Original Article| Volume 33, ISSUE 6, P464-473, July 2010

Download started.


Best Practices Recommendations for Chiropractic Care for Older Adults: Results of a Consensus Process



      At this time, the scientific evidence base supporting the effectiveness of chiropractic care for musculoskeletal conditions has not yet definitively addressed its appropriateness for older adults. Expert consensus, as a form of evidence, must be considered when higher levels of evidence are lacking. The purpose of this project was to develop a document with evidence-based recommendations on the best practices for chiropractic care of older adults.


      A set of 50 seed statements was developed, based on the clinical experience of the multidisciplinary steering committee and the results of an extensive literature review. A formal Delphi process was conducted, following the rigorous RAND-UCLA (University of California, Los Angeles) methodology. The statements were circulated electronically to the Delphi panel until consensus was reached. Consensus was defined as agreement by at least 80% of the panelists. There were 28 panelists from 17 US states and Canada, including 24 doctors of chiropractic, 1 physical therapist, 1 nurse, 1 psychologist, and 1 acupuncturist.


      The Delphi process was conducted in January-February 2010; all 28 panelists completed the process. Consensus was reached on all statements in 2 rounds. The resulting best practice document defined the parameters of an appropriate approach to chiropractic care for older adults, and is presented in this article.


      A multidisciplinary panel of experienced chiropractors was able to reach a high level (80%) of consensus on evidence-informed best practices for the chiropractic approach to evaluation, management, and manual treatment for older adult patients.

      Key Indexing Terms

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Manipulative & Physiological Therapeutics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • U.S. Census Bureau
        An older and more diverse population by mid-century: Washington, DC: U.S. Census Bureau; 2008.
        (Available from)
        • Christensen M
        • Kollasch M
        • Ward R
        • Webb K
        • Day A
        • ZumBrunnen J.
        Job Analysis of Chiropractic.
        NBCE, Greeley, CO2005
        • United States Bone and Joint Decade
        The Burden of Musculoskeletal Diseases in the United States.
        American Academy of Orthopaedic Surgeons, Rosemont IL2008
        • American Geriatric Society
        The management of chronic pain in older persons: AGS panel on chronic pain in older persons.
        J Am Geriatr Soc. 1998; 46: 635-651
        • American Geriatric Society
        The management of persistent pain in older persons.
        J Am Geriatr Soc. 2002; 50: S205-S224
        • Bronfort G
        • Haas M
        • Evans R
        • Leiniger B
        • Triano J
        Effectiveness of manual therapies: the UK evidence report.
        Chiropr Osteopat. 2010; 18: 3
        • Cassidy JD
        • Boyle E
        • Cote P
        • et al.
        Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.
        J Manipulative Physiol Ther. 2009; 32: S201-S208
        • Hurwitz EL
        • Morgenstern H
        • Vassilaki M
        • Chiang LM
        Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study.
        Spine. 2005; 30: 1477-1484
        • Gouveia LO
        • Castanho P
        • Ferreira JJ
        Safety of chiropractic interventions: a systematic review.
        Spine (Phila Pa 1976). 2009; 34: E405-E413
        • Hawk C
        • Rupert R
        • Colonvega M
        • Boyd J
        • Hall S
        Comparison of Bio-Energetic Synchronization Technique and customary chiropractic care for older adults with chronic musculoskeletal pain.
        J Manipulative Physiol Ther. 2006; 29: 540-549
        • Hondras MA
        • Long CR
        • Cao Y
        • Rowell RM
        • Meeker WC
        A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain.
        J Manipulative Physiol Ther. 2009; 32: 330-343
        • Bougie J
        Geriatric practice-specific issues.
        in: Haldeman S Principles and Practice of Chiropractic. 3rd ed. McGraw-Hill, New York2005: 1079-1098
        • Triano J
        The mechanics of spinal manipulation.
        in: Herzog W Clinical Biomechanics of Spinal Manipulation. Churchill-Livingstone, New York2000: 92-190
        • Cooperstein R
        • Perle SM
        • Gatterman MI
        • Lantz C
        • Schneider MJ
        Chiropractic technique procedures for specific low back conditions: characterizing the literature.
        J Manipulative Physiol Ther. 2001; 24: 407-424
        • Cooperstein R
        • Gleberzon B.J
        Diversified technique.
        in: Cooperstein R Gleberzon B.J. Technique Systems in Chiropractic. 1st ed. Edinburgh, Churchill-Livingstone2004: 143-149
        • Forster A
        • Lambley R
        • Hardy J
        • et al.
        Rehabilitation for older people in long-term care.
        Cochrane Database Syst Rev. 2009; : CD004294
        • Howe TE
        • Rochester L
        • Jackson A
        • Banks PM
        • Blair VA
        Exercise for improving balance in older people.
        Cochrane Database Syst Rev. 2007; : CD004963
        • Liu CJ
        • Latham NK
        Progressive resistance strength training for improving physical function in older adults.
        Cochrane Database Syst Rev. 2009; : CD002759
        • Robitaille Y
        • Laforest S
        • Fournier M
        • et al.
        Moving forward in fall prevention: an intervention to improve balance among older adults in real-world settings.
        Am J Public Health. 2005; 95: 2049-2056
        • Lin MR
        • Wolf SL
        • Hwang HF
        • Gong SY
        • Chen CY
        A randomized, controlled trial of fall prevention programs and quality of life in older fallers.
        J Am Geriatr Soc. 2007; 55: 499-506
        • American Geriatric Society
        Guideline for the prevention of falls in older persons.
        J Am Geriatr Soc. 2001; 49: 664-672
        • American Geriatric Society
        Exercise prescription for older adults with osteoarthritis pain: consensus practice recommendations.
        J Am Geriatr Soc. 2001; 49: 808-823
        • Ganz DA
        • Alkema GE
        • Wu S
        It takes a village to prevent falls: reconceptualizing fall prevention and management for older adults.
        Inj Prev. 2008; 14: 266-271
        • AHRQ
        Adult preventive care timeline.
        Agency for Healthcare Research and Quality, 2006 (AHRQ Publication No. APPIP06-IP001, June 2006. Agency for Healthcare Research and Quality, Rockville, MD)
        • Council on Chiropractic Education
        Standards for Doctor of Chiropractic Programs and requirements for institutional status.
        Council on Chiropractic Education, 2007
        • Borggren CL
        • Osterbauer PJ
        • Wiles MR
        A survey of geriatrics courses in North American chiropractic programs.
        J Chiropr Educ. 2009; 23: 28-35
        • Bougie J
        • Morgenthal JP
        The aging: conservative management of common neuromusculoskeletal conditions.
        McGraw-Hill, New York2001
        • Gleberzon BJ
        Chiropractic care of the older patient.
        Butterworth-Heinemann, Oxford2001
        • Killinger LZ
        Chiropractic and geriatrics: a review of the training, role, and scope of chiropractic in caring for aging patients.
        Clin Geriatr Med. 2004; 20: 223-235
        • Hawk C
        • Killinger Z
        • Zapotocky B
        • Azad A
        Chiropractic training in care of the geriatric patient: an assessment.
        J Neuromusculoskelet Syst. 1997; 5: 15-25
        • Hawk C
        • Byrd L
        • Killinger LZ
        Evaluation of a geriatrics course emphasizing interdisciplinary issues for chiropractic students.
        J Gerontol Nurs. 2001; 27: 6-12
        • Manchikanti L
        • Boswell MV
        • Giordano J
        Evidence-based interventional pain management: principles, problems, potential and applications.
        Pain Physician. 2007; 10: 329-356
        • Driever MJ
        Are evidence-based practice and best practice the same?.
        West J Nurs Res. 2002; 24: 591-597
        • Fitch K
        • Bernstein SJ
        • Aquilar MS
        • Burnand B
        • LaCalle JR
        • Lazaro P
        • van het Loo M
        • McDonnell J
        • Vader J
        • Kahan JP
        The RAND UCLA Appropriateness Method User's Manual.
        RAND Corp, Santa Monica, CA2003
        • Maiers MJ
        • Hartvigsen J
        • Schulz C
        • et al.
        Chiropractic and exercise for seniors with low back pain or neck pain: the design of two randomized clinical trials.
        BMC Musculoskelet Disord. 2007; 8: 94
        • Dougherty P
        • Killlinger LZ
        The role of chiropractic in long term care.
        Long Term Care Interface. 2005; 6: 33-38
        • Centers for Medicare and Medicaid Services
        Medicare program; revisions to payment policies under the physician fee schedule, and other Part B payment policies for CY 2008.
        Federal Register. 2007; : 66221-66578
        • Chou R
        • Qaseem A
        • Snow V
        • et al.
        Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
        Ann Intern Med. 2007; 147: 478-491