PMR vs. Chiropractor

[engram]

There are good comparison with other specialties that would treat same patient population.


My question is the competitiveness of PMR against Chiropractor in outpatient setting, specifically back and joints pain. One of my friends asked me what Physiatrist can do for patient which chiropractor can’t do? That was a good question

I understand there are bunch of things PMR does but Chiropractors don’t.
However, patients are more familiar with chiropractors. Chiropractors treat them without sending patients to PT.
When people has a minor MVA, they usually go to them. Even insurance covers about 15 sessions.

Correct me if I wrong.

From serious candidate for PMR

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[axm397]

I think it's a very different philosophy of practicing - Many chiropractic schools have business courses and they like to have many sessions, and they dont' usually "cure" the patients. It's a very passive treatment for the patient - i.e. pts are not doing exercises - different locus of control. Chiropractors can bring comfort temporarily to many patients and they are better at promoting themselves. They usually also have excellent relationships with patients and many patients are very loyal to their chiros.

Physiatrists work with therapists to teach patients how to manage their pain, get better function, and therefore quality of life. They may not "cure" the patient but may be able to correct the underlying factors leading to the dysfunction. (posture retraining, strengthening, healthy compensation mechanisms) Chiropractors will not. Physiatrists also have a medical background - so they can prescribe medications, identify medical issues which may manifest as musculoskeletal problems. (malignancy, CV problems, etc.) Physiatrists and therapists want patients to become independent in their exercises and "graduate", chiropracters want them to come back session after session.

I am talking generalizations and I am not that familiar with the particulars of chiropractic care except anecdotally so take my opinion with a grain of salt.

 

[Disciple]

There are good comparison with other specialties that would treat same patient population.


My question is the competitiveness of PMR against Chiropractor in outpatient setting, specifically back and joints pain. One of my friends asked me what Physiatrist can do for patient which chiropractor can't do? That was a good question

I understand there are bunch of things PMR does but Chiropractors don't.
However, patients are more familiar with chiropractors. Chiropractors treat them without sending patients to PT.
When people has a minor MVA, they usually go to them. Even insurance covers about 15 sessions.

Correct me if I wrong.

From serious candidate for PMR

A Physiatrist is a physician, which means the ability to prescribe medication, perform and properly interpret electrodiagnostic studies, interpret imaging including CT/MRI, provide interventional pain management, make a medical diagnosis and most importantly, provide a comprehensive and multidisciplinary treatment plan.

Much of the way a chiropractor treats patients is to use a single modality i.e. manipulation. This is perhaps not the ideal approach when encountering a complex entity such as low back pain. Yes, a chiropractor may be able to help someone with myofascial pain, sacral torsions, vertebral malalignment, etc., but believe it or not, we actually get referrals to our spine clinic from Chiropractors to diagnose and treat conditions such as Discogenic back pain, radiculopathy, spinal stenosis, failed back surgery syndrome, etc.

 

[macman]

There are many differences between a pm&r doc and a chiro. Many of these have been described above. My experience in comparing fields of MSK rehab/treatment is that I am a D.O., my mom a nationally regarded chiropractor, three brother in laws who are chiros, and I have attended multiple spinal manip. seminars done by both chiros and DOs, and from my experinces rotating on PM&R services as a student. My weakest experience is in PM&R b/c I am just an intern now.

There is no direct comparison between a fully licensed/trained physician and a care provider who is not. That doesn't mean that a chiro cannot really help someone, but they are probably most effective when they realize their limitations and maximize their training and keep an open mind regarding techniques. The least effective/safe chiropractors think they can heal everything with one or two techniques. The most effective chiropractors I have met behave as specialists, taking referals from PCP's not attorneys. Some are involved with trying to get their patients to 'rehab' via PTs or exercises taught in house. This has a financial disincentive for those who rely on volume to build their practices though. The training that most get in school is fairly rudimentary and the best practitioners engage in heavy CME to become experts. Then again, my medical training at the end os MSII was also rudimentary and they do not have a GME system at all. That is a major difference.

The training at my DO school was far superior in terms of depth of learning in spinal manip and diag. approach to MSK pain. This thread is not chiro vs. DO and that has been discussed elsewhere. In reality, since chiros do it day in and day out, the average chiro has better skills, especially in the simpler techniques (HVLA), than your average DO.

As stated above, the GME training PM&R docs receive in medicine, neurology, pathophysiology allows us to kepp the widest of perspectives for anyone presenting with MSK c/o, or any physical impairment. We are trained not only to be able to directly diag. and treat these patients but also recognize what other specialties can help them as well-that is a true difference and strength of our field.

 

[OMMFellow06]

Physiatrists also get extensive training in orthotics which is an essential part of understanding when say a short leg may be the cause of the back pain.

And again, as others have said, there's more to treating back/joint pain than just spinal manipulation. I am an Osteophathic medical student and I am doing an extra fellowship year in Osteopathic Manipulation so I have pretty good knowledge of the MSK system and back pain and I definitely believe that I have a lot to learn when it comes to back/joint pains. Sometimes, it's a muscle relaxant that the patient needs and sometimes it can just be a pain killer/anti-inflammatory to decrease the pain so that they can make it through the days until the body heals itself. Myofascial/muscular complaints don't usually need spinal manipulation, that's when the physiatrist comes in.

There are so many different things that a Physiatrist does, that for those that haven't researched the field enough and haven't done rotations in PM&R, it's a tough field to understand.

Ripal

 

[macman]

Physiatrists also get extensive training in orthotics which is an essential part of understanding when say a short leg may be the cause of the back pain.

And again, as others have said, there's more to treating back/joint pain than just spinal manipulation. I am an Osteophathic medical student and I am doing an extra fellowship year in Osteopathic Manipulation so I have pretty good knowledge of the MSK system and back pain and I definitely believe that I have a lot to learn when it comes to back/joint pains. Sometimes, it's a muscle relaxant that the patient needs and sometimes it can just be a pain killer/anti-inflammatory to decrease the pain so that they can make it through the days until the body heals itself. Myofascial/muscular complaints don't usually need spinal manipulation, that's when the physiatrist comes in.

There are so many different things that a Physiatrist does, that for those that haven't researched the field enough and haven't done rotations in PM&R, it's a tough field to understand.

Ripal

while I agree that soft tissue dysfunction may not be helped by 'spinal manip', what about MFR, LAS/BLT, soft tissue? I think an argument made that treating the soft tissue or at least including it in the treatment (ME) makes for more effective treatments (ever crack someone's L5 for a few months with no sig. relief only to discover all you had to do was release their iliolumbar ligament for total relief?)

Any literature I have seen indicates muscle relaxants are not very beneficial for MSK pain.

 

[paz5559]

while I agree that soft tissue dysfunction may not be helped by 'spinal manip', what about MFR, LAS/BLT, soft tissue? I think an argument made that treating the soft tissue or at least including it in the treatment (ME) makes for more effective treatments (ever crack someone's L5 for a few months with no sig. relief only to discover all you had to do was release their iliolumbar ligament for total relief?)

Any literature I have seen indicates muscle relaxants are not very beneficial for MSK pain.

While I am thrilled to learn what you personally believe, I have to tell you, I credit it with absolutely no scientific validity unless it has some litterature to back it up. Rather than telling me your personal experience, or characterizing what you may or may not have read, why not actually quote articles, so we can review what the source material behind your opinions are, and then decide for ourselves whether what you belive is valid, and/or applicable to our future clinical practices?

Phrases like "in my experience", or "total relief" make me nuts - how do you know it wasn't placebo at work? How do you know the failures weren't due to secondary gain? Find me an RCT or two, and I promise, I really will pay attention. Till then ... not so much.

 

[melancholy]

Hi paz5559- I completely understand where you are coming from because research and EBM is relied upon to give us a solid foundation for what we know works and doesn't work. It reminds me of a quote by Osler that said "medicine is a science of uncertainty and an art of probability."

It is an obvious statement to say that we research the unknown in hopes of finding something we can use to help patients. Areas of medicine including osteopathic manipulation, accupuncture, etc. are more difficult to perform solid, objective research on given the nature of these modalities. Research is growing, but not as rapidly as one might want because of many subjective factors that have to be worked with. It just will never be as managable as doing research on something like nerve conduction velocities.

That being said, the emphasis on structure-function relationships and a holistic approach towards teaching patients is something I've found to be much more prevelant in the field of physiatry and moreso with physiatrists who work in the sports/spine/msk/pain arena. I think the philosophy is there, but the research lags.

I will say that on rotations, I've seen quite a few different approaches to treating msk complaints and I know I will see many more in my lifetime. I beleve doctors stick to what they find works for them... human nature, right? Anecdotal evidence, while absurdly unscientific in some fashion, is prevelant in just about any hospital I've worked in simply because a physician has the clinical experience/trend of finding one thing to help the patient more than another thing.

I know I still have a ton to learn, but I am trying to get the basics down while keeping an open mind. Hopefully this is the approach that will benefit my training the most. Sorry for all my blabbing, but I wanted to write about my feelings on this and see what you and others thought.

 

[paz5559]

Hi paz5559- I completely understand where you are coming from because research and EBM is relied upon to give us a solid foundation for what we know works and doesn't work. It reminds me of a quote by Osler that said "medicine is a science of uncertainty and an art of probability."

It is an obvious statement to say that we research the unknown in hopes of finding something we can use to help patients. Areas of medicine including osteopathic manipulation, accupuncture, etc. are more difficult to perform solid, objective research on given the nature of these modalities. Research is growing, but not as rapidly as one might want because of many subjective factors that have to be worked with. It just will never be as managable as doing research on something like nerve conduction velocities.

That being said, the emphasis on structure-function relationships and a holistic approach towards teaching patients is something I've found to be much more prevelant in the field of physiatry and moreso with physiatrists who work in the sports/spine/msk/pain arena. I think the philosophy is there, but the research lags.

I will say that on rotations, I've seen quite a few different approaches to treating msk complaints and I know I will see many more in my lifetime. I beleve doctors stick to what they find works for them... human nature, right? Anecdotal evidence, while absurdly unscientific in some fashion, is prevelant in just about any hospital I've worked in simply because a physician has the clinical experience/trend of finding one thing to help the patient more than another thing.

I know I still have a ton to learn, but I am trying to get the basics down while keeping an open mind. Hopefully this is the approach that will benefit my training the most. Sorry for all my blabbing, but I wanted to write about my feelings on this and see what you and others thought.

My PD likes to say that practice paterns are either evidence-based or eminence-based.

I tend to trust only the former.

 

[OMMFellow06]

while I agree that soft tissue dysfunction may not be helped by 'spinal manip', what about MFR, LAS/BLT, soft tissue? I think an argument made that treating the soft tissue or at least including it in the treatment (ME) makes for more effective treatments (ever crack someone's L5 for a few months with no sig. relief only to discover all you had to do was release their iliolumbar ligament for total relief?)

Any literature I have seen indicates muscle relaxants are not very beneficial for MSK pain.

We were just talking Chiropractors right? That's why I only mentioned "spinal manipulation" I completely agree that other treatments such as MFR, LAS/BLT work great and I definitely use them. However, sometimes a patient may need some core stabilization and help with their posture and since Physiatrists are trained well in that, we would be able to provide an added level of care.

 

[macman]

While I am thrilled to learn what you personally believe, I have to tell you, I credit it with absolutely no scientific validity unless it has some litterature to back it up. Rather than telling me your personal experience, or characterizing what you may or may not have read, why not actually quote articles, so we can review what the source material behind your opinions are, and then decide for ourselves whether what you belive is valid, and/or applicable to our future clinical practices?

Phrases like "in my experience", or "total relief" make me nuts - how do you know it wasn't placebo at work? How do you know the failures weren't due to secondary gain? Find me an RCT or two, and I promise, I really will pay attention. Till then ... not so much.

EBM is the ideal and I would love to quote you some RCTs, but as I'm sure you are aware any form if manual therapy (massage, OMT, chiro) is a very difficult area to research without the confounding factors of 'sham' treatments, pt. blinding, and probably a whole lot less $$$ avail. than was for vioxx research . But seriously, I view this as an exciting area to look into more deeply and I do repard it as my responsibility as a D.O. and future PM&R doc to conduct research into OMT and its effects for MSK pain, and possibly other applications.

In terms of the muscle relaxants-I did a lit. review today and discovered I was incorrect-by themselves and in conjunctionwith NSAIDs they are 'effective' in certain scenarios. I do not have the articles in front of me now-I was looking at review art.'s on OVID for LBP. There were many that agreed with this.

I found numerous articles in Spine, FP journals, etc. which indicate spinal manip is as effective as other mainstream measures (NSAIDs, education, etc.) and is part of the standard of care for LBP. (AHCPR concensus guidelines)

I found a great article out of Kessler by Nadler and another doc in Mayo Clinic Proceed. which does a great job of saying that although the data is relatively weak in support of spinal manip. it does not mean the modailty is weak-it just means more quality studies are needed.

Another article that is excellent is my Dr. Greenman at MSU talking about the problems encountered in researching manip. and that the reason for so much poor data is that what chiros call sham-we call MFR, ME, etc....among other points. Go to www.jaoa.org and search under author greenman and its the first article that comes up.

stories are not as good as RCTs, for sure.....OMT is not as easy as a pill to use or research. Then again I would imagine adverse effects of OMT are much lower than most medications that have great RCTs. (many articles in Spine on adverse events in spinal manip if you're curious-keep in mind a lot of that is chiro which tends to be more aggressive). The skills of palpation and motor skills are hard to develop. It is probably easier to write the whole thing off than to sit down (or standing) and learn the skills. I know you don't like stories but I'll share one with you just for fun.

In my last run of OMM fellowship I saw a patient that had not been in for awhile. Turns out he got hit by a car while cycling and would have died from laryngeal edema had a hospital not been a block away. Was in a coma for a week and tetraplegic for a week after that. Had C4-6 fused, R brachial plexus injury, left with R vocal cord paralyzed (I don't know his initial ASIA score/class.). When he finally left the rehab floor using a walker they told him "this is probably the best you'll ever get" (that was the physiatrist!!)

I saw him a few months later after he had done intensive home PT and working with his previous martial arts instructor. He refused to accept anything short of full recovery. He used to see us for mechanical LBP but now presented looking for increased ROM in his c-spine (could only rotate about 20 degrees either direction), and increased ROM in his R shoulder (flexion and abduction limited to shoulder height. I found and treated Somatic dysfuntions (used very conservative tech given his hx.) and did a lot of work to relieve myofascial strains from the trauma. After seeing no further progress for the past 1-2 months with his home program, he had full ROM of R shoulder and close to 80 degrees of c-spine rotation after 2 treatments. Is it placebo?-maybe. Nevertheless I contributed to improving his function, quality of life, and decreasing his pain. I thought that's why we get interested in fields like PM&R-b/c we are willing to get creative and think outside the medical or surgical box from time to time and offer unique patients unique modalities.

 

[Gauss]

Phrases like "in my experience", or "total relief" make me nuts - how do you know it wasn't placebo at work? How do you know the failures weren't due to secondary gain? Find me an RCT or two, and I promise, I really will pay attention. Till then ... not so much.

I always prescribe placebo as part of my treatment plan
It works wonders, even better than echinacea for rhinovirus

 

[awdc]

Just to clear up some misconceptions. Manipulation is not the only tool chiropractors use. Many chiropractic schools are actually heavy into the rehab and active treatment side of patient management. We were taught in addition to all the passive treatment techniques (various myofascial and mobilization techniques, physical therapy modalities, and stretching techniques), a large portion of our curriculum included conditioning, use of PT/rehab equipment, core stabilization, progressing through rehab tracks, etc. In fact, I ended up really wanting to become a physician and not a quasi-PT.

You have to understand the chiropractic profession is not a unified one. There are chiropractors that will just manipulate everything that comes in. And there are chiropractors that will consider utilizing everything they learned in chiropractic school.

There are also chiropractic residencies in areas such as orthopedics, research, rehabilitation, clinical practice, and radiology. Of course, these residencies are tailored to the chiropractic scope of practice and are not meant to be equivalent to graduate medical education.

 

[AMIOK]

Just to clear up some misconceptions. Manipulation is not the only tool chiropractors use. Many chiropractic schools are actually heavy into the rehab and active treatment side of patient management. We were taught in addition to all the passive treatment techniques (various myofascial and mobilization techniques, physical therapy modalities, and stretching techniques), a large portion of our curriculum included conditioning, use of PT/rehab equipment, core stabilization, progressing through rehab tracks, etc. In fact, I ended up really wanting to become a physician and not a quasi-PT.

You have to understand the chiropractic profession is not a unified one. There are chiropractors that will just manipulate everything that comes in. And there are chiropractors that will consider utilizing everything they learned in chiropractic school.

There are also chiropractic residencies in areas such as orthopedics, research, rehabilitation, clinical practice, and radiology. Of course, these residencies are tailored to the chiropractic scope of practice and are not meant to be equivalent to graduate medical education.

hey, I am glad to see al of the interest in the comparison of chiropractic and PM&R. I have been a chiro since 1989 and now am a PM&R resident. In short a chiro can do anything a PM&R doc can do except prescribe and invasive procedures. I did not write to add much, just to say thanks for the interesting reading. If a genuine interest is taking in the comparison read the literature...it is growing and is impressive. If opinions are wanted then the forum is great.

 

[paz5559]

hey, I am glad to see al of the interest in the comparison of chiropractic and PM&R. I have been a chiro since 1989 and now am a PM&R resident. In short a chiro can do anything a PM&R doc can do except prescribe and invasive procedures. I did not write to add much, just to say thanks for the interesting reading. If a genuine interest is taking in the comparison read the literature...it is growing and is impressive. If opinions are wanted then the forum is great.

Please, enlighten me - what specific litterature is it you are refering to? I would ask you to cite articles (author, journal, month, and specific pages) so we can all read it, rather than you just paraphrasing articles. If you can also cut and paste the entire abstract so we can all read it, that would be even better. Oh, and if at all possible, could you possibly quote articles that rather than being published in chiropractic digests, are instead sujected to peer review?

Oh, and while we are at it, lets be perfectly clear - awdc makes refernce to a very rareified group of DC's when he speaks of those who chose to use modalities other than manipulation for their patients. The overwhelming majority of chiropractors ALWAYS find something wrong when the patient presents, make reference to the pseudosicentific spinal "subluxation" as the root of all evil (or at least all back pain), believe they can prophylactically maintain good spinal health, believe it is appropriate to manipulate children to prevent future back ailments, suggest their treatment has effects beyond the neck and back (ie benefits to the immune system, central and peripheral nervous system, as well as overall general health and wellness), and never discharge patients from care.

So yes, there are terrific DC's who have a marvelous understanding of biomechanics, and encorporate manipulation into an overarching treatment plan. Does it work better than placebo? I await your extensive litterature citations to learn the anwwer to that question. DO's have, as drusso has pointed out elsewhere in this board, a very hard time proving to statisitcal significance that their techniques are effective. I am skeptical that DC's can prove what DO's can't, but I await your litterature to the contrary

 

[macman]

Please, enlighten me - what specific litterature is it you are refering to? I would ask you to cite articles (author, journal, month, and specific pages) so we can all read it, rather than you just paraphrasing articles. If you can also cut and paste the entire abstract so we can all read it, that would be even better. Oh, and if at all possible, could you possibly quote articles that rather than being published in chiropractic digests, are instead sujected to peer review?

Oh, and while we are at it, lets be perfectly clear - awdc makes refernce to a very rareified group of DC's when he speaks of those who chose to use modalities other than manipulation for their patients. The overwhelming majority of chiropractors ALWAYS find something wrong when the patient presents, make reference to the pseudosicentific spinal "subluxation" as the root of all evil (or at least all back pain), believe they can prophylactically maintain good spinal health, believe it is appropriate to manipulate children to prevent future back ailments, suggest their treatment has effects beyond the neck and back (ie benefits to the immune system, central and peripheral nervous system, as well as overall general health and wellness), and never discharge patients from care.

So yes, there are terrific DC's who have a marvelous understanding of biomechanics, and encorporate manipulation into an overarching treatment plan. Does it work better than placebo? I await your extensive litterature citations to learn the anwwer to that question. DO's have, as drusso has pointed out elsewhere in this board, a very hard time proving to statisitcal significance that their techniques are effective. I am skeptical that DC's can prove what DO's can't, but I await your litterature to the contrary

paz-

I will hold you to the same standard you like to hold everyone else to. Where is the literature to back up your slam of chiropractic? You get pretty specific. Can you provide me with articles quanitifying your criticism-or is it just anecdotal ? If you want to get anecdoctal I personally know several D.C.'s who are consumate pros who diag, treat, and discharge. Last time I checked there are probably a few bad MDs and DOs out there too.

Also please provide one study which shows spinal manip. is less effective than other standard regimens for LBP. While you're at it where is the data that shows anything is the gold standard for chronic spinal pain? Please see Giles Spine 2003 and follow up in JMPT 2005 for statistically sig. data on SM vs. acup. and cox-2's. also see Assendelft et al. JAMA 274 (24) 1995 for a review of the reviews. Don't you have OVID down there???

I wonder if you are truly interested in a collegial discussion or just like putting poeple down? I see no comments from you on my last post in which I attempt to answer your ciritcism of my assertions. Frankly, your posts sound like a DO who has lost his skills and may be looking for excuses for why that might be......maybe?

 

[paz5559]

Rather than quoting Assendelft's work from 10 years ago, perhaps his Cochran Database article might be worth a look?

Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.:Spinal manipulative therapy for low back pain: Cochrane Database Syst Rev. 2004;(1):CD000447

BACKGROUND: Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain. OBJECTIVES: To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened. SELECTION CRITERIA: Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure. DATA COLLECTION AND ANALYSIS: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). MAIN RESULTS: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. REVIEWER'S CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.


Assendelft WJ, Koes BW, Knipschild PG, Bouter LM: The relationship between methodological quality and conclusions in reviews of spinal manipulation:JAMA. 1995 Dec 27;274(24):1942-8

OBJECTIVE--To study the relationship between the methodological quality and other characteristics of reviews of spinal manipulation for low back pain on the one hand and the reviewers' conclusions on the effectiveness of manipulation on the other hand. DATA SOURCES--Reviews identified by MEDLINE search, citation tracking, library search, and correspondence with experts. STUDY SELECTION--English- or Dutch-language reviews published up to 1993 dealing with spinal manipulation for low back pain that include at least two randomized clinical trials (RCTs). DATA EXTRACTION--Methodological quality was assessed using a standardized criteria list applied independently by two assessors (range, 0% to 100%). Other extracted characteristics were the comprehensiveness of the search, selective citation of studies, language, inclusion of non-RCTs, type of publication, reviewers' professional backgrounds, and publication in a spinal manipulation journal or book. The reviewers' conclusions were classified as negative, neutral, or positive. DATA SYNTHESIS--A total of 51 reviews were assessed, 17 of which were neutral and 34 positive. The methodological quality was low, with a median score of 23%. Nine of the 10 methodologically best reviews were positive. Other factors associated with a positive reviewers' conclusion were review of spinal manipulation only, inclusion of a spinal manipulator in the review team, and a comprehensive literature search. CONCLUSIONS--The majority of the reviews concluded that spinal manipulation is an effective treatment for low back pain. Although, in particular, the reviews with a relatively high methodological quality had a positive conclusion, strong conclusions were precluded by the overall low quality of the reviews. More empirical research on the review methods applied to other therapies in other professional fields is needed to further explore our findings about the factors related to a positive reviewers' conclusion.

I will not stoop to your level of name calling, mac, other than to say I am an MD about to start my interventional pain fellowship. That is a field that does not believe in lumping all back pain together, but rather advocates determining pain generators, and THEN treating appropriately. Afterall, do you treat all chest pain the same way? Costochondritis and angina have diferent eitiologies, and you would call anyone who advocated treating them with identical modalities nuts.

 

[macman]

Rather than quoting Assendelft's work from 10 years ago, perhaps his Cochran Database article might be worth a look?

Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.:Spinal manipulative therapy for low back pain: Cochrane Database Syst Rev. 2004;(1):CD000447

BACKGROUND: Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain. OBJECTIVES: To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened. SELECTION CRITERIA: Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure. DATA COLLECTION AND ANALYSIS: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). MAIN RESULTS: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. REVIEWER'S CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.


Assendelft WJ, Koes BW, Knipschild PG, Bouter LM: The relationship between methodological quality and conclusions in reviews of spinal manipulation:JAMA. 1995 Dec 27;274(24):1942-8

OBJECTIVE--To study the relationship between the methodological quality and other characteristics of reviews of spinal manipulation for low back pain on the one hand and the reviewers' conclusions on the effectiveness of manipulation on the other hand. DATA SOURCES--Reviews identified by MEDLINE search, citation tracking, library search, and correspondence with experts. STUDY SELECTION--English- or Dutch-language reviews published up to 1993 dealing with spinal manipulation for low back pain that include at least two randomized clinical trials (RCTs). DATA EXTRACTION--Methodological quality was assessed using a standardized criteria list applied independently by two assessors (range, 0% to 100%). Other extracted characteristics were the comprehensiveness of the search, selective citation of studies, language, inclusion of non-RCTs, type of publication, reviewers' professional backgrounds, and publication in a spinal manipulation journal or book. The reviewers' conclusions were classified as negative, neutral, or positive. DATA SYNTHESIS--A total of 51 reviews were assessed, 17 of which were neutral and 34 positive. The methodological quality was low, with a median score of 23%. Nine of the 10 methodologically best reviews were positive. Other factors associated with a positive reviewers' conclusion were review of spinal manipulation only, inclusion of a spinal manipulator in the review team, and a comprehensive literature search. CONCLUSIONS--The majority of the reviews concluded that spinal manipulation is an effective treatment for low back pain. Although, in particular, the reviews with a relatively high methodological quality had a positive conclusion, strong conclusions were precluded by the overall low quality of the reviews. More empirical research on the review methods applied to other therapies in other professional fields is needed to further explore our findings about the factors related to a positive reviewers' conclusion.

I will not stoop to your level of name calling, mac, other than to say I am an MD about to start my interventional pain fellowship. That is a field that does not believe in lumping all back pain together, but rather advocates determining pain generators, and THEN treating appropriately. Afterall, do you treat all chest pain the same way? Costochondritis and angina have diferent eitiologies, and you would call anyone who advocated treating them with identical modalities nuts.

1) Is "DO" name calling?

2) please address question about your slam of chiros

3) what are your comments on the Spine articles?

4) Thank you for the newer reference, I will read the entire article and check it out-"GP care" sounds a little vauge

5) certainly more research needs to be done-it is a very tough area to research objectively-we all have our own biases as we sift through whats out there. I do not recall advocating for 'lumping' of LBP. I prefer to perform all appr. tests to see where the problem/source might be (L-spine, foot, etc.)

Hey I'm just an intern, but my observation has been that being a good physician takes science+art+?. There's a lot I have yet to learn, that any of us have yet to learn. In the meantime I'll keep an open mind and try to help my patients.

 

[paz5559]

1) Is "DO" name calling?

No, "... a DO who has lost his skills and may be looking for excuses for why that might be" is.

2) please address question about your slam of chiros

My criticisms are direct quotes out of the texts used by students at Life University School of Chiropractic

3) what are your comments on the Spine articles?

Giles LG, Muller R.: Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation: Spine. 2003 Jul 15;28(14):1490-502

STUDY DESIGN: A randomized controlled clinical trial was conducted. OBJECTIVE: To compare medication, needle acupuncture, and spinal manipulation for managing chronic (>13 weeks duration) spinal pain because the value of medicinal and popular forms of alternative care for chronic spinal pain syndromes is uncertain. SUMMARY OF BACKGROUND DATA: Between February 1999 and October 2001, 115 patients without contraindication for the three treatment regimens were enrolled at the public hospital's multidisciplinary spinal pain unit. METHODS: One of three separate intervention protocols was used: medication, needle acupuncture, or chiropractic spinal manipulation. Patients were assessed before treatment by a sports medical physician for exclusion criteria and by a research assistant using the Oswestry Back Pain Disability Index (Oswestry), the Neck Disability Index (NDI), the Short-Form-36 Health Survey questionnaire (SF-36), visual analog scales (VAS) of pain intensity and ranges of movement. These instruments were administered again at 2, 5, and 9 weeks after the beginning of treatment. RESULTS: Randomization proved to be successful. The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%). Manipulation achieved the best overall results, with improvements of 50% (P = 0.01) on the Oswestry scale, 38% (P = 0.08) on the NDI, 47% (P < 0.001) on the SF-36, and 50% (P < 0.01) on the VAS for back pain, 38% (P < 0.001) for lumbar standing flexion, 20% (P < 0.001) for lumbar sitting flexion, 25% (P = 0.1) for cervical sitting flexion, and 18% (P = 0.02) for cervical sitting extension. However, on the VAS for neck pain, acupuncture showed a better result than manipulation (50% vs 42%). CONCLUSIONS: The consistency of the results provides, despite some discussed shortcomings of this study, evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication. However, the data do not strongly support the use of only manipulation, only acupuncture, or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain. The results from this exploratory study need confirmation from future larger studies.

Comparing yourself to other unproven modalities is, to say the least, unconvincing litterature to quote. In addition, the time frame of 9-22wks post injury is well within the period of the natural history of the disease where it resolves spontaneously in >85% of cases. It would therefore be hard to make any claim that improvements druing this time period were attributable to a particular theraputic regimen, rather than merely the typical course of all comers.

5) ... I do not recall advocating for 'lumping' of LBP.

Yet the articles you cite do exactly that.

 

[awdc]

Originally Posted by paz5559
My criticisms are direct quotes out of the texts used by students at Life University School of Chiropractic

And therein lies the problem... most chiropractic schools do not militantly espouse the philosophies that Life U (a school with a history of accreditation problems) holds regarding chiropractic. With regards to these "texts," I can't specifically address that issue since I don't know which texts you're referring to and considering that my experience has been different. If you look at my shelf of the books I've accumulated during chiro school, none of them states that subluxation is the root of all evil... only theories as to why vertebral joint dysfunctions may be related to certain conditions. In general the information out there suggests that the few traditional, philosophy-oriented chiropractic schools (e.g. Life, Sherman, Palmer?, Parker?) produce half of this country's DC's while the majority of chiropractic schools (with smaller class sizes) that are more scientific and multidisciplinary in their approach produce the rest. Of course, you will still find individuals at extremes end of the spectrum no matter which school they are from.

Moreover, after rotating with some DO students, I was surprised that osteopathic principles and manipulation addressed and emphasized greater applications to visceral conditions than what I had been exposed to in chiropractic school. Where is the criticism in that?

With regards to the Spine article above, clearly NSAIDS are not unproven modalities. Are you then advocating that we withold NSAIDS in patients with back pain during this time frame since in >85% of cases (quoting your number) it would resolve spontaneously? The Cochrane article you posted also concluded that spinal manipulation is not superior to any of the other modalities cited and it wasn't inferior either.