This article is reprinted with the permission of National College of Chiropractic and JMPT. Our special thanks to the Editor, Dr. Dana Lawrence, D.C. for permission to reproduce this article exclusively at Chiro.Org
J Manipulative Physiol Ther. 2001 (Jan); 24 (1): 52–57
Jeffrey Schneider, DC, and Scott Gilford, DC
Naval Hospital Camp Pendleton,
Camp Pendleton, CA, USA.
OBJECTIVE: The purpose of this article is to present and discuss the idea that chiropractors can be key contributors to the pain management of oncology patients.
DISCUSSION: Although it is an oncologist who institutes the necessary treatment for a cancer patient's primary disease process, a chiropractor can help provide noninvasive and non-pharmacologic options for decreasing pain and improving function. As part of a cancer rehabilitation team, the chiropractor can provide treatment that may significantly enhance a cancer patient's quality of life at any stage in the disease process. Treatment may benefit those patients experiencing pain from the side effects of treatment or from the disease process itself. The chiropractor's treatment may include manipulation, soft tissue techniques, physiotherapeutic modalities, exercise, and ergonomic counseling.
CONCLUSION: This article describes the potential benefits of chiropractic for cancer patients in the area of pain management and quality of life. Two specific case studies are presented in which cancer patients' quality of life benefited from chiropractic treatment.
Keywords Chiropractic, Oncology, Cancer, Pain, Management, Manipulation
From the FULL TEXT Article:
The treatment of patients with cancer has historically, and
justifiably, been focused primarily on the disease entity.
However, there is recent recognition of the importance of the
supplemental needs and concerns of patients with cancer,
along with consideration of alternative courses of action to
improve such patients’ quality of life. Although reliance on
medications is a common protocol for the management of a
patient’s pain complex, chiropractic treatment may offer an
alternative for the open-minded physician. It is estimated that
at least half of patients with cancer do not receive adequate
relief from their pain.  In response to this problem, the cancer
rehabilitation team concept has been introduced into the
literature to help health care providers consider the multidimensional
problems faced by the patient with cancer.  This
team is assembled to address issues regarding physical, emotional,
and/or social disabilities that may result from the disease
entity itself or from the corresponding treatment.
Among these issues is pain management. To address “physical”
rehabilitation of the patient, the team may include a
physiatrist, physical therapist, and/or occupational therapist.
The team may also include appropriate professionals to
address social, employment, and psychologic issues.
In many instances, a chiropractor can offer services
unique to a rehabilitation team. Chiropractic treatment has
consistently been rated favorably in the area of patient satisfaction,
and chiropractic manipulation has been well documented
in the literature to provide relief for mechanical low
back pain. [3, 4] The cancer rehabilitation team is faced with
addressing, among other things, complications of prolonged
bed rest, chronic pain related to radiation fibrosis, chemotherapy-
related neuropathies, and gait or functional abnormalities
associated with the disease or associated treatment
regimen. The chiropractor can assist in the treatment of
these entities, thereby potentially decreasing the patient’s
reliance on pain medication.
The purpose of this article is to demonstrate the practicality
of including a chiropractor on the rehabilitation team for
pain management of the patient with cancer.
The Chiropractic Profession
The barriers of the stereotypical health care system are
beginning to fall. The inclusion of nontraditional providers
has become more commonplace in every aspect of health
care today. From the perspective of the chiropractic profession,
opportunities have presented themselves in new and
exciting areas of health care delivery. Multidisciplinary
practices incorporating medical doctors, osteopaths, chiropractors,
physical therapists, podiatrists, and other medical
professionals are becoming commonplace. As of 1998, at
least 215 US hospitals had some type of relationship for providing
chiropractic services.  In 1995, the US Department of
Defense established the Chiropractic Health Care Demonstration
Program, placing chiropractors in military hospitals/
clinics to provide chiropractic treatment for active-duty
personnel, retirees, and family members; there are now 26
chiropractors serving 13 military treatment facilities, including
the Naval Medical Center, Bethesda, and Walter Reed
The increasing use of chiropractors has come as members
of the general population seek new ideas, methods, and techniques
with regard to their health care. A 1998 study in The
Western Journal of Medicine revealed that nearly 70% of
young and middle-aged adults and half of senior adult members
of health maintenance organizations were interested in
having alternative therapies incorporated into their health
care.  Emphasis in health care is shifting to a more “holistic”
concept. Holism has been described as “the balanced integration
of the individual in all aspects and levels of being:
mind, body, and spirit, including interpersonal relationships
and our relationships to the whole of nature and our physical
environment.”  This shift toward a broader view of health
management is consistent with the previously mentioned
cancer rehabilitation team concept.
Since its inception, chiropractic philosophy has emphasized
the needs of the “whole person.” The following case
reports illustrate the useful application of chiropractic in
concert with standard medical approaches.
In one case, a 57-year-old man with back pain came in for
chiropractic evaluation. His symptoms had been present for
more than 4 months and were described as pain in the area
of the lower rib cage and sharp stabbing pain in the right
upper back. The patient was also complaining of diffuse gastrointestinal
symptoms. He related that his symptoms were
gradually worsening and that he had begun to experience
weight loss, which he attributed to a lack of appetite.
An initial evaluation by the chiropractor revealed pain in
all ranges of motion. There was palpable spasm of the thoracic
and lumbar musculature. Results of testing for disk
involvement or nerve root impingement were negative.
Tenderness was noted in the upper quadrants of the
abdomen. Thoracic and lumbar radiographs were performed;
these showed no abnormalities. Routine laboratory
tests revealed a decreased iron level.
Because of the suspicious history and nature of the back
and gastrointestinal symptoms, the patient was referred to an
internist. In the meantime, he was started on treatment that
included manipulation, therapy modalities, and soft tissue
techniques. He obtained temporary relief (for 24-72 hours)
from the chiropractic treatment; however, he related that the
overall intensity of his symptoms was increasing. The patient
received 6 chiropractic visits over a period of 18 days without
lasting relief. Shortly thereafter, the internist made a
diagnosis of pancreatic cancer and assumed control of the
patient’s medical care. Because the chiropractic treatment
was not providing more effective pain relief at that time, further
treatment was deferred.
Approximately 8 months later, the patient’s hospice nurse
called. She stated that he was experiencing low back pain
with severe radiating pain down his left leg and that his
physician had cleared him to receive chiropractic care. At
that time, the patient was house-bound and sat (slouched) in
a “lounger” most of the day with his legs extended. He had
lost considerable weight and was unable to obtain relief
from his back and leg pain by using morphine.
The chiropractor initiated a house-call treatment plan
involving the use of varying degrees of spinal manipulation,
mobilization, and soft tissue manipulation/massage. In addition,
the patient was provided with a lumbar support cushion
for his back and given instructions regarding his sitting posture.
Other postural/ergonomic suggestions relating to his
limited activities were provided.
Significant relief was obtained from the first 2 treatments.
The patient’s sciatica symptoms were minimal to nonexistent
for the next 6 weeks, and he was able to reduce his medication
intake to some degree. After 6 weeks, 2 more treatments
were provided, the patient noting some benefit.
Unfortunately, the patient succumbed to his disease a short
In this example, the chiropractic treatment offered greater
pain relief with regard to the sciatica and back pain than did
the use of morphine. Neuropathic pain can be less responsive
to opioid drugs than pain from ongoing injury to somatic
tissues such as bone, joint, and muscle.  This might
account for the limited effectiveness of the morphine for this
patient’s sciatic symptoms.
In this case, chiropractic care was able to provide significant
pain relief, reduce the amount of pain medication being
taken (as well as the potential side effects), and temporarily
improve the quality of life for a patient with terminal cancer.
Within the multidisciplinary team, one of the main objectives
of the chiropractor would be to address quality-of-life
issues by focusing on pain management. Sources indicate
that 30% to 40% of patients with cancer experience pain and
that this figure increases to 65% to 85% for patients with
advanced cancer.  “Pain is one of the most feared aspects of
cancer and is a major cause of anxiety, depression, sense of
helplessness, loss of esteem, and anger,” writes Levy,  adding
that “unrelieved pain can add to anorexia, insomnia, immobility,
and weakness and may prevent patients from making
recommended changes in position, leading to painful decubitus
ulcers.” By helping to reduce the patient’s pain, the chiropractor
can help the patient reduce his or her medication
intake (thereby avoiding unwanted side effects) and can be a
contributing factor in the patient’s mental well-being.
In another case, a 54-year-old man received surgical
intervention to remove a primary tumor from his right lung.
Radiation therapy was subsequently provided. The patient
noted pain in the thoracic spine immediately after surgery,
and this pain persisted. He was evaluated by his
medical physician on a periodic basis and given medication
for the back pain.
Approximately 1 year after the surgery, the patient visited
a chiropractor seeking relief from constant pain in his mid
and upper back. Pain medication was not completely effective
in relieving his symptoms. At the time of initial chiropractic
evaluation, he reported that his MD had informed
him that the cancer was in remission. As a result of his back
pain, he was unable to perform deep inspiration without
increased pain and was unable to find a comfortable position
in which to sleep. He reported the focus of this pain in the
T4-8 region, along the rib cage, just lateral to the spine.
The initial history and examination by the chiropractor
revealed palpable tenderness in the area of the costovertebral
joints of the midthoracic spine. There was paravertebral
muscle tension into the right thoracic and shoulder girdle
muscles. Range of motion was slightly limited bilaterally
into side bending, with pain on these motions. Radiography
revealed no significant bony abnormality.
It was felt that a possible mechanism for this individual’s
pain was trauma to the supportive tissues (joint capsules, ligaments,
muscles) of the rib cage and costovertebral joints.
Compromise to the rib cage during surgery was considered a
reasonable mechanism for the initiation of these symptoms.
A less likely contributing factor could be pain arising from
periarticular tissue fibrosis after radiation treatment.
The patient began a chiropractic treatment program that
included high-velocity/low-impact spinal manipulation,
electric muscle stimulation, and application of hot packs to
the thoracic region of the mid to upper vertebral and costovertebral
joints. The manipulation was intended to
improve functional integrity of the vertebral joints. The electric
muscle stimulation and hot packs were used to promote
muscle relaxation in preparation for the manipulation.
Immediate benefit was reported with regard to improved
mobility, decreased pain, and restoration of painless inspiration.
By the second visit the patient was able to discontinue
the use of his medications. At this treatment session, the
patient was given a home exercise program consisting of
stretches and active resistive exercises to strengthen the
involved area. Treatment continued at a frequency of twice
per week for 3 weeks, then once per week for an additional 2
weeks. Additional exercises were added to the patient’s
home program. By the conclusion of the treatment regimen
he was no longer experiencing back pain. He returned a few
weeks later for mild recurrence of the pain, which again
responded favorably. Several months later he returned again
and reported that he had been doing well until recently. His
response after that visit was also favorable.
The second case illustrates an incident of musculoskeletal
pain arising from joint dysfunction that responded favorably
to chiropractic care. In fact, the most common presenting
complaint in chiropractic offices is that of musculoskeletal
pain, as in the second example. Surveys show that 75% of
patient visits to chiropractors are for back- and neck-related
complaints.  This is consistent with the fact that back pain
is a frequent area of complaint among patients with cancer.
There are other factors that can ultimately lead to the
patient’s developing a musculoskeletal complaint. A possible
side effect of certain chemical agents during chemotherapy
is that of axonal neuropathy, potentially causing muscle
weakness leading to pronounced gait abnormalities. 
Sources indicate that approximately 80% of studied patients
with colon, lung, and prostate cancer have related problems
with ambulation. Forty percent to 70% described those
ambulation problems as severe.  The patient requiring a
lower extremity prosthesis undoubtedly has compensatory
pelvic or spinal pain as he or she adapts to beginning ambulation.
Compensatory problems are commonly seen in the
chiropractor’s office in relation to sports injuries and postsurgical
interventions in the knee and foot. It is therefore
natural that chiropractic be considered a treatment option
for the patient with cancer who has pelvic dysfunction or
mechanical pain resulting in a functional gait abnormality.
Chiropractic techniques may also be of benefit in
instances in which joint contracture or adhesions occur. The
effects of radiation therapy on normal tissue can result in
tissue fibrosis.  Fibrosis of this nature potentially leads to a
loss of mobility and/or painful movement. A multidisciplinary
approach offering chiropractic provides an additional
venue for assisting patients with the management of their
joint and muscle pain before it reaches a disabling level. By
offering manipulation, exercise instruction, physiotherapeutic
modalities, and ergonomic counseling, the chiropractic
team member can facilitate the improvement of strength
and mobility in those patients suffering from the side effects
of unrelieved pain.
These clinical examples offer 2 specific instances of how
chiropractic treatment helped improve the quality of a cancer
patient’s life. In conversations that we have had with
several other chiropractors, similar case histories have been
related. In most cases, the chiropractors emphasized, their
patients generally “felt better” after receiving treatment and
were much more “relaxed” in dealing with the overwhelming
stress brought on by their disease and the associated
Of course, there are different criteria that would prompt
referral for chiropractic treatment. Pain of an unrelenting
nature that is not affected by changes in posture or position
is less responsive to chiropractic care. When activity and
changes in position/posture affect the patient’s pain, chiropractic
care might be able to provide significant benefit.
These presentations may exist separately or in unison.
The astute clinician recognizes that every symptom experienced
by a patient with cancer need not be a direct function
of the disease. To assume otherwise can lead to unnecessary
narrowing of the range of treatment options. Further evaluation
could reveal a patient with cancer who coincidentally
also has back pain of a mechanical origin. Because any
unrelieved pain can cause suffering and unnecessary disability,
ancillary options may warrant consideration.
It is necessary to mention that there is a very small percentage
of chiropractors whose practice philosophy falls
outside the mainstream of chiropractic teachings. Such practitioners
might attempt to undertake treatment of the primary
disease process itself. It should be emphasized that this article
does not endorse or condone the behavior of any chiropractor
whose philosophy is to undertake primary treatment
of any patient with cancer. The standard of care within the
chiropractic community is to refer patients with cancer for
treatment (of their primary disease process) to the appropriate
medical specialty. With regard to the patient with cancer,
the chiropractor serves as a supplemental provider, pain
management and enhanced quality of life being the goals of
treatment. To ensure that a cooperative effort among the
providers occurs, it would be wise for a referring oncologist
to take the time to establish a relationship with the chiropractor
with whom he or she is considering working.
If a patient with cancer has been referred to a chiropractor
from an oncologist, it is relatively certain that the patient has
undergone extensive diagnostic examinations, including
radiographs, magnetic resonance imaging, computed tomography,
bone scanning, and laboratory testing. If these studies
are relatively recent, they may be sufficient to determine that
the patient can safely undergo a treatment program that
includes manipulation and/or other manual procedures. As
noted, most patients with cancer are not referred from their
oncologists but rather self-refer to the chiropractic office. In
either instance, it is ultimately the responsibility of the chiropractor
to determine that the patient is a candidate for chiropractic
treatment and that manipulation or other manual
procedures can be performed safely without undue danger or
risk to the patient. This may necessitate that before beginning
a treatment protocol the chiropractor request medical
records from the oncologist and/or obtain the results of any
new diagnostic studies that may be indicated.
Chiropractic Treatment Methods
Regarding the application of methods, the treatment plan
should be individualized to the patient’s needs. Some individuals
will be nonambulatory; others will ambulate with or
without difficulty. Some patients may be experiencing
intense pain from the disease entity itself, whereas others
may be experiencing symptoms in relation to the treatment
regimen or to other lifestyle changes that are accompanying
the disease process. Each patient must be evaluated thoroughly
to determine which chiropractic methods will provide
the greatest benefit in the particular case. In some
instances, treatment may call for nonforce techniques; other
situations could be better addressed through use of more
standard manipulative procedures.
Spinal manipulation is the most widely used treatment
procedure within a chiropractic practice. The variety of techniques
by which such “adjustment” is accomplished varies
from practitioner to practitioner. A study by Leach  in 1986
identified more than 35 different chiropractic techniques,
which illustrates the variability within the profession. The
technique and amount of force used vary according to the
personal preference of the provider and his or her clinical
judgement. Despite the numerous techniques available, most
chiropractors use high-velocity manipulation (“adjustment”)
as part of their treatment. Although the use of high-velocity
manipulation is considered to be an absolute contraindication
in a patient with malignancy because of the possibility
of compromised bone strength,  there may be circumstances
in which it is appropriate. Depending on the patient’s
individual case history, the disease process may be such that
bone strength is not compromised and high-velocity manipulation
can provide significant benefit. In instances in which
extreme joint contracture occurs, consideration may be
given to manipulation with the patient under anesthesia.
Some chiropractors are certified through postgraduate programs
to perform manipulation on patients under anesthesia.
There are methods that chiropractors can use in addition
to manual manipulation. Although most chiropractors perform
manipulation manually, some use adjusting instruments
to deliver less forceful manipulations, and others
apply various indirect techniques to affect the dysfunction of
the vertebra (subluxation). Although the use of adjusting
instruments might not appear to be as effective as manual
manipulation, these techniques are widely and successfully
used with patients who cannot tolerate or do not respond to
more forceful methods.
In addition, less aggressive, nonforce chiropractic techniques
may be used by the experienced chiropractor to
accomplish treatment goals. Soft tissue manipulation, massage,
stretching, and myofascial release are examples of various
techniques used in some chiropractic settings.
Chiropractors often recommend regular exercise routines
within their treatment plans. Encouraging the patient to walk
and perform stretching exercises is common practice. These
activities need to be tailored according to the special needs
and limitations of the patient. Most often, these exercises are
very simple (“low-tech”), requiring minimal use of specialized
equipment. Because inactivity quickly results in muscular
deconditioning and because there is a potential for joint
restriction through contracture or shortening of the periarticular
tissue, it is appropriate to encourage gentle exercises for
maintaining flexibility and muscle tone.
The application of various physiotherapeutic modalities
for the purpose of pain modulation is practiced by many chiropractors,
depending on the licensing regulations of the
state in which each practice operates. The use of cold, heat,
ultrasound, diathermy, electric muscle stimulation, and
transcutaneous electric nerve stimulation have been shown
to be effective in the management of pain for patients with
cancer.  However, because of the ability of some of these
modalities to “stimulate” tissue, extreme caution should be
used with regard to areas of malignancy. In addition, each of
these modalities can have more specific contraindications
with regard to its use.
The chiropractor’s knowledge of ergonomics and activities
of daily living (ADL) can also be extremely beneficial in
the rehabilitation of a patient with cancer in his or her quest
to advance toward as normal a life as possible. The term
ergonomics typically refers to the study of activities in a
work environment, including the implementation of modifications
within that environment to reduce potential injury.
Some of the same principles can apply to a person who is sitting
at home, lying in a hospital bed, or working at a personal
computer. Addressing these biomechanical issues can
alleviate pain that is attributable to any of a number of aggravating
factors. When these issues present in a home environment,
they are often referred to as pertaining to ADL.
Nutritional counseling and supplementation play a large
role in many chiropractic practices. Although numerous volumes
have been written regarding dietary practices and supplementation
to help prevent cancer, there is much less available
literature regarding nutritional supplementation that
may be useful in the pain management, specific to oncology
patients. Many chiropractors recommend herbal remedies or
nutritional supplements that may ease muscular tension,
help patients to relax, or reduce pain symptoms. It behooves
the chiropractor, as part of the cancer rehabilitation team, to
make use of all available resources; this includes working in
concert with a nutritionist or dietician. To avoid adverse
drug/herb interactions, the chiropractor should communicate
with the patient’s oncologist and pharmacist regarding any
other medications that the patient is taking and any known
With regard to a potential role for the chiropractor within
the multidisciplinary team, the emphasis is on working with
the patient’s pain complex and not with the primary disease
process. Therefore, recommending dietary/herbal supplementation
to the oncology patient for the treatment of a primary
disease process without consulting and arriving at a
consensus with the other team members would be inappropriate
and would undermine the benefits of the team approach.
Because of the inherent increased risk associated with
treating patients with cancer, it is incumbent on both the chiropractor
and the physician to provide sufficient information
to enable the patient to give “informed consent.” As in all
cases of musculoskeletal pain, the patient with cancer should
be informed that the treatment protocol might make him or
her sore and, in occasional instances, could actually worsen
the condition. The inherent risk in patients with cancer primarily
involves pathologic fracture and any resulting neurologic
complications. A thorough examination, proper diagnostic
testing, and a carefully constructed and applied treatment
program will greatly decrease the risk of adverse consequences.
A new era in the treatment of patients with cancer has
begun. Helping such patients now includes not only traditional
treatment of the disease process itself but also incorporation
of the contributions of other providers to assist the
patient in living a richer, fuller life. This approach attempts
to view the patient as a “whole person” with needs reaching
beyond the management of the disease entity. The chiropractic
profession has, ever since its inception, embraced
this “holistic” approach toward patient care. Having chiropractic
available to the rehabilitation team adds new opportunities
in the treatment of the cancer patient. Within this
team, the chiropractor’s primary role is to serve as an ancillary
provider by assisting the patient with pain management
and increasing mobility. Especially for the ambulatory
patient, the chiropractic provider widens the scope of treatment
options to include high-velocity and/or low-force
manipulation, soft tissue techniques, physical modalities,
exercise instruction, and recommendations pertaining to ergonomics
The literature most strongly supports the use of chiropractic
treatment for patients with low back pain, which is a
common entity among patients with cancer. Clinically,
many musculoskeletal complaints respond favorably to chiropractic
treatment. Symptoms related to radiation fibrosis,
chemotherapy-induced neuropathy, or postsurgical trauma
to connective tissues and joints may respond favorably to
The clinical examples provided in this article are realworld
cases in which the practical application of chiropractic
treatment benefited patients with cancer. However, as in
the examples, it is usually the patient who takes the initiative
to seek assistance from a chiropractor. The addition of a chiropractor
to the rehabilitation team can improve the physical
and emotional well-being of a patient with cancer, which
will positively impact the quality of his or her life, and it can
provide the team with additional avenues by which to bring
comfort to the patient.
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