SM is the most easily recognizable therapy associated with chiropractic care. SM is often employed because of the wide range of available techniques and delivery modes, and because SM has several known or suspected physiological mechanisms, making, it broadly applicable as a primary or supportive treatment procedure.

Spinal and extremity joint manipulations can be performed with patients in the prone, side-lying, supine, seated, or standing positions. A wide variety of manipulative techniques are available. Those chosen for treatment are dependent on practitioner training and skills, diagnosis, co-morbid conditions, care goals, and patient preferences. Manipulative techniques are broadly classified as either thrust or non-thrust [32], with many subcategories existing under each label. Most manipulative techniques can be delivered in a wide range of force applications, from robust to gentle, depending on patient tolerance, goals of care, and other factors. Though there are numerous named chiropractic techniques , the most common SM thrust intervention used by DCs is called “Diversified” technique. Diversified technique is reported to be used at least some of the time by over 95 % of DCs [33]. A common non-thrust intervention used by DCs is called Flexion-Distraction , or Cox technique [34–36]. Most techniques are manually applied, sometimes with the use of specially designed treatment tables.

Fascia is composed of connective tissues containing important sensory components. The tissues comprising fascia surround, connect, and infiltrate organs, muscles, bones, and nerves throughout the body [37–39]. Fascial pathology can affect the function of most body tissues, and thus, it is an important tissue/organ system considered by DCs when treating patients with musculoskeletal conditions.

Myofascial therapies represent a broad range of treatment techniques used by practitioners within the physical therapy, occupational therapy, and other healthcare professions including chiropractic. Primarily targeting fascial dysfunction or pathology, myofascial therapies are applied manually, sometimes with the aid of specialized tools and active contraction or with stretching on the part of the patient. Common application methods, mechanisms, and indications for using myofascial therapies and other manual therapy techniques used by DCs are listed in Table 44.2.

Therapeutic exercise is not novel to rehabilitation settings. It is used by several professional groups including DCs . Exercises are prescribed by more than 95% of DCs, often designed to improve spinal stability and function [40, 41]. However, many other exercises are used depending on the condition and other individual factors. DCs commonly incorporate team-based care plans that encourage patients to partake in symptom management and recovery activities using therapeutic exercise [30]. Exercises may be employed to reduce pain, increase available motion, increase strength, and to improve coordination in the performance of athletic movements or daily living activities. The performance of therapeutic exercise by patients may also aid recovery by facilitating personal involvement and commitment to recovery, and by enhancing self-efficacy [42].

Chiropractic rehabilitation protocols for patients with spinal conditions follow a general model that typically begins with passive modalities, gradually transitioning to more active therapies, unassisted exercise, and self-management/independence [43]. Care for patients with acute spinal conditions often incorporates thrust or non-thrust SM, traction, and directional preference exercises. Active therapies including basic exercises designed to promote self-efficacy and to reduce symptoms may be employed immediately, or delayed until the patient can tolerate them. Exercises such as directional preference movements, consistent with McKenzie diagnosis and treatment principles, are often employed for acute spinal conditions to facilitate symptom reduction and promote movement [44]. As symptoms improve, care plans tend to focus more on improving function for daily living activities or sport-specific tasks, often by progressively implementing additional or advanced exercises.

Treatment for patients with subacute or chronic conditions will often consist of SM and active exercises oriented toward joint mobilization and stabilization as well as strengthening symptomatic or related areas. Similar to acute care principles, treatment focus usually transitions from symptom management to improving function for daily living activities as patients improve. Monitoring treatment progression and effectiveness is accomplished through the use of established outcome measures such as the Oswestry Disability Index [45]. Those patients who fail to meet rehabilitative goals, or show substantive change on outcome measures, may require additional diagnostic testing, an altered treatment plan, and/or referral to another healthcare provider.

Patient education is an integral part of chiropractic care. Education carries the potential to influence and to address psychosocial factors contributing to health conditions [46]. Regardless of the disease, DCs are trained to help patients understand their condition and to develop strategies that enable patients to manage or to resolve it, including recognizing when referral to other providers with expertise in cognitive behavioral therapy and mental health is appropriate [6]. Examples of chiropractic rehabilitation goals and treatment strategies are listed in Table 44.3.

DCs use the broad array of treatments to treat patients with a wide range of neuro-musculoskeletal conditions. Individualized care plans are necessitated by unique patient presentations, even for those with similar conditions. Therefore, few detailed protocols for specific diagnoses are described in the literature. Most commonly, rehabilitation principles, goals, and strategies are applied based on individual elements.

For example, shoulder pain is a common disorder following stroke [47] and spinal cord injury. Contributing factors include poor seated posture, spasticity , and upper extremity overuse [48]. Patients recovering from spinal cord injury and stroke may benefit from multidisciplinary rehabilitation , which includes chiropractic care. Treatment could include manual shoulder manipulation to disrupt adhesions, reduce pain, and to increase mobility. Other treatments that may be employed include strength training for functioning muscles, myofascial therapies to improve mobility and to reduce pain , and graded exercise to improve posture and the coordination of the remaining functioning muscles. Selective SM may also be employed to help reduce pain or to aid mobility in appropriate cases [49]. Examples of condition-specific chiropractic care protocols that have been described in the clinical literature are displayed in Table 44.4.