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A Trip to the Chiropractor

JeffJeff Wonoprabowo -- A couple weeks ago I spent an afternoon at a university in Southern California that offers degrees in Oriental Medicine as well as Chiropractic (Doctor of Chiropractic). The afternoon was spent at their University clinic where four classmates and I had a chance to observe the chiropractors. The trip was part of an LCME requirement that the curriculum must cover a certain number of hours in complementary and alternative medicine (CAM). (The LCME is the Liaison Committee on Medical Education and is the accrediting body for all medical schools offering an M.D. in the United States.)

We were asked to pick up a handout from our school office about chiropractic care. Admittedly, this handout did not inspire very much confidence. The tone of the article felt like the authors were desperately trying to convince the readers that chiropractic care is effective and safe. I'm not saying it isn't. For the record, at this time I am undecided on whether or not I will recommend patients to a chiropractor once I am in medical practice. I think I need more info to make a decision either way.

The article talked about how manipulative therapies could help in the treatment of headache, disk herniation, neck pain and upper extremity disorders, asthma and COPD, digestive disorders, and even otitis media. The word "treatment" is important because even the authors admitted that chiropractic, in some of these instances, is only used to treat symptoms and not to cure the ailment. The claims of being able to treat such a wide range of problems were backed by research studies the authors cited. However, the authors noted significant criticisms of the early literature, citing a number of problems that I hope would not have been allowed in peer reviewed journals like the New England Journal of Medicine and the Journal of the American Medical Association.

Needless to say, I was a bit suspicious when I arrived at the chiropractic clinic. We took a tour and I waited for the grandiose claims that they could heal anything a medical doctor can. Fortunately, they never came. The staff there told us how they felt that the treatments they utilized had to be backed by evidence found in the primary literature. They didn't believe they could heal everything and they felt that they knew when it was time to refer patients to a medical doctor.

One doctor shared about how a patient of his had asked for a breast exam, thinking that a chiropractor would be more familiar with how the body should feel. He said he refused and referred her to a medical doctor, stating that he did not have experience in breast exams. Another doctor, when asked of the difference between chiropractors and physical therapists, stated that there isn't much difference.

Apparently there is a wide range of opinions within the chiropractic world. The doctors and students I met there seemed to be more conservative in what they felt they could properly treat (unlike the authors mentioned above).

I had the chance to watch as a young athlete was treated. At the end of my stay I was very impressed with the interns' (3rd year students) depth of knowledge in the areas of biomechanics and the musculoskeletal system.

I'm glad that the LCME wants us to have some familiarity with CAM. So many people take CAM treatments in one way or another that it is important for doctors and medical students to understand what is going on -- whether we believe in it or not.

October 1, 2008 in Jeff Wonoprabowo | Permalink

Comments

Another modality of treatment that all physicians should be aware of is OMM (Osteopathic Manipulative Medicine) which makes use of established knowledge of biomechanics, neuromuscular reflexes, and viscerosomatics to treat patients. The goal of osteopathic physicians is to treat the whole patient - not just symptoms, but the cause of illness as well.

Posted by: scott | Oct 7, 2008 8:23:26 PM

I have found that you need to find the right chiropractor. I found one that told me that he did not want me to come back on a regular basis - only when I felt a twinge, or pain that lasted more than a day. He sent me home with a variety of stretches and exercises. I appreciated this and probably average two trips per year for a back adjustment.

I recommend the chiropractor route. After several doctors visits, they could not help my pain. The doctor could not help me and did not suggest the chiro route.

Posted by: Glenn | Oct 8, 2008 8:02:36 AM

I won't go on at length regarding this inanity; you yourself note you would hope that the relevant 'research' would not be allowed into a respectable journal.

Allow me to simply ask that you propose a mechanism for chiropractics affecting asthma.

Chiropractics should be out and out illegal. If you need PT, see a PT: not someone that plays mystic with your "subluxations."

Posted by: J | Oct 8, 2008 9:27:27 AM

Ok. Only for clarify some things...physical therapist isn´t the even though chiropractors.
Physical therapy treat disorders of spine, but work too in unit intensive care, public health, health women...

Posted by: elisa | Oct 8, 2008 10:34:27 AM

The trick is finding the right chiropractor. Some are good, but not good for you. Make sure they specialize in exactly what you need and they will be able to help you with everything you need.

Posted by: Chiropractor | Oct 8, 2008 3:36:42 PM

Be aware that chiropractic treatments are not risk free - it is not "natural" to manipulate the spine, and, as with any drug or other procedure, there are definitely risks involved. Specifically, there are significant risks associated with neck manipulations - most notably the potential for vertebral- basillar artery compromise or dissection, resulting in infarction or haemorrhage. This can occur in people with no previous neurological signs or symptoms, and can result in development of serious neurological deficits, including brain stem strokes and death.

Manipulation increases the risk of vertebral artery dissection by about 6-fold. To date, chiropracters have the highest kill-rate from this complication of neck manipulation of any profession. Definitely partly due to the frequency with which they perform this treatment....perhaps suggesting there is a reason that other professions, including PTs, are often loathe to manipulate?

Posted by: sg | Oct 8, 2008 4:34:20 PM

As stated above, one needs to find the right Chiropractor.

To J, I don't believe in 'subluxations', and wasn't taught to believe in them - I was trained in differential diagnosis. The 3 most common conditions I treat are mechanical back pain, mechanical neck pain, and tension type headaches.

I don't believe there is much difference between a PT and a DC, other than that in Canada, DCs can(must) diagnose, and that DCs can read/order radiographs. PTs work in hospitals - so do DCs. DCs manipulate the spine - so do PTs (see the latest APTA guidelines on neckpain).

As for the risks - yes, there are risks. Every treatment (and lack of treatment for that matter) carries a risk. The best research to date shows that there IS a statistical association between visiting a Chiropractor and vertebral artery dissection. However, that association exists after visiting a GP as well - that is, it is likely explained by pre-existing conditions.

Posted by: Canadian DC | Oct 13, 2008 10:25:16 PM

What is chiropractic? It is a drug free treatment option that focuses on working with patient's to find the cause of their pain/dysfunction rather than just masking symptoms. We use manipulation to restore proper motion to the involved joints (spine or other) as well as soft tissue therapy (i.e. Active Release Technique or Graston technique favored by many of our olympic athletes), rehab exercises (much like a PT), and nutritional/lifestlye counseling. Chiropractor's must pass 4 separate national board examinations that test knowledge in areas such as basic sciences (biochemistry, microbiology, pathology...), neuromusculoskeletal diagnosis/DDx, nutrition, radiology, and practical application.

Regarding manipulation it is a very safe treatment despite what a prior post may say. The incidence of VBI strokes and cervical manipulation are in the range of 1/1-2 million adjustments (compared to 15,000 who die yearly from complications related to NSAID use). A recent article in Spine (2008,Vol 33, No 45, pg 176-183 Risk of vertebral artery stroke and chiropractic) found no difference in the risk of VBI stroke when comparing patients who went to a chiropractor versus those that went to a primary care MD/DO. This indicates that the manipulation does not directly cause the stroke, rather the stroke was in progress and the clinician failed to recognize the headache or other presenting complaint as being consistent with a stroke and not a typical muscle tension headache. How safe is chiropractic care? Chiropractors pay on average between 1,000-5,000/year for malpractice insurance.
Overall, chiropractors are specialists in neuromuscular skeletal disease. I have personally witnessed cases where asthma has resolved following chiropractic manipulation, but I would also be the first to tell you that those cases are the exception and not the rule. If you hear exceptional claims from a DC (or any other medical professional) it is important to look at those claims critically. If anybody has any questions regarding chiropractic care or the mechanism behind how manipulation works please feel free to e-mail me directly. fhartford@hotmail.com

Posted by: Forrest Hartford | Oct 22, 2008 9:38:22 AM

I'm glad you took the time to check out chiropractic. I hope that when you are in practice that you don't take the attitude of many of your medical colleagues who treat musculoskeletal pain as if the problem were some sort of NSAID or Muscle Relaxant deficiency (I'm sorry Mrs. Jones it appears that your liver or kidney or whatever part isn't producing ibuprofen like it should - ha ha). In your article you hit on a crucial element of a good relationship between not just DCs and MDs but any health care professionals. There are just somethings that some of us manage better than others. Its not to say that one profession is irrelevant or unimportant they are just different. DCs receive far more training in managing musculoskeletal conditions that their MD counterparts, therefore for the patient's sake the referral is logical and obvious. On the other hand I probably make a referral to an MD just about everyday because while I can help somebody with lifestyle changes to manage something like hypertension the logical choice is to get their GP involved again: for the patient's sake.

When I get referrals from MDs I talk them up to the patient like they are the smartest doctor in the world for understanding what is best for the patient. Unfortunately not every chiropractor does this but I feel it is very important that the patient feel that there is a team of people interested in their well-being not just competing for their business.

Posted by: Jason | Nov 5, 2008 1:24:54 AM

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Posted by: Lincoln Park Chiropractic | Dec 23, 2009 4:14:19 AM

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