
Many older adults utilize chiropractic services throughout the US and Canada. A recent longitudinal study reported 14.6% utilization over a 15 year period (1993-2007) with an annual prevalence rate of between 4.1%-5.4% [11]. The most common reason for older adults to seek chiropractic care is MSK pain, most often LBP [12]. Although chiropractic encompasses many different treatment modalities, the focus of this paper will be specifically on interventions that are commonly utilized by Chiropractors: SMT, physical activity/exercise, nutritional counseling and acupuncture. [13]. Treatment approaches used by chiropractors to treat older adults vary widely. Most chiropractors utilize some form of SMT. More than 90% provide nutritional advice and recommend nutritional supplements such as glucosamine sulphate, chondroitin, MSM, etc. Most also recommend therapeutic exercises and recommend patients to engage in physical activity [13]. There is also a growing trend in the utilization of acupuncture in older adults by chiropractors [14].
From the perspective of the public, chiropractic care is most closely associated with SMT, which is traditionally high-velocity, low-amplitude (HVLA) maneuvers applied manually to spinal and peripheral joints [15]. These maneuvers move the joints from the end of their active and passive ranges of motion into the para-physiological joint space, but not beyond their limit of anatomic integrity to deliver a therapeutic stimulus to the joint complex [15-18]. The theoretical framework from which hypotheses about the neurophysiological effects of spinal manipulation can be developed is based on an experimental body of evidence indicating that SMT impacts primary afferent neurons from para-spinal tissues, the motor control system and pain processing [18]. Improvements in the knowledge of the mechanism of action of SMT suggest that at least three anatomic effects should be sought on the side of the pain (determined by the physical examination) [18]:
- Separation of the facet joint surfaces,
- Stretching of the para-spinal muscles (and psoas muscle at the lumbar level)
- Lowering of the intra-discal pressure
Physical rehabilitation and prescription of therapeutic exercises are vital to improving functional outcomes in the older patient. Exercise can improve gait, balance, coordination, proprioception, reaction time, and muscle strength even in very old and frail elderly people. Increasing and maintaining physical activity is also important in the management of persistent pain in older adults because physical inactivity is common in this population and it can endanger their independence and quality of life, with reduced levels of fitness and function leading to increased levels of disability [29]. The majority of chiropractors report recommendation of physical activity and utilization of therapeutic exercises for their older adult patients [13]. Position statements for osteoarthritis recommend exercise as a key component of disease management [30]. Painful limitation of function and sarcopenia (i.e., loss of muscle) are two common reasons for the utilization of exercises in geriatric population. The loss of muscle strength has been identified as a physiologically limiting factor to living independently among older persons [31]. Recent reviews have shown the positive effects of aerobic exercise and strength training on strength, balance, and physical functioning [32]. These reviews demonstrate a modest beneficial effect of resistive training on strength outcomes and strong evidence for the improving function, particularly gait speed and chair stands. There are a few studies evaluating long term improvements in disability in older patients who undergo resistance training specifically [33]. There are also strong data supporting the role of resistance exercise in improving pain associated with knee OA [34]. A recent study reported lower levels of pain-related disability in community dwelling older adults who were adherent to an adaptive physical activity program [35]. Chronic LBP is a common problem among the older adult population and the most common condition for which they seek chiropractic care. Recent studies have demonstrated the benefits of exercise alone [36], combined with SMT [37] and combined with cognitive-behavioural therapy [38] for management of chronic LBP in older adults. A recent systematic review found that there is moderate evidence on the use of exercise for fall prevention [39] and balance [40] in older adults. Another systematic review found that interventions with balance exercises reduced falls or fall-related fractures and improved balance in the majority of the studies reviewed [41]. Muscle strengthening exercises were also found to be effective in improving lower extremity strength and back extensor strength. Bone strength was improved by weight-bearing aerobic exercise with or without muscle strengthening exercise when the duration of the intervention was at least a year [41].
Studies report that prevention strategies in the form of improvement in diet and health promotion counseling can lead to improved quality of life, significant reductions in disability, and reduction in health care costs [44,45].The main goal for nutritional counseling in older adults should be improvement of food choices, particularly with respect to increasing the intake of fruits and vegetables [44]. Current research indicates that a large percentage of older adults do not receive adequate amounts of micronutrients in their daily diet [46, 47]. Thus if consumption of adequate micronutrients cannot be managed with dietary modification, the use of dietary supplements may be considered. However, due to lack of rigorous clinical trials regarding evaluation of dietary supplements’ effectiveness, it is difficult to make strong recommendations for or against nutritional supplements for meeting the nutritional needs of older adults. Although multivitamin-mineral (MVM) supplements are used commonly by older adults, there is limited evidence of their impact on health outcomes [48]. Vitamin D and calcium supplements appear to have the most beneficial effects [49,50]. They have been found to be a critical adjunct to any pharmacotherapy of osteoporosis [50]. In addition, a recent systematic review on Vitamin D found that it effectively reduces the risk of falls in older adults [51].
Rooted in tradition Chinese medicine, acupuncture refers to any of a variety of interventions that are administered using acupuncture needles to stimulate anatomical points [55]. This includes but is not limited to traditional Chinese acupuncture, percutaneous electrical nerve stimulation (PENS), auricular acupuncture, trigger point deactivation, and deep intramuscular electrical stimulation [10].
- Lumbar PENS and a general conditioning and aerobic exercise (GCAE) program
- Lumbar PENS alone
- Limited lumbar PENS (only 2 of 12 needles were stimulated for 5 minutes as compared with full PENS during which all needles were stimulated for 30 minutes)
- Limited lumbar PENS and GCAE.
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