Is Chiropractic Care Safe and Effective for Older Adults?

Cheryl Hawk, DC, PhD, and William J. Lauretti, DC, comment on Best Practices for chiropractic care for older adults.

Peer Reviewed

Chiropractic care represents a safe and effective treatment alternative for older adults, according to evidence-based recommendations published in the May issue of the Journal of Manipulative and Physiological Therapeutics

“The most important take-home point from this updated document is that given the growing need for evidence-based, cost-efficient care in the older adult population, chiropractic care is a very attractive alternative,” explained lead author Cheryl Hawk, DC, PhD, Professor at Texas Chiropractic College in Pasadena, Texas.

“Chiropractic care incorporates many different treatment modalities, as outlined in the document,” Dr. Hawk told SpineUniverse. “One of the key treatments that chiropractors deliver is spinal manipulative therapy (SMT). The evidence base for SMT continues to grow.”
Picture of an older manChiropractic care represents a safe and effective treatment alternative for older adults.Spinal Manipulation Is First-Line Treatment for Low Back Pain
“The most important recent update is the new American College of Physicians clinical practice guideline, in which spinal manipulative therapy (SMT) is included as a first-line treatment for low back pain,”1 Dr. Hawk said. “In addition to SMT, these updated clinical practice guidelines also recommend other treatments commonly delivered by chiropractors, including exercise recommendations.”

The Best Practices paper lists considerations to apply when treating older adults with manual procedures (Table 1). In addition, the recommendations emphasize the need to incorporate the biopsychosocial model of pain in the assessment and management of older adults, including age-related changes in the neurologic and musculoskeletal systems of older adults that may require consideration during physical examination (eg, peripheral neuropathy, muscle loss, and decreased flexibility).
Table 1. Considerations for Treating Older Adults With Manual ProceduresConsiderations for Treating Older Adults With Manual Procedures.“Health professionals caring for older adults must recognize that these patients may have cognitive issues, depression, substance use issues, or other factors that make their care complex,” Dr. Hawk said. “It is essential that providers caring for geriatric patients become fluent in evidence-based screening tools to assure that the entire clinical picture is being considered.”

How to Counsel Elderly Patients on the Safety of Chiropractic Care
The updated recommendations include data from recently published randomized-controlled trials that provide additional support for the safety of SMT in older adults.

“The most valid studies suggest that about half of all patients will experience adverse events after SMT,” Dr. Hawk explained, adding that the events are usually mild (muscle soreness or stiffness) and transient (24-72 hours). “No reliable data exist about the incidence of serious adverse events, but they appear to be extremely rare.”

“Based on our review of the literature on safety, reported in our paper, the bottom line is that the risk for cerebrovascular accidents associated with SMT in the older adult is minimal given that even the small risk that exists is in a younger (<45 years of age) population,” Dr. Hawk said. “It is important for ALL health professionals to be aware of and to screen patients for risk of cervical arterial dissection and inform patients of their risk.”2

“Similarly, ALL health professions should recognize stroke risk factors and counsel patients on prevention strategies, and risks,” Dr. Hawk said. “It is noteworthy, that the risk of stroke after a medical visit is slightly higher than the risk of stroke after a chiropractic visit. In both cases, patients who have bad headaches seek care and all health professionals should be vigilant for signs of stroke and make appropriate referrals. Chiropractic care has been shown to be safe in the general population.”

Chiropractic Care May Be Least Invasive Option for Musculoskeletal Pain
“Both chiropractors and other professionals try to care for older adults using a ‘least invasive to most invasive’ approach,” Dr. Hawk concluded. “Often, complementary and alternative therapies, such as chiropractic (SMT) may be that least invasive option.”

“We all strive to care for all of our older patients as if they were our own grandmothers,” Dr. Hawk added. “Particularly in the management of musculoskeletal pain, chiropractic care may be the most safe, effective, and cost effective conservative management strategy.”

COMMENTARY

William J. Lauretti, DC
Associate Professor of Chiropractic Clinical Sciences
New York Chiropractic College
Seneca Falls, NY
Media Spokesperson
American Chiropractic Association

As practicing chiropractors, we still face much misunderstanding and bias against our care from many medical specialists. The most pervasive myth we face is that chiropractic is risky for certain populations, particularly the elderly. I think this review article covers that topic in detail, and makes a strong case for the safety and effectiveness of this option.

It can be challenging to council elderly patients about the safety of chiropractic care, especially since many patients are misinformed about the topic. As this paper notes, most doctors of chiropractic are well aware of contraindications to care and “red flags” suggesting a patient requires a referral for other specialty care.  It is also important to educate elderly patients that all treatments will be customized to a particular patient’s needs and abilities. Many patients (and medical specialists) associate chiropractic treatments only with high velocity manipulation. While this approach is safe and effective for most patients, chiropractors are able to modify their treatment approach based on a patient’s medical condition or personal preference.

 One important point that is not well discussed in this article is that many of the so-called “conventional” approaches to spinal pain carry significant and often under-appreciated safety concerns, particularly in the older population. For example, non-steroidal anti-inflammatory drugs (NSAIDs) are often a first-line treatment for spinal pain, even though there is little evidence for their effectiveness. These drugs carry significant risks of gastric ulcerations, especially among elderly patients. Recent studies have also demonstrated these drugs have cardiovascular risks, such as increased risk of heart attack and strokes. Skeletal muscle relaxants are also often used to treat spinal pain, but they have risks that are concerning among elderly patients, including behavioral problems and increased risk of falls.  Finally, narcotic pain relievers, despite all their well-recognized risks of addiction and abuse, are commonly prescribed to patients with back pain. One study found 45% of patients with back pain took a narcotic, but found that patients were less likely to take a narcotic after receiving chiropractic services.

Even though the biopsychosocial model of spine pain is a relatively new concept, I think aspects of it have long been a part of chiropractors’ approach.  Our non-pharmaceutical emphasis has always included encouraging the patient to return to normal activity and to take an active role in recovery. Also, the unique relationship many patients have with their chiropractors is often based on relatively frequent visits where the patient receives not only active treatments like manipulation and exercise, but also gets positive encouragement and useful advice.

I hope that this study will encourage your readers to take a fresh look at chiropractic care for their older patients, and perhaps inspire them to seek out an evidence-based doctor of chiropractic to help them safely and effectively co-manage elderly patients with spine pain.

Updated on: 03/20/18
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Mobilization, Manipulation, and Clinical Massage Are Effective Treatments for Neck Pain
William J Lauretti, DC, FICC, FACC
Associate Professor
New York Chiropractic College
Seneca Falls, NY
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