ChiroACCESS Article

Chiropractic: the Challenge of Avoiding Injury

This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Harrison Ndetan, MSc, MPH, DrPH


Parker College of Chiropractic Research Institute

Published on

February 5, 2008

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The chiropractic profession relies largely upon specialized manual therapy procedures (adjustment/manipulation) as a means of patient care. The methods of delivering chiropractic adjustments are not homogeneous and often require complex motor skills.1 These manipulative procedures involve biomechanical variables such as velocity, amplitude and the line of drive of force. Consideration of these variables is important in order to render them therapeutically safe and functionally effective.2-3 Learning these techniques in private practice or in chiropractic colleges is a process that involves significant repetition. These teaching methods have potentially damaging effects. Doctors or students learning new manipulative procedures are initially at greater risk in the skill acquisition phase, when the neuromuscular system is adapting to the new skills associated with the manipulative procedure.3-8 Epidemiological studies demonstrate that work related musculoskeletal disorders are common among health providers.9-11 Chiropractors also risk injuries of various types related to their work.12-16 Some DC’s are forced to leave practice due to injury sustained in practice. Thus, an emphasis needs to be placed upon safety to ensure practice longevity.

Chiropractic AdjustmentCross-sectional and longitudinal designs have identified a high prevalence of injuries among students of chiropractic.17-20 Practicing “highly-skilled” un-familiarized techniques and /or serving as “guinea pigs” for their novitiate colleagues during training, expose chiropractic students to risk of injury. Recent research of student injury associated with delivering or receiving adjustments has shown, the neck is most prone to injuries from being adjusted and the hand/wrist from giving adjustments in chiropractic college.20 Doctors in the field as well as chiropractic students need to be aware of risk factors associated with training. Pre-injury history or baseline discomfort is high on the list of potential risk factors.

Many of the practice-related injuries among chiropractors/students could be prevented if a proper understanding of the risks and appropriate recommendations for prevention had been considered. The following are recommendations for the prevention of practice-related injuries and the development of safe practice patterns to protect both doctor and patient:

• Chiropractors/students need to both understand and develop the culture of engaging in moderate strength /flexibility exercises, taking adequate rest and applying other cross-training strategies in order to reduce possible tissue damage and recurrent injury (especially during training). A “warming up” process is recommended.7

• The biomechanics and stresses on the joints involved in delivering an adjustment should be emphasized. Special attention should be placed on the wrist and low back as they are the most common sites of injury among chiropractors.

• Strength and range of motion testing of the hand, wrist, shoulder and low back should be made early in chiropractic education in order to identify students with limitations and appropriate stretching & strengthening exercises recommended. This should be accomplished before the student begins delivering regular adjustments.

• Three-dimensional dynamic/kinetic augmented feedback can help students and practitioners improve their palpation and force delivery skills.17 Equipment is now available that measures force, velocity and other factors related to risk of injury and delivery of a chiropractic adjustment. Consideration should, thus, be given to including this equipment in teaching labs so preliminary skills are acquired using simulated patients before the student is free to adjust other students.

• Students that have had a previous history of injury, especially to the wrist, should be encouraged to focus and develop a high level of skill in techniques during training, including consideration of instrument and table assisted techniques that minimize loading to the wrist.

• All technique classes should educate the student to the unique doctor related loading and stresses associated with the technique.

Based upon current research it is clear that there are substantial risk of injury associated with the repetitive nature and musculoskeletal stresses associated with chiropractic practice. As a profession that emphasizes biomechanics, prevention, and care of the musculoskeletal system, DCs should look to themselves to set an example. This focus should begin early in chiropractic education and carry though the years of active practice.
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