Introduction
Pain can be defined as a distasteful sensory or emotional feeling that is linked to possible tissue damage as a result of physical, chemical, mechanical, or thermal stimuli. It is a common symptom that accompanies many illnesses and is responsible for many hospital visits (Drazin et al., 2016). Pain may be classified as chronic or acute depending on the duration of its persistence. Acute pain lasts anywhere between a few days and several weeks and may resolve on its own. It is also referred to as eudynia and is considered protective because it conveys a message that there is an abnormality that needs to be addressed (Audette & Bailey, 2008.) In contrast, chronic pain may subsist for at least three months notwithstanding treatment. The correct assessment and treatment of pain are central to the quality of care offered by healthcare providers because poor management of physical discomfort lowers the quality of life of affected individuals. The nature of activities that athletes engage in predisposes them to injuries and acute or chronic pain.
Opioids are the mainstream pharmacological agents for severe pain management. However, they are associated with numerous adverse upshots, for example, heightened sensitivity to pain, respiratory depression, gastrointestinal disturbances, constipation, dependence, addiction, withdrawal symptoms, and mental health comorbidities (Murphy et al., 2018). Furthermore, athletes are governed by anti-doping regulations to prevent the misuse of performance-enhancing medications, which include commonly used prescription opioids such as morphine and fentanyl (Heuberger & Cohen, 2019; Yousefifard et al., 2019). For these reasons, managing pain in this group is a challenge. Complementary alternative medicine (CAM) offers feasible pain alleviation options without contravening the anti-doping regulations. It includes techniques such as acupuncture, chiropractic therapy, art and music, dietary modifications and supplements, meditation, massage, among many others. Nonetheless, its application is limited by inadequate knowledge about its efficacy and safety levels. Chiropractic therapy, which entails the management of neuromuscular disorders through skilled manipulation of the spine to get rid of misalignments, is a viable alternative for the alleviation of pain in athletes to mitigate the negative effects of opioids analgesics. This literature review reports published findings regarding the use of chiropractic therapy in athletes.
Methodology
Online databases such as PubMed and Google Scholar were searched for articles on the use of chiropractic therapy for pain management in athletes. The key search phrases used were chiropractic, complementary alternative therapy, pain, and athletes. The search was restricted to articles and books published from 2002 to date. The retrieved articles and books were skimmed to determine their relevance to the topic and their potential contribution to the expansion of knowledge on the use of chiropractic therapy in pain management in athletes. A total of 8 articles were selected for this literature review. The following section provides a synthesis of the information obtained from the evaluation of the literature. Details about the authors, year of publication, and conclusion are summarized in Table 1.
Results
History of Chiropractic Therapy
Chiropractic is a therapeutic art that deals with an all-inclusive but mechanical approach to human health and disease course. It looks at the patient as an assimilated entity but focuses on the interconnections between the spinal cord, muscular, neurological, and vascular systems (Zabrecky, 2018). The word chiropractic originated from the Greek terms cheir and praktos whose meaning is healing using hands (Dagenais & Haldeman, 2002). The use of chiropractic dates back to 1895 when David Daniel Palmer discovered that health and disease have a direct relationship with the environment, inherent biological features, and cognitive aspects (Dagenais & Haldeman, 2002; Homola, 2006; Zabrecky, 2018). The most notable achievement was the restoration of hearing following a spinal adjustment in a deaf patient.
Chiropractic was introduced to the United States in the late 19th century. Since then, more than 70,000 doctors have specialized in the field. This figure was 52,000 in 2002 (Dagenais & Haldeman, 2002). Consequently, the World Health Organization has published guidelines on the fundamental principles and safety in chiropractic, which has facilitated the formal education and practice of the therapy. The inclusion of chiropractic services in Medicare and compensation coverage for federal workers in the 1970s was a breakthrough in the field because it implied that more patients could benefit from the treatment. To date, chiropractic remains the only CAM treatment that is covered by Medicare and most insurance policies.
Numerous studies have since been conducted to determine the efficacy of chiropractic on the alleviation of pain involving the neck, back, extremities, and headaches, as well as health issues that are not directly related to the musculoskeletal system, including colic, epilepsy, and hypertension. The US Health Resources and Services Administration has also funded an annual conference for 12 years (between 1995 and 2006) to facilitate the dissemination of research knowledge on chiropractic. These studies provide useful information regarding the history of chiropractic care and its applications, which can direct its use in athletes. Information about Medicare funding is particularly useful for chiropractors in the US given that it is the predominant insurance cover. However, the main weakness of these studies is that they do not provide a historical account of the application of chiropractic therapy to athletes.
Prevalence of CAM Use in the US and the General Population
The prevalence of chiropractic doctors in the US and the success of conferences could be attributed to positive responses and acceptance of chiropractic therapy by the public. Barnes, Bloom, and Nahin (2008) conducted a study to determine the use of CAM therapies among adults and children in the US in 2007. The authors used data from the National Health Interview Survey (NHIS) and conducted a trend analysis by comparing 2002 and 2007 statistics. Approximately 40% of adults had used some form of CAM in 2007. The most common therapies included treatment with natural products (excluding vitamins and minerals) and deep breathing exercises. The prevalence of CAM use in adults was highest in American Indians followed by whites and Asians. Blacks were least likely to use CAM. In contrast, about 11.8% of children used CAM, with the most common methods involving natural products and chiropractic manipulations (Barnes et al., 2008).
The probability of CAM use was fivefold higher in children of parents who used the treatment than those who did not. Factors that promoted the use of CAM included worry about the cost of care. CAM was often used when its cost was considered cheaper than conventional treatment. The trend analysis showed that the utilization of CAM forms such as acupuncture, yoga, deep breathing exercises, naturopathy, and massage increased over the years. In contrast, the use of CAM to treat colds and headaches decreased over time. Pain and cost of treatment were the driving forces behind the use of CAM. The findings of this study indicated that the public has embraced CAM as a form of treatment. The popularity of chiropractic can be attributed to its capacity to provide neuromuscular pain relief at affordable costs.
Chiropractic therapy has gained popularity in other countries outside the US. Dagenais and Haldeman (2002) reported that the therapy was recognized in parts of Africa, Asia, Europe, Oceania, North America, and South America. Estimates show that the use of chiropractic ranges from 3 to 18% of the population. On average, about 10% of the population seeks the services of a chiropractor annually. Cost is an important consideration in the use of CAM treatments (Dagenais & Haldeman, 2002; Barnes et al., 2008). Dagenais and Haldeman (2002) report that chiropractic is widely used to manage pain associated with whiplash, neck problems, and headaches, arthritis, sprains or strains, digestive complications, and chronic pain. Individuals with lower back pain were more likely to visit chiropractors in addition to general practitioners and orthopedics. These studies highlight the widespread acceptance of chiropractic treatment in the US and various parts of the world. Nonetheless, they do not document the prevalence of chiropractic use in athletes, which could be useful to determine its acceptance in this patient group.
Mechanism of Pain
Understanding the mechanism of chiropractic is the first step towards the appropriate utilization of the therapy in pain mitigation. However, in-depth comprehension of the occurrence of pain is a prerequisite. Pain is an event that is associated with the central nervous system (CNS) and does not occur in peripheral tissues. What happens is that the peripheral nervous system (PNS) transduces mechanical signals associated with tissue damage through a mechanical event referred to as nociception (Audette & Bailey, 2008). Neuronal rejoinders in the PNS trigger the activity of the spine and convey the signals to the thalamus and brainstem, resulting in the sensation of pain by the brain. It is worth noting that nociception and pain are distinct, unrelated occurrences because nociception can take place in the peripheral tissues devoid of being interpreted as pain by the CNS. Chronic pain may happen when there is a malfunction of the PNS and CNS. This information elucidates the themes of pain reduction, which is useful when delivering primary care to athletes.
Mode of Action of Chiropractic Therapy
The positive effects of chiropractic are attributed to changing the afferent input that determines how the CNS processes pain. Consequently, the clinical upshots are linked to changes in the innervated lumbar areas. Another interesting observation was that the intensity of chiropractic adjustment thrusts was directly proportional to reductions in pain, meaning that low-intensity manipulations would not generate optimal outcomes. Additionally, chiropractic spinal amendments influence mechanoreceptors and nociceptors at the joints, resulting in a central change in the brain or spinal cord and lessening of pain at various body points (Zabrecky, 2018). Overall, to achieve precise outcomes, a chiropractor needs to manipulate specific areas of the brain. For example, triggering the somatosensory cortex results in changes in the perception of touch, pain, temperature, proprioception, and mechanoreception. Similarly, stimulating the periaqueductal gray modulates the spinothalamic zones that carry nerve fibers responsible for temperature and pain signals. This information, which is backed by peer-reviewed evidence, is crucial to clinicians because it clarifies the mechanism of chiropractic therapy to facilitate informed decisions.
Theories and Methods in Chiropractic Therapy
The vertebral subluxation theory is the main philosophy that guides chiropractic therapy. This model asserts that organic diseases arise from nerve interference attributed to misalignments in the pelvic and vertebral segments (Homola, 2006). Subluxation was assumed to be a complex that encompasses the whole nature of the human body, for example, health, comfort, the therapeutic associations between doctors and their patients, as well as alterations in connective, nerve, vascular, and muscle tissues that go together with the kinesiologic anomalies of spinal connectivity. Simply put, diseases are exacerbated by interruptions in the nervous system, which ultimately affect other parts of the body. Therefore, chiropractors aim at rectifying and precluding vertebral subluxations. The two common methods used during chiropractic treatment are manipulations and mobilization. Manipulations are used to realign the spinal vertebrae to reinstate and sustain health, whereas mobilization helps to move joints passively within their usual range of motion. Homola (2006) provides essential knowledge of the principles of chiropractic therapy. The main shortcoming of this study is that it does not address the specific needs of athletes directly.
Chiropractic Therapy in Pain Management for Athletes
One of the most common sports-related injuries is concussions, comprising about 300,000 head injuries per year in the US. Johnson, Green, Nelson, Moreau, and Nabhan (2013) evaluated the literature to determine the recommended guidelines for the management of concussions in sports. Five articles of relevance to the topic were retrieved but none reported any practice guidelines, position statement, or negative effects of chiropractic treatment of concussions in sports. However, the review highlighted standard procedures that should be done when treating a patient with a concussion. The health history should include how the injury was sustained, general health history, loss of consciousness, and any pronounced signs. Typical tests that should be performed following treatment include a mental status examination, neurological, and orthopedic evaluations. Even though there were no specific articles documenting practice guidelines for chiropractic management of concussion, Johnson et al. (2013) recommended that chiropractors should adhere to the American Academy of Neurology for the treatment of concussions in sports as well as the basic practicing guidelines stipulated by the World Health Organization. This article provides useful guidelines for the use of chiropractic use in any patient population, including athletes.
Chiropractic treatment can hypothetically lengthen each step by modulating restraining joint dysfunctions, thereby enhancing the state of the arthrokinematics chain and optimizing movement. Sandell, Palmgren, and Björndahl (2008) investigated the impact of chiropractic therapy on hip joint extension potential and running speed in athletes with notable joint limitations. A randomized controlled trial involving 17 participants aged between 17 and 20 was done. The treatment group recorded a significant increase in hip extension potential at the end of the study. However, there was no significant change in the running velocity. The outcomes demonstrated that the treatment could enhance performance by improving hip extensibility. The main strength of this study is that it demonstrates the impact of chiropractic care on hip joint extension, which is a common problem experienced by athletes. Its shortcoming was the inability to prove the effect of chiropractic on running speed and other performance measures as well as the application of chiropractic manipulation in pain management.
Chiropractic therapy may cause a few adverse effects that patients and chiropractors should know. Hurwitz, Morgenstern, Vassilaki, and Chiang (2004) investigated the incidence of adverse effects of chiropractic therapy and their impact on patient satisfaction in subjects experiencing neck pain. Perceived satisfaction and improvement of symptoms were recorded in participants who were randomized to chiropractic and standard care groups. The incidence of negative upshots was higher in the treatment (manipulation) group than the control (mobilization) group and was accompanied by low levels of satisfaction with care. The most common side effects included pain or local discomfort just after therapy, queasiness, dizziness, exhaustion, and headaches (Hurwitz et al., 2004). Therefore, chiropractors should minimize iatrogenesis by applying mobilization strategies instead of manipulation of patients with neck pain to enhance satisfaction. The strength of this study is that it highlights the possible adverse effects of chiropractic treatment that clinicians can expect while caring for athletes and what can be done to minimize them.
Education, Legal, and Ethical Considerations in Chiropractic Therapy
Legal and ethical considerations play an important role in any practice. Dagenais and Haldeman (2002) explain the legal and educational requirements for chiropractors. In the first few years following the introduction of chiropractic, early practitioners were arrested and charged with practicing unlicensed medicine. However, following a series of tussles and lawsuits between chiropractors’ associations and the American Medical Association (AMA), proper rules and regulations to govern the training and practice of chiropractic were developed.
To practice as a chiropractor in the US, one must receive accreditation from the Council on Chiropractic Education (CCE). They should also pass several national exams issued by the Federation of Chiropractic Examination Boards. However, there are no differences between the educational requisites for chiropractors and other health professions. An individual should meet at least 90 credits in undergraduate education, a minimum of learning 4200 hours, precise clinical competencies, and practical experience (Dagenais & Haldeman, 2002; Homola, 2006; Johnson et al., 2013). The training emphasizes spinal disorders with minimal reference to pharmacology and no surgical training. Graduates can undergo further training in rehabilitation, radiology, sports medicine, or orthopedics for an additional 3 years. These studies clarify the legal and educational obligations that chiropractors should be aware of before providing care. The shortcoming of these studies is that they do not specify the ethical guidelines for the profession. Therefore, it can be assumed that chiropractors are governed by the same ethical principles that bind all health workers.
Table 1: Application of chiropractic therapy for pain management in athletes.
Conclusion
The review showed that chiropractic therapy is an effective CAM treatment for pain management that has been used successfully in the treatment of lower back and neck pain. A question that remains unanswered is its application in the routine management of sports-related injuries in athletes to avoid the adverse effects associated with opioid therapy. Further research should be done to determine the applicability of this mode of treatment in everyday pain management in athletes. Doing so will eliminate some of the negative effects of analgesics and enhance the well-being of athletes.
References
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