The Role of Chiropractic Care in Older Adults
Written by Editor   
Wednesday, August 16, 2017 06:17 PM

There are a rising number of older adults; in the US alone nearly 20% of the population will be 65 or older by 2030. Chiropractic is one of the most frequently utilized types of complementary and alternative care by older adults. Used by an estimated 5% of older adults in the U.S. annually, the most common reason for an older adult to see a DC is musculoskeletal pain, most often lower back pain.  

Although this is the most common reason for older adults seeking chiropractic care DCs may also provide a diverse range of services to these patients. Chiropractic care involves many different types of interventions, including preventive strategies. It is imperative that providers be familiar with the evidence for and the prudent use of different management strategies for older adults.

The authors of the study reported here have chosen to focus on five specific interventions that are commonly utilized by DCs: spinal manipulative therapy (SMT), acupuncture, physical activity/exercise, nutritional counseling and fall prevention. Most DCs utilize some form of SMT. More than 90% provide nutritional advice and recommend nutritional supplements. Most also recommend therapeutic exercises and advise patients to engage in physical activity. There is also a growing trend in the utilization of acupuncture in older adults.

These have been chosen because they are commonly utilized treatments and they align with certain goals of Healthy People 2020: 1) to reduce the proportion of older adults with functional limitations and 2) to increase the proportion of older adults with reduced physical or cognitive function engaging in physical activities; 3) to reduce the number of falls among older adults.  

Spinal pain is a significant musculoskeletal problem among older patients. A recent report states the prevalence of disabling and non-disabling back pain in community-dwelling adults is 6% and 23%, respectively. There are data that suggest that SMT may play an important role in the management of patients with spinal and peripheral joint pain and associated dysfunction. It is important to recognize that SMT used by DCs in practice may incorporate multiple techniques. These techniques may include varying levels of biomechanical force, instrument-assisted manipulation, use of specialized tables, use of padded wedges and many low-force techniques.

There are a number of case reports and case series that describe the successful management of older patients with spinal or peripheral joint pain using manipulation, padded wedges and other low force techniques. The 2010 UK Report of Manual therapies reported that "SMT is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain."

Current research indicates that a large percentage of older adults do not receive adequate amounts of micronutrients in their daily diet. 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. The main goal for nutritional counseling should be to improve food choices, particularly with respect to increasing the intake of fruits and vegetables. If consumption of adequate energy and micronutrients cannot be managed with dietary modification the use of dietary supplements may be considered. 

A recent survey on dietary supplement use in the U.S. found that about one-half of the U.S. population and 70% of adults ≥ 71 years of age use dietary supplements; one-third use multivitamin-multimineral dietary supplements. Overall, 68% of older adults using prescription medications are concurrently using over-the-counter medications, dietary supplements, or both. It is imperative for both the consumer and the DC to understand the benefits and risks for utilization of dietary supplements, identify potential interactions with other medications, and avoid large combinations to decreased overconsumption. 

Physical activity and exercise are often recommended by DCs to their older adult patients. A recent population survey demonstrated that exercise recommendation was underutilized by providers of multiple disciplines. The loss of muscle strength has been identified as a physiologically limiting factor to living independently among older persons. Recent reviews have shown the positive effects of aerobic exercise and strength training on strength, balance, and physical functioning. 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.  

Given the evidence for the use of exercise recommendation, it is important that the clinician be aware of any risks associated with exercise therapy in older adults. A recent review article found that among 121 trials identified, 53 trials provided no comments about adverse events, 25 trials reported no adverse events occurred, and 43 trials reported some types of adverse events. Most adverse events reported were musculoskeletal problems such as muscle strain or joint pain. Adverse events were reported more often in trials that recruited participants with certain health conditions, functional limitations, or sedentary lifestyle. The most important considerations in providing an exercise program for older adults is to assess their general health status and to assure that the program is tailored to their needs, whether it is strength, endurance, balance or improved motion. The older adult should be educated in warning signs such as chest pain or shortness of breath.  

The most important principle in developing an exercise program for the older adult is to work with him/her in order to agree on a program to which they will adhere to. Patient centered exercise prescription involves shared goals between the patient and the provider. Patients should be encouraged to participate in activities they enjoy; in fact one study found that leisure time activity was more effective than structured exercise in patients with lower back pain.  

Falls can result in decreased quality of life, disability, and/or death in older adults. Approximately one-third of those aged 65 and older fall each year, and falls are the leading cause of unintentional injuries and unintentional injury deaths in this population. Fall prevention in older adults is a national priority, and is the subject of two Healthy People 2020 objectives. A consensus statement on "best practices" for chiropractic care for older adults specifically recommends that DCs collect falls history information, and states that they provide treatment and exercises for musculoskeletal conditions, which can be extrapolated to be appropriate for reducing fall risk. Pain-related musculoskeletal disability may influence balance, gait and the ability to accomplish daily activities, and therefore may contribute to fall risk. There is considerable evidence for positive effects of SMT for spine-related pain. Because chronic musculoskeletal pain, such as that of osteoarthritis, is one factor affecting gait and balance in older people, chiropractic care may have an impact on fall prevention by treating joint pain and stiffness. Also, the literature suggests a possible positive effect of SMT on certain types of vertigo. 

As the number of older adults presenting to chiropractic practices increases it is imperative that the DC not only discuss the patient's current complaints, but also preventive strategies including fall prevention, nutritional counseling and physical activity. As the population continues to age there will be a greater need for the chiropractic profession to meet the needs of the older adult.