Chiropractic procedures may appear dangerous or intimidating, but the reality is far from the rumor. Spinal manipulation to treat low back pain is documented to be safe and effective, especially  in the hands of a properly trained practitioner.

How Safe is Chiropractic Care?
Fewer than one per million patient visits have a serious adverse event (AE) occur during lumbar spine manipulation.¹ In fact, patients seem to be far more at risk when taking a common medication for their low back pain, like nonsteroidal anti-inflammatory drugs (NSAIDs).²

Minor adverse events, like muscle soreness and stiffness do occur shortly after a treatment in some patients.³ However, this is common and typically resolves itself within the next 24 to 48 hours.

Chiropractors pay close attention to a patient's medical history and co-existing conditions because there are times when it is in the patient's best interest to modify the treatment approach.

"Red Flags" in Chiropractic Care
Sometimes, a patient may have a medical condition that actually contraindicates applying high-velocity manipulation to the lumbar spine. Chiropractors refer to these conditions as "red flags," and here are a few examples:

• Severe osteoporosis (metabolic bone fragility disease)
• Multiple myeloma (cancer affecting the body's plasma cells)
• Osteomyelitis (spinal bone infection)
• Bone tumors (benign or cancerous growths)
• Paget's disease (a disease that can cause bone deformities, fractures)

Progressive or sudden neurologic conditions, such as cauda equina syndrome, also can be red flags. Generally, any condition that results in unstable joints is a red flag (including joint infections), so this can include a number of inflammatory conditions, including:

• Rheumatoid arthritis (whether in the active, systemic stage or locally in the presence of inflammation)
• Ankylosing spondylitis
• Psoriatic arthritis (a type of inflammatory arthritis)
• Reactive arthritis (Reiter's syndrome; joint pain caused by infection)

Bleeding disorders and structural instability issues can also be red flags. In fact, a red flag simply could be that a patient has not had an adequate physical examination or that the chiropractor does not have the adequate skills and training necessary to carry out the treatment.

Chiropractic Treatment: Crafting the Best Strategy
Contraindicating medical conditions do not necessarily prohibit soft-tissue, low-velocity, low-amplitude procedures and mobilization. "Red Flags" do not mean chiropractic care is too dangerous; the term just means the treatment approach must be seriously adjusted to protect the patient and best serve his or her needs.

For example, local primary bone tumors are considered a red flag scenario because the tumors may reduce the strength of the affected bone. However, a chiropractor may still determine a treatment approach utilizing other options may help improve the patient's condition without putting him or her in harm's way.

Some chiropractic treatments are contraindicated for specific chiropractic techniques. Spinal fusion (eg, spinal surgery involving fusion and/or instrumentation and fusion) is a red flag condition, in which high-velocity, low-amplitude manipulation is contraindicated at the joint level. This is also true for patients with an artificial disc replacement or other implant (eg, interbody device). However, soft tissue manipulation and other manual techniques may be considered in select patients who have previously undergone spine surgery.

A patient with a pacemaker should not receive electrotherapy treatments. However, the chiropractic may recommend other therapies that do not interfere with the pacemaker's operation.

Many Effective Options to Choose
Chiropractors commonly employ a multimodal approach to caring for their patients. Massage therapy, acupuncture, yoga, Tai Chi, supervised rehabilitation exercises--these are just a handful of treatments that a chiropractor may integrate into a comprehensive, personalized plan of care.

Especially when living with chronic low back pain, biopsychosocial treatments can be very useful, like cognitive behavioral therapy (CBT), risk avoidance counseling, and other effective treatments. There is also ergonomics, home care planning, work planning, and much more.

Chiropractic clinicians often communicate with the patient's primary doctor to work together to insure the patient receives optimal treatment. Treatment of cancer-related pain or postsurgical pain may include communication with the patient's team of health care specialists (eg, primary care physician, oncologist, radiologist).

The goal of care is always to improve symptoms, relieve pain, and improve a patient's physical functioning. Living with low back pain does not have to be a burden bared alone. Chiropractic medicine is generally considered safe, effective, and may help a patient make great strides towards improving his or her quality of life.

This series of articles about chiropractic care for low back pain contains information cited from a recent update in recommended treatment guidelines published by the Council on Chiropractic Guidelines and Practice Parameters (CCGPP). All authors and panelists involved in the publishing of the new updated guidelines stated receiving no compensation from any organization. There were no conflicts of interest reported.