The manipulative therapies: osteopathy and chiropractic

British Medical Journal, Oct 30, 1999 by Andrew Vickers, Catherine Zollman

Osteopathy and chiropractic share a common origin. Their roots can be found in folk traditions of "bone setting," and both were systematised in the late 19th century in the United States: Daniel D Palmer, the founder of chiropractic, is said to have met with Andrew Taylor Still, the founder of osteopathy, before setting up his own school. The therapies remain relatively similar, and many textbooks and journals are relevant to both. The term "manipulative therapy" refers to both osteopathy and chiropractic.

Background

Osteopathy and chiropractic are therapies of the musculoskeletal system: practitioners work with bones, muscles, and connective tissue, using their hands to diagnose and treat abnormalities of structure and function.

The best known technique is the "high velocity thrust," a short, sharp motion usually applied to the spine. This manoeuvre is designed to release structures with a restricted range of movement. High velocity thrusts often produce the sound of joint "cracking," which is associated with manipulative therapy. There are various methods of delivering a high velocity thrust. Chiropractors are more likely to push on vertebrae with their hands, whereas osteopaths tend use the limbs to make levered thrusts. That said, osteopathic and chiropractic techniques are converging, and much of their therapeutic repertoire is shared.

Practitioners also use a range of soft tissue techniques that do not involve high velocity thrusts. For example, the "muscle energy techniques" (known as "proprioceptive neuromuscular facilitation" by physiotherapists) make use of post-isometric relaxation to increase restricted ranges of movement.

Osteopaths and chiropractors may also use what are termed "functional techniques" such as treating hip pain by applying a gentle, prolonged pull to the leg while slowly rotating it in the hip joint. If a restriction is detected, however slight, the leg is held at the point of restriction until a release of muscle tension occurs. Techniques like these are based on an understanding of subtle neuromuscular behaviour, which conforms to mainstream theory. In practice, they also rely on finely developed palpatory skills.

Some osteopaths also practise a technique known as cranial osteopathy or craniosacral therapy. Practitioners place their hands on the cranium and sacrum and gently handle the bones of the skull. They say that, by feeling for and working with subtle rhythmic pulsations of the cerebrospinal fluid, they can correct disturbances in the neuromuscular system. There are some therapists, usually known as craniosacral therapists, who use similar techniques but who do not have an osteopathic background.

A relatively recent branch of chiropractic, the McTimoney school, has developed some of its own manipulative techniques that do not place as great an emphasis on high velocity thrusts as do osteopathy and mainstream chiropractic.

With the exception of cranial osteopathy, many of the treatment methods used by osteopaths and chiropractors are similar to techniques used by those physiotherapists with additional training in manipulative therapy. From a general practitioner's perspective, there are few important practical differences between the three types of practitioner.

What happens during a treatment?

Manipulative therapists take a history, palpate for significant changes in muscle tension and skin circulation, and look for any restricted movements in order to diagnose musculoskeletal abnormalities and "neuromuscular dysfunction" (such as "trigger points" or signs of "pain-spasm cycles"). Chiropractors may use x rays to assist diagnosis, whereas osteopaths do so largely only for the purposes of excluding serious pathology.

A typical treatment session lasts 15-30 minutes, although first consultations may take longer. A variety of the techniques described above will be used. Not more than four high velocity thrusts are usually given in a single treatment session. A course of chiropractic treatment for back pain might consist of six sessions, initially frequent and then at weekly intervals. Osteopaths are more likely than chiropractors to treat on an "as needed" basis.

Therapeutic scope

Both osteopathy and chiropractic were originally regarded as complete systems of medicine. For example, Andrew Taylor Still treated infectious diseases and blindness among a range of conditions. Interestingly, the treatment of back problems features only rarely in his writings. Similarly, early chiropractors believed that most diseases could be attributed to misalignments of the spine and were therefore amenable to treatment with chiropractic.

Contemporary practitioners have moved away from this position and concentrate primarily on musculoskeletal disorders. Low back pain is the most common presenting complaint Guidelines from the Royal College of General Practitioners recommend physical therapy (any of the manipulative techniques) within six weeks of the start of persisting uncomplicated back pain.

Other conditions often seen include neck and shoulder pain, sports injuries, repetitive strain disorders, and headache. Practitioners also treat various conditions such as arthritis; although they cannot affect disease pathology or progression, they claim to be able to treat secondary symptoms such as pain from associated muscle spasm. Cranial osteopathy has a particular reputation for treating children with conditions such as infantile colic, constant crying, and behavioural problems.