DC and MD/DO

[facetguy]

I am an internist (MD).

I think the chiropractic profession would make more headway in getting MD and DO's to want to work with you if there weren't chiropractors around who do really wacky things. I mean, some are selling their patients vitamins of dubious or no benefit, and some are telling patients they have "disseminated yeast infections" when there is no evidence of that. Also, they need more research/trials to show that chiropractic techniques are effective...I think it's probably hard to do, though, since I'll bet a lot of it depends on the skill of the person doing the techniques. Many MD/DO's also are familiar with the risks of stroke after chiropractic manipulation in people who have carotid artery dz, so chiropractic gets a bad name for that reason. I actually believe that chiropractic could be useful for some back and hip pain, etc. ...it seems logical that it could but it's a shame there isn't more extensive research about these techniques.

Finally, although there are unscrupulous MD/DO's, it seems to me from my personal experience that there are more shady chiros who seem to be willing to do anything for money. It's a shame b/c I think it leads to all of them getting tarred with the same brush. I personally had a roommate who was getting over influenza, was feeling a bit run down and went to see a chiro...he basically told her she needed to come back to his office every week for the next 8 weeks, or she was basically going to die or something. It was RIDICULOUS. He left a message on our answering machine that was basically kind of scary, making it sound like she had some deadly health problem that only HE could fix. Luckily, I was in 1st year of med school at the time, and put a stop to that nonsense ASAP. With a little R and R, she was fine in a week. Another thing that I think is bad is that some of the DC's seem to go around telling their patients that we (MD's) are somehow in a conspiracy with the drug companies and that we just don't want patients to get better because we are all evil and money grubbing and just want to poison patients with a bunch of pills, and that is totally not true.

As far as knee arthroscopy for OA, there's not much evidence that it helps...unless the patient has mechanical symptoms such as the knee locking up on them, etc. In those cases there is evidence of benefit, probably b/c the orthopod might be able to find the problematic area(s) and clean them up. I think a lot fewer patients with OA are getting knee arthroscopy now that the NEJM published that study...I certainly don't recommend it to any of my patients with garden variety OA knee pain.

These are fair points. Outlandish claims by anyone, chiropractors included, are simply unacceptable.

As far as risk of stroke following cervical manipulation, I think it's important to keep the numbers in perspective. This is an exceedingly rare occurrence, to the point where it has been difficult to quantify. Estimates range from one in 500,000 to one in several million. The most recent and extensive review on the subject (Spine, 15 Feb 2008) found that the incidence of stroke following cervical manipulation was no greater than the incidence of stroke following a visit to a PCP, leading to the thought that in most cases the vertebral artery has already dissected prior to seeking treatment. (You mentioned carotid artery disease. There isn't much out there in terms of injury to the carotid and cervical manipulation. The vertebral/vertebrobasilar artery is the one in question.) The risk needs to be kept in mind here.

Regarding availability of research, there are about 40 or so RCTs looking at spinal manipulation and low back pain and a dozen or so for neck pain. That's not all that bad. It's probably fair to say that, for low back pain at least, there isn't any intervention more studied than spinal manipulation. There have been over the years a number of 'guidelines' issued for low back pain, and spinal manipuation is always there in the "Recommended" category. A recent one is from the American College of Physicians (http://www.annals.org/cgi/content/full/147/7/478), where spinal manipulation is the ONLY non-pharmacologic treatment recommended for BOTH acute and chronic low back pain.

As I've stated elsewhere, if we've learned anything from the spine pain literature it's that no single intervention works perfectly. There is no silver bullet. Spinal manipulation works about the same as everything else, in some cases better and in some cases not better. For your neck and back pain patients, consider chiropractic care for those that aren't doing well with the standard treatment efforts.

And bear in mind that there are many types of spinal manipulation/mobilization, and that chiropractors also advise patients on rehabilitative exercises, postural and ergonomic issues, etc. Please don't be of the belief that chiros simply lay patients down and start banging recklessly on their spines.

As far as the drug company conspiracy thing, I don't think that is much of an issue. I do, however, think that chiropractors and any healthcare professionals for that matter do not want to see patients simply default to a lifelong usage of a medication when other options are available and haven't been tried. Of course there are lifesaving meds, and of course there are situations where a patient has no choice but to take a med for life. Although this goes beyond the scope of discussing any single MD/DO's role, there is a tremendous lack of seriousness paid to lifestyle interventions in our healthcare system despite very compelling evidence in their favor. Some of that, you must admit, has been driven by pharmaceutical dollars influencing our system.

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[facetguy]

I agree with dragonfly. I have no problem with Chiros that stay within their boundaries. But I see advertisements for chiros who say that spinal manipulatation can cure allergies and asthma. Others that say that immunization is a scam and that manipulation can boost the immune system making immunization unnecessary? My question for the chiros on the board. Why aren't you policing yourself? If I did what many chiros are doing, I'd lose my medical license. Your chiro brethren are committing blatant fraud, why don't you fix it.

It's not just the charlatans that bother me. For many, if not most chiropractors, it's business first, medicine second. How many patient's get X-rays? What percentage need maintenance therapy? What about the requirement of many chiropractic schools for their students to bring in a certain number of patients to pass.

This is not to say that the medical community doesn't have problems, we certainly do.

Ed

Irresponsible advertising shouldn't be tolerated, and as far as I know chiro state boards would have a lot to say about such ads, at least in my state. They would be the ones to do the policing. Fraud, particularly blatant fraud, is likely overstating things a bit.

I think the immunization notions are changing within chiropractic, although I haven't actually looked for any data to back that up. Perhaps some of the original criticisms were based on the prior presence of mercury. It is surely a minority of chiropractors who oppose vaccination and even fewer advise their patients along those lines.

 

[dragonfly99]

facetguy,
You are correct about the artery dissection vs. carotid artery dz/blockages...I must have been having a TIA when I mentioned that (LOL). The risk is for arterial dissection, not embolization from carotid plaques, w/spinal manipulation. 1/500,000 is the risk I learned, but perhaps it is difficult to quantify when the numbers are small...

I don't know many internists who oppose trying manipulation for back pain...I've never told my patient(s) not to see a chiro for musculoskeletal low back pain.

I also share dr madison's concerns about immunizations too. I know of several chiropractors who discouraged their patients from getting their kids vaccinated...this may be changing, as I know that was several years ago.

Incidentally, there isn't much of any evidence that the thimerosal (mercury-containing preservative that used to be in some childhood vaccines) has any neurotoxicity at the doses that vaccines contained. Numerous studies and an Institute of Medicine report concluded it isn't linked to autism. Also, that preservative was used since the 1930's and the bump in autism cases was not seen until recent years...we need to look at other factors, such as problems in utero, premature birth, etc.

Finally...r.e. lifestyle changes I agree that these are not emphasized enough. Perhaps if we physicians had a little more time with our patients to actually counsel them (like I do at the free clinic where I volunteer) it would happen more often. If insurance companies keep reimbursing doctors primarily for doing procedures, we're gonna keep having the situation we've currently got.

 

[TMP-SMX]

Autism is diagnosed much more now because of awareness and also because the definition has been broadened to include all autism spectrum disorders that were not included in traditional autism.

 

[facetguy]

Autism is diagnosed much more now because of awareness and also because the definition has been broadened to include all autism spectrum disorders that were not included in traditional autism.

I'm no expert, but I believe this claim as the sole cause in the rise of autism rates has been disputed.

 

[TMP-SMX]

I'm no expert, but I believe this claim as the sole cause in the rise of autism rates has been disputed.

I'm not saying it is the sole reason. It is a major reason though. We can say this because we don't know the other reasons.

 

[facetguy]

I'm not saying it is the sole reason. It is a major reason though. We can say this because we don't know the other reasons.

As long as we aren't saying we should stop looking. Autism is a huge unsolved problem, and it's not a problem of labeling, defining or categorizing.

 

[DOctorJay]

I am a 3rd year chiropractic and master's sports rehab student, i also study Musculosketetal Ultrasound (for extremities only) in radiology dept., my personal opinion about this possible integration is that chiropractic needs to become more scientific based through research not only as nonallopathic but with medical use. For instance, manipulation (not any technique, but highest form of evidence-based), decompression, rehabilitaion methods with use of specific medications for a specified diagnosis. If this could happen and the chiropractic profession would quit allowing some of these doctors to treat patients for (subluxations only) and try to provide evidence for their technique with double blinded studies so all physicians know the truth about chiropractic. We know its benefits, but we don't really know what is happening in the direct joints being manipulated and rehabilitated or the ones above and below, nor what is happened exactly with the surrounding soft tissue. There are way too many chirodocs out there using crazy techniques and giving nutrition prescriptions without the knowledge and evidence. This in my personal opinion and it is hurting healthcare. There are faults to every form of treating a diagnosis, but as for our profession we need to be more respected by providing evidence and for medical physicians to be more aware of the side affects of overmedicating or using a trial and error approach to treating a specific problem. this affects chiropractors, medical doctors, physical therapists, rehab specialists, and most especially the patients care and treatment no matter their choice of physician. Healthcare needs to change and we all need to work together, but without the evidence and research with and without medical use, we can't begin integration! I'm open to anyone's opinions on this matter

I hold a Master of Science in Physical Therapy and a Doctorate of Osteopathic Medicine. I am currently an intern at a traditional rotating osteopathic internship. In June I will begin my residency in Physical Medicine & Rehabilitation.

Please enlighten me as to what a master's sports rehab student is, as I have never heard of such a thing. From a previous post you clearly are not a PT student which comes to mind with the above description.

Also, what exactly is this training in MSK U/S that you are receiving. Is it from an accredited Rad Tech program? Will you be licensed to use this modality some day?

I only have a problem with DCs who refer to themselves as physicians (in the US this means MD, DO, MBBS) or who say they perform physical therapy (PT, MPT, DPT, PTA) or simply misrepresent themselves to patients.