To review written resources dis-closing reliable facts and know-ledge in chiropractic services in cancer pain management.
D
ATAS
OURCES:
Conventional and biomedical and complementary and alternative medicine journals, electronic me-dia, full text databases, electronic resources, books in print, and newsletters.
C
ONCLUSION:
The judicial use of chiropractic services in cancer patients ap-pears to offer many economical and effective strategies for reduc-ing the pain and sufferreduc-ing of can-cer patients, as well as providing the potential to improve patient health overall.
I
MPLICATIONS FORN
URSINGP
RACTICE:
Clinicians should assess and sup-port the use of chiropractic services in cancer patients. Chiropractic is one of the leading alternatives to standard medical treatment in can-cer pain management.
A
LTERNATIVES IN
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REATMENT
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HE
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PPLICATION OF
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HIROPRACTIC
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ARE
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ONALDC. E
VANS ANDA
NTHONYL. R
OSNERA
LMOST 1.37 million people (710,000 men,662,870 women) will be diagnosed with cancer in 2005.1 In the United States, nearly 46% of men
and 38% of women will be diagnosed with cancer in their lifetime, with 80% of all cancers diagnosed at ages 55 and older.1The direct medical costs of treating cancer
are estimated to be about $60 billion per year.
Statistics show that one out of three cancer patients suffers from pain, either from the primary lesion or secondary to its treatment; if the cancer has advanced or metastasized, the chances of a patient experiencing pain are even higher.2The gamut of pain expression
(dull, aching, sharp, constant, intermittent, mild, moderate, or severe sensations) may be the result of cell infiltration or necrosis of tissue near the primary lesion. In terms of medical treatment, there are other potential sources of pain such those as shown inTable 1.
Partly because of the prospect of side effects and additional pain encountered during therapy, cancer pain is often undertreated. Interrelating factors that might contribute to the undertreatment of pain include: (1) physician knowledge, (2) patient reluctance, (3) fear of addiction, and (4) fear of side effects.
C
ANCERS
URVIVORSD
espite the aforementioned widespread prevalence of cancer in the United States, the number of cancersurvivorsis actually growing such that there are currently 8.9 million individuals in the From the Foundation for ChiropracticEducation and Research, Norwalk, IA.
Ronald C. Evans, DC, FACO, FICC:
Trustee, Foundation for Chiropractic Edu-cation and Research, Norwalk, IA. An-thony L. Rosner, PhD, LLD (Hon):Director of Research and Education, Foundation for Chiropractic Education and Research, Norwalk, IA.
Address correspondence to Ronald C. Evans, DC, FACO, FICC, 1441 29th St, Suite 100, West Des Moines, IA 50266; e-mail: [email protected]
© 2005 Elsevier Inc. All rights reserved. 0749-2081/05/2103-$30.00/0
United States living with cancer. Mortality rates for most major cancers are declining such that today more people survive cancer than ever be-fore. Among the growing ranks of cancer survivors are the following groups1,3,4: (1) 2 million women
are breast cancer survivors; (2) 1 million men are prostate cancer survivors; (3) 5-year survival rates of children with cancer increased from 56% in the early 1970s to 79% for those diagnosed in 1995-2003; and (4) the 5-year survival rate for all can-cers increased from 51% in the early 1970s to nearly 66% from 1995-2000.
As a result of this increased survival in cancer, the focus of treatment has now been able to shift toward the management of pain issues, acute and chronic, both during and after medical therapies. Given the prospect of pain accompanying stan-dard treatment options alluded to above and given the multifactoral nature of pain,5the patient may
harbor attitudinal barriers to effective pain man-agement that could be overcome with novel inter-ventions.
Nearly all patients with cancer-related pain ex-perience have used medications at one time or another to treat their pain, but pharmacologic treatments are neither suitable for all patients nor universally effective. Drug treatments may also produce undesired side effects. Largely for these reasons, significant interest has developed among both patients and health care providers in alter-native treatments for cancer pain.
Physical treatments for pain most frequently studied are chiropractic, (largely but not exclu-sively dominated by spinal manipulation), physio-therapy, and acupuncture.6If effective and
avail-able, these nonpharmacologic treatments may be
the first choice for patients and may also be best suited for those patients who: (1) have poor re-sponses to medical treatment or medical contra-indications for further pharmacologic treatment; (2) wish to become pregnant or are nursing; (3) have a history of long-term, frequent, or excessive use of analgesic or pain-abortive medications that can aggravate other problems; or (4) simply prefer to avoid the use of medications.7
Based on the strength of research findings, its accreditation, its safety, and its widespread recog-nition, chiropractic management of pain such as that experienced in cancer patients would appear to be one of the leading alternatives to standard medical treatment for one to consider seriously. For reasons that will become apparent, the re-mainder of this article will address this very issue.
D
EFINITIONS ANDT
HEORETICALB
ASIS OFC
HIROPRACTICI
n its 109-year history, chiropractic has achieved distinction in addressing disorders of the musculoskeletal system and how these aber-rations may impinge upon the nervous system, subsequently affecting our general health. This branch of health care is concerned with the diag-nosis, treatment, and prevention of these disor-ders primarily (but not exclusively) through the application of manual treatments, which include spinal manipulation.8The cardinal clinical feature of musculoskeletal disorders is pain. To no great surprise, both the rationale and outcomes of chiropractic manage-ment have always revolved around the relief of pain. Indeed, this conjecture is supported in both theory and fact. If such documentation can be found to be convincing, and if the risks of chiro-practic interventions are found to be minimal compared with its benefits, a strong case can be made for considering chiropractic as a treatment option for controlling pain associated with cancer. The theoretical basis of chiropractic in alleviat-ing pain can best be demonstrated by a variety of mechanisms that have been buttressed with evi-dence in the literature (Table 2). It can be seen that the effects of spinal manipulation have been proposed to be multifaceted, ranging from the reduction of nerve root encroachments to the release of trapped meniscoid fluids to the suppres-sion of inflammatory mediators to possibly the release of analgesic opioids. The net effect of all of
TABLE 1.
Common Groups of Oncologic Therapies and Pain Expressions
Medical Treatment Pain Expression Surgery Often painful, recoveries
protracted in compromised patients.
Radiation therapy Associated with post-treatment regional pain sensations of burning. Scars are often painful.
Chemotherapy Associated with potentially painful side effects, including nerve damage.
these is to reduce pain generation,9-13,18,19-23 its
sensation,14-18or its aggravation caused by
anxi-ety.24
E
MPIRICALB
ASIS FORC
HIROPRACTICI
n just the past 20 years, at least 73 randomized clinical trials involving spinal manipulation have made their appearance in the English litera-ture. Even more remarkable is the fact that the majority of these have been published in general medical and orthopedic journals. These trials ad-dress not only back pain, but also headache and neck pain, the extremities, and a surprising vari-ety of nonmusculoskeletal conditions. When spi-nal manipulation is used, the majority of thesetrials have shown positive outcomes with the re-mainder yielding equivocal results. There are 43 trials addressing acute, subacute, and chronic low back pain, with 30 trials showing that manipula-tion is more effective than control or comparison treatments and the remaining 13 reporting no significant differences between treatment groups. None of these studies appears to have produced a negative outcome and none indicate that manip-ulation is anyless effectivethan any comparison intervention.25,26
S
AFETYA
s with any therapeutic intervention, contra-indications exist for chiropractic, however rare. The two primary complications that have been reported are (1) cauda equina syndrome following manipulation in patients with lumbar disc herniation, consisting of neurogenic bowel and bladder disturbances, saddle anesthesia, bilat-eral leg weakness, and sensory changes; and (2) cerebrovascular accidents as a result of cervical manipulations.The symptoms of cauda equina syndrome have been extensively described27,28; a review of the
world’s medical literature indicates that 16 of the 26 reported cases occurred with the far more vigorous manipulation applied under anesthesia. Of the remaining 10 cases, only four have been reported in North America.29 Estimates of the
frequency of cauda equina syndrome range from 2 per million30to 1 per 12 million adjustments.31
As established by researchers from both the medical and chiropractic professions, the risk of cerebrovascular accidents was traditionally re-garded to be as low as one case per million treat-ments,31ranging upwards to 2 to 4 per million.32,33
The more recent data from the RAND Corporation suggests the rate of vertebrobasilar accident or other complications (cord compression, fracture, or hematoma) to be 1.46 per million manipula-tions, with the rates of serious complications and death from cervical spine manipulation estimated to be 0.64 and 0.27 per million manipulations, respectively.34The most recent and definitive
cal-culation of the likelihood of a treating chiroprac-tor being made aware of an arterial dissection following a cervical manipulation is 1 per 5.85 million (0.17 per million) cervical manipula-tions.35 These rates are 400 times less than the
death rates observed from gastrointestinal
bleed-TABLE 2.
Proposed Mechanisms of Spinal Manipulation
Action Mechanism Mechanical/anatomic Alleviation of entrapped facet
joint inclusion of meniscoid that has been shown to be heavily innervated.9,10
Mechanical/anatomic Repositioning of a fragment of posterior annular material from the innervated disc.10,11
Mechanical/anatomic Alleviation of stiffness induced by fibrotic tissue from previous injury or degenerative changes that may include adaptive shortening of fascial tissue.12,13
Neurologic/mechanical Inhibition of excessive reflex activity in the intrinsic spinal musculature or limbs and/or facilitation of inhibited muscle activity.14-17
Neurologic/mechanical Reduction of compressive or irritative insults to neural tissues.18
Biochemical Release of endogenous opioids.19,20
Biochemical Suppression of aldosterone, which promotes
inflammation.21,22
Biochemical Suppression of PGE2a,
believed to cause uterine cramping.23
Psychoneurochemical Reduction of anxiety (which aggravates pain
ing caused by the use of nonsteroidal anti-inflam-matory drugs36 and 700 times lower than the
overall mortality rate for spinal surgery.37
R
ECOGNITION OF THEC
HIROPRACTICP
ROFESSIONN
early 110 years in existence, chiropractic has become the third largest profession of health care delivery in the world. It is recognized and licensed in every state and province in North America, as well as in Australia, New Zealand, and many jurisdictions in Europe, Africa, and the Mid-dle East. Interest is increasing in other parts of the world where access to expensive medical and sur-gical modalities is limited.The increasing acceptance of chiropractic as a legitimate health care profession has occurred in part through the increasing emphasis on research by professional organizations and colleges with funding by outside agencies. It also stems from the accrediting and review of educational curricula at chiropractic colleges around the world, 16 of which are accredited by the Council for Chiro-practic Education. The Council for ChiroChiro-practic Education has accrediting agency status with the US Department of Education (since 1974) and the Council on Postsecondary Accreditation (since 1976).
With over 55,000 licensed practitioners in the United States, chiropractic has taken its place as the foremost profession through which spinal ma-nipulations have been administered—primarily in the treatment of back pain. Despite the fact that chiropractic has existed as a formal profession worldwide for over a century, most of what we consider to be rigorous, systematic research in support of this form of health care has emerged in just the past two and a half decades. In 1975, Murray Goldstein of the National Institute of Neu-rological Diseases and Stroke concluded that there was insufficient research to either support or refute chiropractic intervention for back pain and other musculoskeletal disorders.38Nearly 30
years later, back pain management has been as-sessed by government agencies in the United States,39 Canada,40 Great Britain,41 Sweden,42
Denmark,43Australia,44and New Zealand.45All of
these reports are highly positive with respect to spinal manipulation. It would seem that spinal manipulation, at least for back pain, appears to
have vaulted from last place to first as a treatment option.
Other recent major accomplishments relating to the chiropractic profession within the United States have included:
1. The appearance of a variety of favorable sys-tematic literature reviews7,46,47;
2. The establishment of the first federally funded chiropractic Center for Excellence at Palmer University by the National Institute of Health’s National Center for Complementary and Alter-native Medicine in 1997;
3. The publication of the Headache Report by Duke University in 20017;
4. The securing of over $20 million in federal grants within the past decade, when in 1991 this accomplishment was considered unlikely48;
5. The establishment of chiropractic services within the military; and
6. The historic signing of Public Law 107-135 on January 23, 2003, mandating the establish-ment of a permanent chiropractic health ben-efit within the Department of Veterans Affairs health care system.
C
HIROPRACTICT
REATMENTS
TRATEGIESA
lthough a great multiplicity of chiropractic techniques have been described,49 over halfof practicing chiropractors have reported using just a half-dozen different adjusting methods.50
When combined with soft tissue techniques such as in the successful management of fibromyalgia51
or with exercise in the treatment of low back52or
neck pain,53spinal manipulation has been found
to be particularly effective in reducing pain and increasing functionality. It may very well be that the potentially beneficial effects of spinal manip-ulation in managing cancer pain would be en-hanced by being combined with adjuvant thera-pies used in acupuncture or physiotherapy.
C
ONCLUSIONT
he increased survivorship seen in cancer pa-tients in the United States in recent years indicates that more and more individuals are ex-periencing pain, to which cancer treatments are becoming increasingly devoted. Given the preva-lence, research documentation, relative safety, uniform licensure and accreditation, cost-effec-tiveness, and high patient satisfaction observed inthe chiropractic management of musculoskeletal pain, the choice of chiropractic care as an alter-native in the treatment of cancer pain becomes a highly attractive one. Its judicial use would seem
to offer many economical possibilities for reduc-ing the pain and sufferreduc-ing of cancer patients as well as providing the potential to improve patient health overall.18,24
R
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