heat, electrotherapy, ultra-sound and laser therapy are not oftenused by chiropractors.

ExercisesExercise and training are a natural part ofthe treatment of patients with pain synd-romes and repetitive-strain injuries. Trai-ning may include strengthening exercises,conditioning training, or stretching andrelaxation techniques. The patient is givenindividual instruction as required, or thechiropractor recommends the patient tocontact a physiotherapist for supervisedfollow-up training.

Advice/instructionInformation to the patient inthe form of advice and guidan-ce is an important part of thetreatment. It is often necessaryto examine the patient’s workand family situation, his or herleisure time activities and general level of physical activi-ty in order to provide the rightguidance. The chiropractorgains a good overview of thepatient’s overall situation bytaking his or her case history,carrying out clinical examina-tions, examining X-rays, making a diagnosis, providing

treatment and following up onthe treatment.

When should treatmentbe initiated?The significance of rapid painrelief, reassuring the patientand advice on early activity ispointed out in literature asbeing most important for pre-venting chronification (Shekelle PG, Adams AH et al.1991, Royal College of GeneralPractitioners 1996).

Most chiropractors have ar-ranged their practice so thatunnecessary waiting between

examination and treatment isavoided. If X-rays are neces-sary, these are taken promptly,and any findings explained bythose chiropractors who havetheir own X-ray equipment.

Referral from a chiro-practorIn Norway two-thirds of pati-ents use the chiropractor astheir primary contact. Manyare referred for further evalua-tion or treatment. The presentNorwegian regulations standin the way of a formal referralfrom a chiropractor to a speci-

alist or physiotherapist, so thepatient’s GP has to make thereferral; a somewhat wastefularrangement in terms of timeand costs.

However, in 2001 a two-yeartrial will commence in threeNorwegian countries wherechiropractors may refer to amedical specialist and physio-therapist as well as give pati-ents leave of absense. In thesame trial period, all chiro-practic patients will have auto-matic partial reimbursement.

The chiropractic exercise centreat the Palmer College of Chiropractic around 1935

8

A chiropractor’s field of activi-ty has traditionally been per-ceived as the treatment ofback pain. However, chiro-practic has a wide indicationarea that includes all condi-tions involving functional lesions in the neuromusculo-skeletal system.

Two European surveys showthat almost half of all chiro-practic patients came for treat-ment within four weeks of theonset of pain. Around 25%came more than six monthsafter the onset of pain – seeleft-hand figure (Pedersen P1994, Leboeuf-Yde et al.1997).

Low back pain and sciaticaPeople with these complaintsrepresent between 50 and80% of chiropractic patients(Pedersen P 1994, Leboeuf-Ydeet al. 1997, Kilvær et al. 1997).Publicly appointed multidisci-plinary expert panels in theUSA, the UK and Canadahave evaluated chiropractictreatment and found it to besafe and effective. This appliesto both acute low back pain(Shekelle PG, Adams AH et al.1991, Royal College of GeneralPractitioners 1996), and chro-nic low back pain (Manga P etal. 1993).

Clinical guidelinesIn 1994, the US Departmentof Health published new, evidence-based, clinical guide-lines for back care in the USA.A multidisciplinary expert pa-nel carried out a critical exami-nation of the available docu-mentation on the diagnosisand treatment of back pain – a total of almost 4,000 titles(Shekelle PG, Adams AH et al.1991). The conclusions of thisreport agree to a great extentwith that of later clinical gui-delines for dealing with acutelow back pain prepared in theUK (Royal College of GeneralPractitioners 1996). TheRCGP guidelines recommendgrouping patients according toa diagnostic triad that formsthe basis of further examinati-ons, referrals and treatment.

The Diagnostic Triad1) Simple back pain2) Nerve root pain3) Possible spinal pathology

Since the vast majority of backpatients have neither seriouspathology nor nerve root painrequiring surgery, most ofthem belong in the groupswith uncomplicated back painand nerve root pain that canbe treated without surgery.Most chiropractic patients alsobelong in these groups.

The RCGP guidelines re-commend manipulative the-rapy within the first six weeks– usually complemented byother measures – for the groupwith acute, simple back pain,in order to alleviate the painand enable the patient to re-turn to a normal activity levelas quickly as possible. TheRCGP guidelines adviseagainst staying in bed formore than a couple of days, as a treatment for acute backpain.

Clinical experience and research also demonstate thegood results of chiropractictreatment of low back painand sciatica (Kirkaldy-WillisWK 1983, Meade et al. 1990,1995, Stern et al. 1995).

Acute47%

Subacute25%

Chronic

28%

Criteria used in this survey: Acute: less than 4 weeksSubacute: from 4 weeksto 6 monthsChronic: more than 6 months(Data from “A survey of chiropracticpractice in Europe”, Pedersen P1994.)

Low back andleg 51.8%

Headaches,neck and arm

28.5%Thoracic/chest 7.3%

Lower extremity3.8%

Upper extremity4.4%

Miscellaneous4.2%

Scope of practice

Distribution of patientsaccording to the lengthof illness

Anatomical areas of complaint

Painful areas reported by 1,013 patients. (Data from “Survey of chiropractic practice in Europe”, Pedersen P 1994.)

9

Neck pain and headacheThe second largest group ofchiropractic patients, about athird, has neck pain and head-ache. The conclusions drawnby international expert panelsare positive to manipulativetherapy in this group of pati-ents as well (Spitzer et al.1995, Hurwitz EL et al.1996).

In practice, chiropractorstreat both acute neck pain,such as in the case of acutetorticollis, and more chronicneck, shoulder and arm synd-romes. Headaches, dizzinessand posttraumatic neck pain,i.e. a whiplash injury, are dis-cussed later in a separate section.

Pain in the thoracicspine and the thoraxDysfunctions in the thoracicspine are normal and may cause symptoms in the arms,shoulders and neck. The thora-cic spine is often a stress baro-meter, along with the thorax itis the biomechanical basis forthe respiratory function. Thethoracic spine is also the anchorpoint for the shoulder, arm andneck musculature. General ten-seness, stress and repetitive armmovements can affect breathingand often manifest themselvesas dysfunctions in this area.Acute dysfunctions in the cost-overtebral joint can cause dra-matic pain in the front of thechest that spreads to the upperextremities and can cause breathing difficulties. The paincan be frightening, and adifferential diagnosis is impor-tant. Patients usually respondrapidly to chiropractic treat-ment. The number of treat-ments needed to treat such conditions may vary with thedegree of chronicity and severity. In most cases 2-6 treat-ments will suffice.

Other conditionsClinical experience has shownthat chiropractic treatmentmay in some cases help dis-orders caused by other organsystems as well. Several clinicalresearch projects are underway to shed light on this.

Other joints and sports injuriesVarious chiropractic examinationand treatment techniques have beendeveloped for all the joints in thebody. These are important for

treating both acute sports injuriesand chronic repetitive-strain injuries.Chiropractic thus has a role to playin the treatment of both acutesprains/strains and chronic tendoni-tis, for example. Many doctors refer

patients with such com-plaints to chiropractors, andthe chiropractor should havea natural place in the medicalteams around top athletes.Chronic dysfunctions in theextremities may be an under-lying cause of back pain, andcan easily be overlooked. Forexample, it may be relevantto examine and treat thefoot/ankle/knee of a patientwith back pain. The oppositemay also be true, and the chi-ropractor will always examinehow the spinal column func-tions if the patient has chro-nic tendonitis, for instance.

10

Ever since Mixter and Barr described discprolapse as the cause of LBP with or withoutradiation/leg pain, the intervertebral disc hasbeen the focus of spinal research up to thepresent time (Mixter WJ, Barr SJ 1934). As a result of this, the treatment of spinal disorders has mainly been based on structuralfindings, such as disc pathology and degene-rative changes.

The reasons for disc degeneration are stilllargely unknown. Risk factors such as liftingheavy loads, sedentary lifestyle, vibrationand smoking seem to be less important thanpreviously assumed, while hereditary factorsplay a greater role (Battie et al. 1995).

A lack of correlation between degenerativechanges in the disc and facet joint and backsymptoms has also been demonstrated (Fullenlove TM, Williams AJ 1957, Boos et al.1995). With the use of CT scans, disc pro-lapse has been found in up to 40% ofasymptomatic individuals at the age of 40(Wiesel SW 1984), and, with the use of MRI,disc prolapse has later been found in all of76% of asymptomatic individuals (Boos et al.1995). The picture is further complicated bythe fact that patients with severe pain oftenhave no degenerative changes or disc lesionsat all. Thus, traditional back diagnoses basedon structural findings are not necessarily associated with pain.

Sixty years after Mixter and Barr’s famousarticle, we still do not know why some peo-ple get back pain and others do not. At thesame time, we see that the economical cost of back pain has grown enormously over the past few decades.

These developments show that there is a need for innovative thinking in this area.Disciplines that are new in this context, suchas immunology, biochemistry and neurophy-siology, will most likely significantly enhanceour understanding of the nature of back pro-blems (Saal J 1995).

From structure to function

11

The concept of a functionalspinal lesion has recently beenintroduced in the chiropracticliterature (Triano JJ 1992).

DefinitionIn order to define an FSL, wemust assume that a normalfunction can be defined on thebasis of a movement patternthat contains a harmonious in-teraction between the spinaljoints and musculature. Activ-ity in the spinal musculatureresults in movement in thespinal joints. Receptors in thespinal joints provide continu-ous feedback via the nervoussystem about the joint move-ments, so that muscle activitycan be adjusted. When the in-teraction between the nervoussystem, joints and musculatureis disturbed, this is called anFSL.

Innervation and control of the deepspinal musculatureThe deep spinal musculatureis not under direct voluntarycontrol to any great extent.Impulses from thousands ofnerve cells converge on onesingle motorneuron, which inturn integrates sensory infor-mation with signals fromdownward motor circuits.

It is the overall synaptic acti-vity in the individual motor-neuron that determines the ac-tivity to be emitted from thesame motorneuron to its asso-ciated muscle fibres (motor

unit). This will always be thecase initially, but it has alsobeen proven that the activity(frequency of action potential)in a motonreuron can operateindependently of the inco-ming synaptic activity in cer-tain circumstances. In litera-ture, this is described as themotorneurons’ bistable firingproperties or plateau potentials(Hounsgaard et al. 1988).

Functional Spinal Lesion (FSL)

Key branches from sensory cells(including from muscle spindles).

MOTORNEURONRetrograde marked with D:I.(Approx. L2 Level in chicken)A.L. Eide, Department of Physiology,University of Oslo.

Motorneuron

12

A brief, synaptic activity inmonosynaptic links from mus-cle spindles has been showncapable of starting a long-lasting train of action poten-tials in the motorneuron, i.e.long-lasting muscle contrac-tion in the motor unit in ques-tion. Similarly, a brief inhibi-tory impulse (such as fromantagonistic musculature) canstop the signal train in themotorneuron (Chrone et al.1988). Chiropractic treatmentcan probably provide a similarinhibitory impulse.

This could explain what weobserve clinically in manipula-tive therapy. Long-lasting con-tractions of the back muscula-ture seem to cease immediatelyin connection with a short-las-ting mechanical stimulationthat possibly generates an in-hibitory impulse. The experi-mental observations made inthis field of research will be ofgreat importance to the futureunderstanding of chiropractictreatment.

Pain theoryTissue damage causes the re-lease of potassium, prostaglan-dins, bradykinin and other signal substances with a localeffect that activate peripheralpain receptors (Ottesen S 1993).Persistent static contractions ofdeep back muscles will proba-bly have the same effect on thepain receptors owing to the accumulation of metabolites.The pain receptors are free nerve endings, and the painsignal is led into the spinal cord’s posterior horn. Reducedmobility results in less activityin the fast-conducting sensoryfibres from the mechanorecep-tors in the spinal muscles, tendons and joint structures.According to the gate theory,the signal traffic in these fibres

normally inhibits the pain sig-nals from slow-conducting Cfibres, (Melzack and Wall1965).In the field of pain physiology,much attention is now given tothe changes that take place inthe spinal column’s posteriorhorn. The pain signals fromperipheral receptors are trans-mitted via synaptic links to se-condary sensory nerve cells inthe posterior horn. The synap-tic strength is important forhow the stimulus in question isreceived and transmitted in thenervous system.

In the case of intense pain

over a long period of time, thesynaptic strength may change.These changes can be regardedas a learning mechanism; thenerve cell in the posterior horn“learns” to transmit pain. Suchinherent plasticity seems to bean important mechanism indeveloping chronic pain. Effective pain relief from theonset of pain may thus preventthe development of chronicpain (Tjølsen A, Hole K 1993).

Because chiropractic treat-ment has a documented pain-relieving effect (Terret AGJ,Vernon H 1984, Vernon T etal. 1990, Cassidy JD et al.1992), chiropractic treatmentmay also play a role in preven-ting chronic pain.

Referred painMechanical or chemical sti-mulation of the pain receptorsin the back can give distal painor so-called referred pain (Travell 1983). Discs and facetjoints are well documentedpain sources in the case ofback and neck pain, while themusculature’s role as a sourceof pain is more uncertain(Bogduk 1995). When an FSLgives referred pain, this is usu-ally felt along the correspon-ding level’s sclerotome (Kirkaldy-Willis 1983). Thisdiffers slightly from the corres-ponding dermatome from thesame level.

The autonomic nervous systemActivity in the autonomic nervous system is affected bystimulation of mechanorecep-tors. This has been documen-ted through demonstrablechanges to the pupil diameter,blood pressure, sweat produc-tion and local circulation aftersuch stimulation (Yates et al.1988, Briggs L, Boone WR

SCLEROTOMESL4 (red) and L5 (blue) sclerotomesin the lower extremity

13

1988, Harris W, Wagnon RJ1987, Chiu TW, Wright A1996). Somatovisceral reflexes,in which the stimulation ofstructures in the spinal co-lumn leads to changed activityin the visceral organs, havealso been proven (Sato 1992).

This may explain why chi-ropractic treatment can affectconditions such as infant colic,asthma and menstrual pain(Klougart et al. 1989, Miller1975, Hviid C 1978, BoeslerD et al. 1993).

Changed muscle activityExperiments have proven thatthe activity pattern in the deepspinal musculature (multi-fidus) changes if the tissue inthe disc and facet joints is irri-tated. Irritation of the tissuecaused changes in the activitypattern both bilaterally andover several segmental levels– depending on the structuresthat were stimulated (Indahl etal. 1995). On the basis of these and other findings, tissueirritation may probably resultin an imbalance in the normalactivity pattern in the form ofan FSL.

In patients with acute/sub-acute low back pain, ultra-sound scans have shown unila-teral atrophy in the multifiduson one level. The level ofatrophy corresponded with theclinical determination of thelevel of the painful segment(Hides JA et al. 1994).

Why recurrent pain?Even several weeks after thepain had ceased, and the pati-ents had returned to normalactivity levels, there was stillevidence of multifidus atro-phy. The authors concludethat the change in muscle acti-vity does not cease automati-

cally when the pain stops(Hides JA et al. 1994). A mus-cular imbalance, as in the caseof an FSL, will probably makethe patient susceptible to recurrent low back pain.

14

Swedish studies show thataround 10% of back distur-bance sick days are due to dis-turbances that last for morethan three months. It is alsoworth noticing that the long-term absentee back patients ac-count for 85% of the costs asso-ciated with back care. Althoughmost of those absent due to

back disturbances return towork within four weeks, morethan half of these have recur-rent pain within one to twoyears (Nachemson A 1991).

As regards treatment, an in-creasing amount of data indica-tes that activity-promotingtreatment has the best effect,and that unnecessary passivityis harmful (Royal College of General Practitioners 1996).

A Norwegian study has re-cently shown that making thesituation less dramatic and en-couraging the patients to be ac-tive clearly reduced the timelost due to illness, comparedwith a control group given dif-ferent treatment (Indahl et al.

1995). In the worst case, treat-ment that makes the patientpassive gives rise to increaseddependency on the therapist,contributes to chronifying thecomplaints and deprives the pa-tient of responsibility for his orher own health. This may alsoapply to chiropractic treatment,although encouraging patients

to be physically active is a basicchiropractic principle.

Up to now, there has beenlittle research on the long-termeffects of various treatmentforms as regards the risk of re-currence and chronicity.

In an extensive survey, inwhich more than 700 patientswere followed over three years,the effect of chiropractic treat-ment was compared with hos-pital outpatient treatment (Meade TW et al. 1990, 1995).

This survey – a clinically con-trolled, randomised study pub-lished in the British MedicalJournal – showed that bothforms of treatment had an ef-fect, initially with a significantly

greater effect on the group thatwas given chiropractic treat-ment. The difference betweenthe groups grew over the nextthree years and the survey’sconclusion indicated positivelong-term effects from the chi-ropractic treatment.

In another study, with only a six-month follow-up period,

no significant difference wasshown in the effects of physiot-herapy and chiropractic treat-ment on patients with neck andback pain (Skargren et al. 1997).This proves that more researchis needed to identify which sub-groups among back patients re-spond best to various forms oftreatment. Clinical experienceindicates that this may varyfrom patient to patient, depen-ding on the diagnosis and otherknown and unknown factors.

From passive to active treatment

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An immediate, temporary in-crease in the passive jointmovement and improved sym-metry in the joint occurs aftermanipulation (ChristensenHW, Nilsson N, Hartvigsen J1996). The increased mobilityin the joints can be explainedby the fact that the ligament,joint capsule and deep muscu-lature are stretched. When thesurfaces of the joint are separa-ted, a vacuum occurs in thejoint resulting in the formationof a gas bubble inside the joint.The gas bubble increases thejoint volume for the first 20minutes after the clicking noisethat is associated with the for-mation of the gas bubble (Mierau D, Cassidy JD et al. 1988).

The joint movement can bedivided into three areas (Sandoz R 1978). The first arearepresents the active turningmovements. In addition, thejoint can be stretched passivelyinto the next area, so that theelastic elements around thejoint are stretched. The limitfor the passive movement iscalled the physiological limit.The last limit is the anatomicalone, and this represents the limit of how far the joint canbe stretched. The movementarea between the physiologicaland anatomical limit is calledthe paraphysiological space.

Mobilisation is defined as a technique in which the jointis only moved within itsphysiological limits up to thelimit of its passive movement,while manipulation moves the

joint further into the paraphy-siological space towards its ana-tomical limit. The joint may be damaged if the anatomical limit is exceeded. Good techni-cal skills and long training arenecessary for carrying out suchtreatment properly (Kirkaldy-Willis WH 1983, Mierau D,Cassidy JD et al. 1988).

What happens to themuscles?The back’s musculature haslong surface muscles and short,deep intersegmental muscles.The deep musculature is a re-flexively controlled stabilizati-on musculature that controlsthe back’s fine mechanics.

Following experimental sti-mulation of the disc and facetjoints by injections, reflex con-tractions of the multididushave been demonstrated in a specific segmental distribu-tion (Indahl 1995).

Chiropractic manipulationtechniques aim for a high de-gree of specificity in order toisolate the involved joints andassociated musculature as far aspossible. The treatment at-tempts to change the tonus ofthe deep musculature by sti-mulating the stretch andspindle receptors. A normal-ised joint function involves a normalised muscle tonus andvice versa (Caillet R 1995).

Neurophysiological effect?Manipulative therapy stimul-ates the mechanoreceptors inthe joint capsules, ligamentsand muscles immediately, dueto both the speed and depth ofthe manipulation. This stimu-lation of the mechanoreceptorsactivates fast-conducting, thicknerve fibres that impede im-pulses from slow-conductingpain fibres (the pain gate theory). Experiments haveshown that manipulation results in increased pain tole-rance (Terret AGJ, Vernon H1984) and less joint pain(Vernon T, Aker P et al. 1990,Cassidy JD, Lopes AA et al.1992).

Furthermore, immediate effects have been observed onthe autonomous nervous sys-tem, such as a lowering of blood pressure (Yates et al.1988), and changes to the pu-pil diameter (Briggs L, BooneWR 1988) and skin temperatu-re (Harris W, Wagnon RJ 1987,Chiu TW, Wright A 1996).

Long-term effectsManipulation is meant to normalise the movement inhypomobile joints and willtherefore lead to increased sti-mulation of the mechanore-ceptors and a reduction in painafter the manipulation. Thisprovides a basis for rehabilitati-on activities that are also veryimportant to the joint’s functi-on and the plasticity of thenervous system.

The effect of manipulation

MOBILISATION

MANIPULATION

Active range

Passive range

Paraphysiological Space

The stages of an adjustment and definition of joint manipulation. (From: Sandoz R: Some physical mechanisms andeffects of spinal adjustments. Ann Swiss ChiropAssoc 6:91, 1976.)

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As with all efficient treat-ment, chiropractic treatmentmay give rise to side-effects.

Slight to moderate reacti-ons to treatment arise regu-larly after manipulation.Through the analysis of datafrom several thousand chiro-practic treatments in parallelsurveys in Norway and Sweden, these side effectshave now been charted as re-gards their character, frequen-cy and predictors (Senstad etal. 1996-97, Leboeuf-Yde etal. 1997).

During a series of up to sixtreatments, around half thepatients in the survey had a treatment reaction. Of these, local tenderness wasthe most frequently reported(53%), followed by headaches(12%), tiredness (11%) andradiating pain/discomfortfrom the area treated (10%).

Most of the reactions oc-curred shortly after the treat-ment and were described asmild to moderate and ofshort duration. They usuallylasted for less than 24 hours.Reactions lasting for morethan two or three days wereextremely rare.

These reactions were pro-bably caused by tissue irritati-on in joints and musculatureafter the mechanical stimula-tion of a painful area, and canbest be compared with thestiffness and tenderness feltafter unusual physical activity.

More uncommon reactionsto treatment were dizziness(5%), nausea (4%), a skin

heat sensation (2%) and others (2%).

No permanent or seriousside-effects/complicationswere found in these surveys,which covered 1,683 chiro-practic patients who received a total of 6,570 treatments.

ComplicationsSerious complications as a re-sult of manipulation of theneck may arise as a result of anacute failure in the cerebrovas-cular circulatory system, nor-mally in the form of ischae-mia/infarction in the brainstem in a vertebrobasilar dis-tribution. Such complicationsoccur very rarely, and havebeen estimated to occur in oneout of 1.3 million neck treat-ments in Denmark (TerretAGJ 1987, Terret AGJ, Kleynhans AM 1992, HurwitzEL et al. 1996, Klougart et al.1996).

Treatment using techniquesthat involve rotating the upperpart of the neck seem to be asso-ciated with greater risk thantechniques with little or no rota-tion of the neck, so therefore arethe latter to be recommended(Klougart et al. 1996).

However, most cases (80%)of injury to the vertebrobasilarartery occur spontaneouslywithout any prior mechanicalevent such as manipulation(Haldemann S 1996). It is there-fore possible that the figuresabove represent an over-repor-ting of the actual risk involvedin neck treatments (Leboeuf-Ydeet al. 1996, Terret AGJ 1995).

The risk of developing cau-da equina syndrome as a com-plication after the manipulati-on of the lower back isestimated to be one in 100million treatments (Halde-mann S, Rubinstein SM 1992,Shekelle P 1994).

Compared with the far hig-her risk of serious complicati-ons involved in other treat-ment alternatives, such as themedicinal treatment of a head-ache or neck and back pain,manipulation is a very safetreatment choice based on anymedical criterion (Dabbs Vand Lauretti WJ 1995).

ContraindicationsExtra caution must be shownin cases of moderate or severeosteoporosis and with patientson blood-thinning medicine.These are therefore relativecontraindications.

Absolute contraindicationsare neoplasm (primary and secondary), pathological frac-tures and joint dislocations,infections or acute rheumatoidinflammations of the joints.Likewise some forms of con-genital anomalies involvingthe danger of instability/luxa-tion, aneurysms of the carotidartery and vertebrobasilar arterial insufficiency, signs andsymptoms of progressive nerveroot compression and acutecauda equina syndrome areabsolute contraindications(Guidelines for ChiropracticQuality Assurance and PracticeParameters 1993).

Side-effects

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A model describing low backpain as a pathophysiologicalprocess has been developed inclose collaboration between orthopaedists and chiropractorsat a Canadian university hospi-tal,. The model is based on theunderstanding that back painresults from changes in functi-on. Structural or degenerativechanges occur as a result of afunctional change over a periodof time (Kirkaldy-Willis WH 1983).This model has won wide-spread acceptance in profes-sional environments.

In the pathophysiologicalmodel, the process is normallydivided into three successivephases; dysfunction, instabilityand stabilization.

The dysfunction phaseDuring the dysfunction phase,which represents the first stageof the pathophysiological pro-cess, there are few, if any, de-monstrable structural changes.The phase is characterised bychanges to the movement pat-tern in the spine as occurs witha functional spinal lesion asdescribed earlier.

The majority of all so-calledunspecified back and neckcomplaints are to be foundhere. Experience shows thatsuch dysfunctions are reversi-ble, and the prognosis is goodif this patients receive chiro-practic treatment.

The segmental movement isdetermined by anatomical con-ditions such as the three-di-mensional shape of the verte-

brae, the height of the disc andthe elasticity of the joint capsu-les and ligaments. Changes tothese anatomical structures (de-generative bone changes, redu-ced disc height or scar tissue in the joint capsule or ligament) may alter the mobil-ity. It is well known that a reduction in themobility ofjoints over timeleads to degene-rative changes inthe joint cartila-ge and disc (Videmann T1987).

The interver-tebral disc is thebody’s largest avascular struc-ture and is there-fore particularlydependent on movement forthe supply of nutrients throughdiffusion. Reduced segmentalmobility may thus over timeincrease the risk of developinga prolapsed intervertebral disc(Kirkaldy-Willis WH 1983).Disc lesions may also lead tofacet joint arthrosis, since inbiomechanical terms the facetjoints and the disc function as athree-jointed unit.

The instability phaseThe theory is based on the factthat this breakdown of thejoint structures may lead to in-stability in the affected joints.The degenerative process doesnot necessarily have manysymptoms and may take placein quiet intervals over the

space of many years (Kirkaldy-Willis WH 1983). In some cases, so-called segmental insta-bility may arise. This is descri-bed in a separate section.

The stabilization phaseIn time, the degenerativechanges will usually compensa-

te to a certain extent for the in-stability, and the patient willeventually enter the last phase;the stabilization phase.

This involves more definitedegenerative changes in theform of obvious facet joint ar-throsis, disc degeneration, andspondylosis/osteo-phytosiswhich may lead to constrictionresulting in lateral and/or cen-tral spinal stenosis. During thisphase, the patients often expe-rience that the pain recedeswhile they grow stiffer.

Some of this stiffness andpain may be due to elements ofdysfunction, and clinical expe-rience shows that chiropractictreatment can reduce thesymptoms and muscular stiff-ness. Often, a combination of

intermittent flexion and trac-tion treatment is used on dege-nerative conditions such aslumbar stenosis and pseudos-pondylolisthesis.

Functional spinal lesions thatoften respond to chiropractictreatment can be found duringall the phases of a back disor-

der. The prognosis is best during the dysfunctional phase, during which little or nodegenerative changes take pla-ce, but experience shows thatchiropractic treatment can alsohave a good effect on lesionsduring the instability and stabi-lization phases (Kirkaldy-WillisWH 1983).

During both the instabilityand stabilization phases, chiro-practors may find what theycall coexisting lesions in thesame patient; a sciatica patientwith a disc prolapse might haveco-existing sacroiliac joint dys-function that also gives radiating pain. The response tothe treatment will often revealsuch links and be of diagnosticvalue.

Degenerative changes of the spine

The dysfunctional phase The instability phase The stabilization phase

Photo: Ø

istein H. H

aagensen

18

Disc prolapseA herniated disc demonstratedby diagnostic imaging was pre-viously considered to be an in-dication for disc surgery. However, with the increasing

use of CT and MR scans veryhigh false positive rates havebeen found (Wiesel SW 1984,Boos et al. 1995).

Any surgical treatment mustbe based on both clinical and

radiological findings. In gene-ral, therefore, conservativetreatment should be attemptedas long as there is no progres-sive nerve root dysfunction orintolerable pain (NorwegianBoard of Health 1995, RoyalCollege of General Practitioners1996). Manipulation in sideposture has been a controversi-al issue for some time. Accor-ding to the literature on thesubject, manipulation is nowregarded as a safe, effective wayof treating most of these pati-ents, but there is a need formore research in this area befo-re definite conclusions can bedrawn (Nwuga VCB 1982,Kuo PP, Loh ZC 1987, d’Orn-anon et al. 1990, Cassidy JD etal. 1993, Stern et al. 1995,Hartvigsen et al. 1996).

The annulus fibrosis in thedisc is designed to resist rotati-onal forces. A normal disc hasbeen proven to withstand a 23degree rotation before damage occurs and a degenerated disccan withstand a 14 degree rota-tion (Farfan et al. 1970). Thefacet joints only allow for 2 to3 degrees of rotation, so that itis difficult to imagine that in-jury to the disc or a worseningof existing disc injury will arisethrough manipulation whenthe patient is lying in a lateralposition.

SciaticaTrue compression of the nerveroot will always result in neuro-logical deficits and motor loss.

In brief:

19

Recent research shows thatthe pain of sciatica is mainlydue to the inflammatory re-sponse around the nerve rootfollowing a disc prolapse(Grønblad M 1994). A discprolapse may cause circulatorychanges with local oedemaand ischaemia of the nerveroot. Over time, this may leadto fibrosis of the nerve rootand chronic pain (Cooper etal. 1995). Manipulative the-rapy has been proven to havea good effect on radiatingsymptoms in the case of a discprolapse (Stern et al. 1995),but there is no evidence thatthe size of the prolapse is re-duced by such treatment(Cassidy JD et al. 1993). Itmay well be, therefore, thatmanipulative treatment fornerve root pain has a favour-able effect on the inflammato-ry response and local circulati-on, rather than reducing thesize of the prolapse.

However, repeated MR exa-minations following chiro-practic treatment have alsoshown a reduction/resorptionof prolapses in 63% of the pa-tients. In addition to manipu-lation, traction techniques,soft-tissue techniques andexercises were also used inthese cases (BenEliahu DJ1996).

Structures other than thenerve root may also give riseto sciatic pain. For example,an irritation in both the facetjoints and the sacroiliac jointmay give referred, radiatingpain in the buttocks, thigh,groin or calf. In the same way,myofascial trigger points inthe buttock musculature, forexample, may also give refer-red pain down the legs. Thechiropractor can treat all thesefunctional lesions in sciaticapatients.

Segmental instabilityThis term describes a patholo-gical hypermobility or slippageat a level in the spinal column.Patients with segmental instabi-lity often have a history of re-current attacks/episodes of acute back pain. They often ex-perience that these attacks occur more and more frequent-ly and are of longer duration.Some patients get sudden at-tacks of intense pain when theymake certain movements. Theyoften have an antalgic postureand experience pain, both withand without radiation to theleg. Some develop so-called dynamic, lateral stenosis, inwhich certain movements causecompression of the nerve rootdue to the segmental instability.

X-rays can confirm clinicalsuspicions of segmental instabi-lity. X-rays reveal segmental in-stability by showing degenerative changes to the disc, facetjoints, joint capsules and liga-ments. Postural errors and slip-pages (spondylolisthesis, retro-listhesis or laterolisthesis) canalso be seen. X-rays taken withmaximum movements (func-tion X-rays) can reveal suchsegmental instability in theform of pathological slippageswhen under strain (Dupuis etal. 1985).

In the case of instability, themovement pattern in the spinalcolumn changes due to thestructural changes. This predis-poses it do dysfunctions. It isimportant for the chiropractorto identify any instability in thejoints, since this must be takeninto account in the patient’sfurther treatment. Clinical ex-perience shows that most pati-ents in the instability phase be-nefit greatly from chiropractictreatment methods that do notinvolve an increase in segmen-tal instability.

HypermobilitySo-called hyper-mobile pati-ents can also consult a chiro-practor, since these may havedysfunctions in some jointsthat require specific manipula-tive therapy. Correctly perfor-med manipulative therapydoes not lead to increased hypermobility.

Pelvic pain and pregnancyPregnancy may lead to backand pelvic pain due to factorssuch as an increase in weight,change of posture and hormo-nal influences on the liga-ments. A normal pregnancy isno contraindication to chiro-practic treatment.

In our experience, low backpain, pain in the groin andsciatic pain during/after preg-nancy are often due to functi-

Photo: Ø

istein H. H

aagensen

20

onal lesions in the pelvis or lower back. On the otherhand, patients with strong in-stability of the pelvic girdleand strong pain in the sym-physis benefit less from chiro-practic treatment.

HeadacheHeadache patients are a large,heterogeneous group inclu-ding diagnoses from tensionheadaches to migraine. Theso-called cervicogenic headaches, in which the pain is due

to referred pain from the neck,are of special interest. Around1–5% of the adult populationis estimated to suffer from cer-vicogenic headaches. Accor-ding to a Danish study, this represents 8–32% of the diag-noses for patients who oftenhave a headache (Nilsson N1995).

A controlled clinical studyshowed that chiropractic treat-ment had a significant, positi-ve effect on cervicogenic head-aches (Nilsson N 1997).

Even though some studieshave reported positive treat-ment effects both for migraine(Parker GB et al. 1978) andtension headache (Boline et al.1995), more research is neces-sary before we know whichsub-groups respond best tochiropractic treatment (Vernon HT 1995).

Chiropractic treatment maytherefore be a medication-freetreatment alternative for head-aches, with the advantages thisentails, not least avoiding theside-effects of drugs (Dabbs and Lauretti 1995).

When treating headaches,trigger-point treatment of theneck, jaw and face musculature is also used in addition tomanipulation. Temporoman-dibular joint dysfunction isalso assessed and treated whenrelevant, possibly in cooperation with a dentist.

Whiplash injuriesA report from the QuebecTask Force on Whiplash Associated Disorders, presented in Stockholm inMay 1995, evaluated all theavailable scientific material onthe cause, diagnosis and treat-ment of conditions triggeredby whiplash injuries. The seriousness of the injuries

21

were graded from 1 to 4 (Spitzer et al. 1995):

Grade 0: No subjective com-plaints, no clinical findings.Grade 1: Neck complaintsconsisting of pain, stiffness,tenderness, no clinical fin-dings.Grade 2: Neck complaintsand clinical findings of muscle/skeleton injuries thatreduced movement as well astender points.Grade 3: Neck complaintsand clinical neurological findings, such as reduced tendon reflexes, power andsensitivity findings.Grade 4: Neck complaintsand fractures/dislocation.

The report pointed out thatmany of the therapeutic inter-ventions in normal use forwhiplash injuries lack scienti-fic documentation. This appli-es to heat-treatment, massage,ultrasound and laser treat-ment, for instance.

The report found sufficientevidence to warn against thelong-lasting use of collars andmuscle-relaxant medication.Injection treatment was foundto be documented as ineffective. Furthermore, the reportcaution against other long-lasting treatment that rendersthe patient passive and invol-ves a danger of dependency.

For grade 1 injuries, the report recommends no treat-ment, and that grade 1–3 in-juries should be treated by calming the patient and encouraging a return to normal activities as soon aspossible. The report states thatonly in exceptional cases arethere indications that a patientshould rest his or her neck,and that in these few cases, activating measures should

start within four days. The report recommends someanalgesics (NSAIDs and non-opioid medication) for painrelief. Grade 4 injuries, how-ever, require immediate admis-sion to hospital.

For grade 2 and 3 injuries,the report found sufficient sci-entific evidence to recommendthe use of activity-promotingtreatment, such as manipula-tion, mobilisation and exerci-ses. There was agreement thatmanipulative therapy was favourable both for pain reliefand to improve the neck’s mobility. The treatmentshould be limited in time andcarried out by health person-nel with special expertise. Thereport warns against repeatedmanipulative therapy over along period of time unless amulti-disciplinary assessmentof the patient have been carried out.

Dizziness and disturbedpostural controlIn order for normal co-ordina-tion to take place in the move-ment apparatus, signals fromthe mechanoreceptors in themuscles and joints must be in-tegrated centrally with infor-mation from the vestibularsystem and the eyes. In litera-

ture, this is called the “PosturalControl System”.

A hypothesis has been putforward as to how metabolitesfrom long-lasting muscle ten-sion affect the proprioceptors(Johansson H, Sojka P 1991).

Of the centrally integratedsensory signals, the signalsfrom the neck’s mechanore-ceptors are assumed to be ofgreat significance. Therefore,altered impulse activity from a functional spinal lesion maywell cause symptoms such asdizziness or reduced motorcontrol (Wyke B 1979).

This is supported by a studyshowing that patients withchronic neck and arm painhave reduced postural control(Karlberg et al. 1995).

A Norwegian study showedthat whiplash patients havedisturbed eye-muscle control.The eye-muscle control wor-sened when the examinationwas carried out while the neckwas rotated in relation to thebody. The authors concludethat this is probably due todisturbances in the neck’s me-chanoreceptors (Gimse et al.1996).

For dizziness due to functio-nal spinal lesions in the upperpart of the neck, so-called cer-vicogenic vertigo, chiropractic

treatment may have a positiveeffect, and clinical tests to dif-ferentiate cervicogenic vertigofrom other types of dizzinesshave been described (Fitz-Ritson D 1991).

In some other forms of diz-ziness, such as when vertebro-basilar arterial insufficiency issuspected, manipulation of theneck is contraindicated (Guidelines for ChiropracticQuality Assurance and PracticeParameters 1993).

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First year Anatomy 1 (168 hours)Chemistry (160 hours)Physics (74 hours)Lifestyle related diseases (50 hours)First aid (20 hours)

Theoretical biomechanics (40 hours)

Third year Microbiology (51 hours)Pharmacology (24 hours)Family medicine (30 hours)Biochemistry (13 hours)Radiology (12 hours)

Human genetics (14 hours)Physiology (106 hours)Neurobiology (50 hours)

Pathology (75 hours)Microbiology (40 hours)Pharmacology (30 hours)Epidemiology and statistics (60 hours)Radiology (12 hours)Sports medicine (15 hours)Clinical biomechanics and techniques (135 hours)

Fourth year Epidemiology & statistics (60 hours)Microbiology (53 hours)Pharmacology (84 hours)Psychology (48 hours)Environmental medicine (90 hours)Dermatology (30 hours)Sociology (36 hours)

Case history taking and physical examinations (24 hours)Radiography (36 hours)Radiology (24 hours)Principles of diagnostics (144 hours)*Clinical biomechanics and techniques (120 hours)

2–4 week practical course in a hospital, covering gynaecology, oncology, anaesthesiology, psychia-try, neurology and dermatology.

3 week course in hospital in general medicine and general surgery

3 week course in emergency medicine in a hospital

License as: Physician Chiropractor

Sixth year Clinical practice in a hospital: internal medicine, surgery, paediatrics, general medicine etc.

* The course in principles of diagnostics in the fourth and fifth years of the chiropractic

programme is organised as a case-oriented course following the McMaster model.

Curriculum of University level chiropractor training in Scandinavia

Medical and Clinical Biomechanics curricula at Odense University (1998)

Courses exclusively for medicalstudents

Common courses for medicaland clinical biomechanics students

Courses exclusively for chiropractor students

Second year Histology (40 hours) Anatomy 2 (110 hours)Molecular biology (60 hours)Biochemistry (130 hours)Communication (25 hours)Ethics (30 hours)Physiology (68 hours)

Theoretical biomechanics (40 hours)Clinical biomechanics and techniques (40 hours)

Degree: B.Sc. (Biomechanics)

Fifth year Pathology (120 hours)Psychiatry (60 hours)Forensic medicine (40 hours)Ophthalmology (40 hours)Paediatrics (45 hours)Radiology (12 hours)Ear-nose-throat (40 hours)Gynaecology/obstetrics (60 hours)Cases – problem solving techniques (120 hours)

Principles of diagnostics (144 hours)*Radiology (72 hours)Clinical biomechanics and techniques (72 hours)In a clinic: practice and theory (= 500 hours)

Project thesis

Degree: Cand. Manu.

Degree: Cand. Med.

In Norway: Followed by a oneyearinternship