Semin Oncol Nurs 2005 (Aug); 21 (3): 184–189
Ronald C. Evans, DC, FACO, FICC and Anthony L. Rosner, PhD, LLD (Hon)
Foundation for Chiropractic Education and Research,
OBJECTIVES: To review written resources disclosing reliable facts and knowledge in chiropractic services in cancer pain management.
DATA SOURCES: Conventional and biomedical and complementary and alternative medicine journals, electronic media, full text databases, electronic resources, books in print, and newsletters.
CONCLUSION: The judicial use of chiropractic services in cancer patients appears to offer many economical and effective strategies for reducing the pain and suffering of cancer patients, as well as providing the potential to improve patient health overall.
IMPLICATIONS FOR NURSING PRACTICE: Clinicians should assess and support the use of chiropractic services in cancer patients. Chiropractic is one of the leading alternatives to standard medical treatment in cancer pain management.
From the FULL TEXT Article:
Almost 1.37 million people (710,000 men,
662,870 women) will be diagnosed with cancer in
2005.  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.  The 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.  The 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 in Table 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.
Despite the aforementioned widespread prevalence of cancer in
the United States, the number of cancer survivors is actually
growing such that there are currently 8.9 million individuals in the
United States living with cancer. Mortality rates
for most major cancers are declining such that
today more people survive cancer than ever before.
Among the growing ranks of cancer survivors
are the following groups [1, 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–
(4) the 5–year survival rate for all cancers 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 standard
treatment options alluded to above and given
the multifactoral nature of pain,  the patient may
harbor attitudinal barriers to effective pain management
that could be overcome with novel interventions.
Nearly all patients with cancer-related pain experience
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 alternative
treatments for cancer pain.
Physical treatments for pain most frequently
studied are chiropractic, (largely but not exclusively
dominated by spinal manipulation), physiotherapy,
and acupuncture.  If effective and available,
these nonpharmacologic treatments may be
the first choice for patients and may also be best
suited for those patients who:
(1) have poor responses to medical treatment or medical contraindications 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. 
Based on the strength of research findings, its
accreditation, its safety, and its widespread recognition,
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 remainder
of this article will address this very issue.
DEFINITIONS AND THEORETICAL BASIS OF CHIROPRACTIC
In its 109–year history, chiropractic has
achieved distinction in addressing disorders of
the musculoskeletal system and how these aberrations
may impinge upon the nervous system,
subsequently affecting our general health. This
branch of health care is concerned with the diagnosis,
treatment, and prevention of these disorders
primarily (but not exclusively) through the
application of manual treatments, which include
spinal manipulation. 
The cardinal clinical feature of musculoskeletal
disorders is pain. To no great surprise, both the
rationale and outcomes of chiropractic management
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 chiropractic
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 alleviating
pain can best be demonstrated by a variety of
mechanisms that have been buttressed with evidence
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 suppression
of inflammatory mediators to possibly the
release of analgesic opioids. The net effect of all of
these is to reduce pain generation, [9–13, 18, 19–23] its
sensation, [14–18] or its aggravation caused by anxiety. 
EMPIRICAL BASIS FOR CHIROPRACTIC
In just the past 20 years, at least 73 randomized
clinical trials involving spinal manipulation
have made their appearance in the English literature.
Even more remarkable is the fact that the
majority of these have been published in general
medical and orthopedic journals. These trials address
not only back pain, but also headache and
neck pain, the extremities, and a surprising variety
of nonmusculoskeletal conditions.
manipulation is used, the majority of these
trials have shown positive outcomes with the remainder
yielding equivocal results. There are 43
trials addressing acute, subacute, and chronic low
back pain, with 30 trials showing that manipulation
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 manipulation
is any less effective than any comparison
intervention. [25, 26]
As with any therapeutic intervention, contraindications
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, bilateral
leg weakness, and sensory changes; and (2)
cerebrovascular accidents as a result of cervical
The symptoms of cauda equina syndrome have
been extensively described [27, 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.  Estimates of the
frequency of cauda equina syndrome range from 2
per million  to 1 per 12 million adjustments. 
As established by researchers from both the
medical and chiropractic professions, the risk of
cerebrovascular accidents was traditionally regarded
to be as low as one case per million treatments,
31 ranging 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 manipulations,
with the rates of serious complications and
death from cervical spine manipulation estimated
to be 0.64 and 0.27 per million manipulations,
The most recent and definitive calculation
of the likelihood of a treating chiropractor
being made aware of an arterial dissection
following a cervical manipulation is 1 per 5.85
million (0.17 per million) cervical manipulations.  These rates are 400 times less than the
death rates observed from gastrointestinal bleeding caused by the use of nonsteroidal anti-inflammatory
drugs  and 700 times lower than the
overall mortality rate for spinal surgery. 
RECOGNITION OF THE CHIROPRACTIC PROFESSION
Nearly 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 Middle
East. Interest is increasing in other parts of the
world where access to expensive medical and surgical
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 Chiropractic
Education. The Council for Chiropractic
Education has accrediting agency status with the
US Department of Education (since 1974) and the
Council on Postsecondary Accreditation (since
With over 55,000 licensed practitioners in the
United States, chiropractic has taken its place as
the foremost profession through which spinal manipulations
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 Neurological
Diseases and Stroke concluded that
there was insufficient research to either support
or refute chiropractic intervention for back pain
and other musculoskeletal disorders. 
Nearly 30 years later, back pain management has been assessed
by government agencies in the
United States, 
Great Britain, 
Australia,  and
New Zealand. 
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
Other recent major accomplishments relating
to the chiropractic profession within the United
States have included:
The appearance of a variety of favorable systematic
literature reviews [7, 46, 47];
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 Alternative
Medicine in 1997;
The publication of the Headache Report by
Duke University in 20017;
The securing of over $20 million in federal
grants within the past decade, when in 1991
this accomplishment was considered unlikely ;
The establishment of chiropractic services
within the military; and
The historic signing of Public Law 107–135 on
January 23, 2003, mandating the establishment
of a permanent chiropractic health benefit
within the Department of Veterans Affairs
health care system.
CHIROPRACTIC TREATMENT STRATEGIES
Although a great multiplicity of chiropractic
techniques have been described,  over half
of practicing chiropractors have reported using
just a half-dozen different adjusting methods. 
When combined with soft tissue techniques such
as in the successful management of fibromyalgia 
or with exercise in the treatment of low back  or
neck pain,  spinal 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 manipulation
in managing cancer pain would be enhanced
by being combined with adjuvant therapies
used in acupuncture or physiotherapy.
The increased survivorship seen in cancer patients
in the United States in recent years
indicates that more and more individuals are experiencing
pain, to which cancer treatments are
becoming increasingly devoted. Given the prevalence,
research documentation, relative safety,
uniform licensure and accreditation, cost-effectiveness,
and high patient satisfaction observed in
the chiropractic management of musculoskeletal
pain, the choice of chiropractic care as an alternative
in the treatment of cancer pain becomes a
highly attractive one. Its judicial use would seem
to offer many economical possibilities for reducing
the pain and suffering of cancer patients as
well as providing the potential to improve patient
health overall. [18, 24]
IMPLICATIONS FOR NURSING PRACTICE:
Clinicians should assess and support the use of chiropractic services in cancer patients. Chiropractic is one of the leading alternatives to standard medical treatment in cancer pain management.
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