Supporting the unsupportable

This is entirely my fault.  I have been staying away of late from more confrontational posts about altmed, mostly out of fatigue.  I also would prefer to blog about medicine, family, and various train-of-thought nonsense.  But I went and got myself quoted and a number of folks seem displeased.  Supporters of chiropractic neck manipulation, a practice I recommend against, are quoting a number of studies and making a number of comparisons that aren’t really supportable, so I have to respond.

First, my bias: for a medical practice to be routinely recommended, it should work, and how much it works should be worth whatever risk attends it.  In order to prove its worth, there should be studies that, in aggregate, support the practice.  For those studies to be taken seriously, the must  be well done and the practice must have a plausible mechanism of action.

Let’s look at neck pain.  This is a common condition, affecting most of the population at some point, but rarely associated with significant disability; those are what the statistics say, but when your neck hurts, you want it to feel better and you might seek professional advice.  And, like low back pain, neck pain does tend to recur.  It also tends to remit spontaneously, especially in younger people, the same people unlikely to have significant spine pathology.  In assessing neck pain outside the setting of trauma, X-rays, a common practice among both chiropractors and doctors, do not appear to help guide diagnosis in a significant way.

In a typical primary care practice, neck pain without alarm signs (such as weakness, fevers, weight loss) tends to be treated quite conservatively, with stretches, tylenol or anti-inflammatory drugs (NSAIDS) for pain relief, and tincture of time.  When this fails to give relief, patients are often referred for imaging and physical therapy. It’s certainly plausible that manipulation of the neck, whether done by a chiropractor, masseuse, physical therapist, or beneficent spouse may help.  The question becomes does it help, and if so how much and with what risk.

NSAIDs, despite their easy over-the-counter availability, are potent drugs and come with significant risks, risks which increase with length of use and with other risk factors.  NSAIDs probably increase the risk of cardiovascular events in certain subsets of patients, and are one of the two primary causes of stomach ulcers.  But short term treatment with NSAIDs, as would be typical for someone with benign neck pain or low back pain, is relatively safe.  There is very little risk to an otherwise healthy young person who uses NSAIDs at a normal dose for a week or two.  They probably do not lead to quicker resolution of an episode of neck pain, but they may give comfort while the episode resolves.

From what I gather having read the above-referenced blog post, the main arguments seem to be that chiropractic neck manipulation never leads to vertebral artery dissection, and that other treatments are much more dangerous.

As to the first claim, my colleague Mark Crislip has given a nice explanation of the data, the gist of which is that we shouldn’t be seeing vertebral artery dissections in young people, and the fact that many of these rare events are coincident with chiropractic neck manipulation should give us pause.

The writer’s strong emphasis on the risk of NSAIDs is based on a misunderstanding of the use of NSAIDs to treat benign neck pain.  What patients choose to do on their own is less relevant, but as physicians, we rarely give long courses of high-dose NSAIDs to these patients.  They tend to get better on their own, and short courses of NSAIDs in young, healthy patients come with little risk.

Most benign neck pain is self-limited.  According to the study cited by the chiropractors:

Quality of life years (QALYs) associated with standard NSAIDs, Cox-2 NSAIDs, exercise, manipulation, and mobilization were compared in a decisionanalytic model. None of the active treatments was found to be clearly superior to any other in the short or long term when estimates of the course of neck pain, adverse event risks, treatment effectiveness and risk, and patient-preferences for health outcomes were considered.

Given that most treatments for neck pain probably provide a bit of relief while the condition resolves on its own, what most physicians and chiropractors should do is simply get out of the way.  Patients should be assessed for non-benign causes of their pain, NSAIDs can be prescribed safely for short term use, and patients will get better. There is no evidence that chiropractic provides additional benefit, especially in the long term.

But when it comes to risk, there is a small but definite association between chiropractic neck manipulation and the rare form of stroke known as vertebral artery dissection.  This correlation is most clearly seen in young patients, those who would not normally suffer from strokes.  Given the lack of superiority of chiropractic, and the small but real association with VAD, I stand by my advice that one should not allow a chiropractor near the neck.

16 Comments

  1. luba petrusha

     /  October 2, 2011

    Believers in chiropractic are like believers in any particular religion; you can argue with them all you want, bring up science and facts, but in the end it doesn’t matter. It comes down to belief, not understanding.

    • People who don’t acknowledge solid scientific evidence that chiropractic manipulation is effective are like believers in any particular religion; you can argue with them all you want, bring up science and facts, but in the end it doesn’t matter. It comes down to belief, not understanding.

      Aure, O. F., J. Hoel Nilsen, et al. (2003). “Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-up.” Spine 28(6): 525-531.

      Cecchi, F., R. Molino-Lova, et al. (2010). “Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up.” Clinical Rehabilitation 24(1): 26-36.

      Dagenais, S., R. E. Gay, et al. (2011). “NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain.” The spine journal : official journal of the North American Spine Society 10(10): 918-940.

      Descarreaux, M., J.-S. b. Blouin, et al. (2004). “Efficacy of Preventive Spinal Manipulation for Chronic Low-Back Pain and Related Disabilities: A Preliminary Study.” Journal of manipulative and physiological therapeutics 27(8): 509-514.

      Giles, L. G. F. and R. Muller (2003). “Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation.” Spine 28(14): 1490-1502.

      Gross, A., J. Miller, et al. (2010). “Manipulation or Mobilisation for Neck Pain. .” Cochrane Database of Systematic Reviews Reviews 2010(1).

      Gross, A. R., J. L. Hoving, et al. (2004). “A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Disorders.” Spine 29(14): 1541-1548 10.1097/01.BRS.0000131218.35875.ED.

      Haas, M., E. Groupp, et al. (2004). “Dose-response for chiropractic care of chronic low back pain.” The spine journal : official journal of the North American Spine Society 4(5): 574-583.

      Hoiriis, K. T., B. Pfleger, et al. (2004). “A Randomized Clinical Trial Comparing Chiropractic Adjustments to Muscle Relaxants for Subacute Low Back Pain.” Journal of manipulative and physiological therapeutics 27(6): 388-398.

      Korthals-de Bos, I. B. C., J. L. Hoving, et al. (2003). “/ Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial / Commentary: Bootstrapping simplifies appreciation of statistical inferences.” BMJ 326(7395): 911-914.

      Lawrence, D. J., W. Meeker, et al. (2008). “Chiropractic Management of Low Back Pain and Low Back-Related Leg Complaints: A Literature Synthesis.” Journal of manipulative and physiological therapeutics 31(9): 659-674.

      Meade, T. W., S. Dyer, et al. (1995). “Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up.” BMJ 311(7001): 349-351.

      Muller, R. and L. G. F. Giles (2005). “Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes.” Journal of manipulative and physiological therapeutics 28(1): 3-11.

      Murphy, D. R., E. L. Hurwitz, et al. (2009). “A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study With Follow-Up.” Journal of manipulative and physiological therapeutics 32(9): 723-733.

      Senna, M. K. and S. A. Machaly (2011). “Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome?” Spine 36(18): 1427-1437 10.1097/BRS.0b013e3181f5dfe0.

      Team, U. B. T. (2004). “United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care.” BMJ 329(7479): 1381.

      Vernon, H., K. Humphreys, et al. (2007). “Chronic Mechanical Neck Pain in Adults Treated by Manual Therapy: A Systematic Review of Change Scores in Randomized Clinical Trials.” Journal of manipulative and physiological therapeutics 30(3): 215-227.

      Wilkey, A., M. Gregory, et al. (2008). “A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-Back Pain in a National Health Service Outpatient Clinic.” The Journal of Alternative and Complementary Medicine 14(5): 465-473.

  2. That is certainly a more rational post. Thank you. However, you have gone out of your way to perpetuate an irrational fear of chiropractic while remaining completely silent about similar (and often greater) risks in your own profession. If you are going to claim to be “evidence-based” you can’t ignore evidence that doesn’t agree with your preconceptions. This is known as “confirmation bias”.

    I can agree that both professions need to consider risks when prescribing any treatment. For instance, a longer course of NSAIDs is likely to carry greater risk than short-term NSAID use. And, an acute neck complaint is perhaps more likely to carry risk of VAD. Further, the research supporting chiropractic manipulation for chronic neck pain is more convincing than for acute neck pain. Therefore, a rational approach based on the evidence would be for chiropractors to perform fewer manipulations on acute neck pain patients and for MDs to refer for more of their chronic neck pain patients for chiropractic manipulations. This would be “evidence-based”.

    Because I am an evidence-based practitioner, I will be applying more mobilization procedures and fewer manipulations in my acute neck pain patients. I expect that you, as an evidence-based practitioner, will be referring more of your chronic neck pain patients for chiropractic manipulation. The evidence suggests that this will decrease their risk and improve their outcomes.

    Evidence:

    A literature review of quality clinical trials (scoring above 11.5 on the Amsterdam-Maastricht Scale) found that “There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks posttreatment.” Vernon, H., K. Humphreys, and C. Hagino, Chronic Mechanical Neck Pain in Adults Treated by Manual Therapy: A Systematic Review of Change Scores in Randomized Clinical Trials. Journal of manipulative and physiological therapeutics, 2007. 30(3): p. 215-227

    In a study evaluating the long-term benefits of medication (NSAIDs), acupuncture, and spinal manipulation researchers concluded that: “In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.” Muller, R. and L.G.F. Giles, Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes. Journal of manipulative and physiological therapeutics, 2005. 28(1): p. 3-11.

    A clinical trial comparing manipulation with acupuncture and medication found that: “In patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication.” The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%). Giles, L.G.F. and R. Muller, Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation. Spine, 2003. 28(14): p. 1490-1502.

    A literature (Cochrane) review from 2004 found that mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders. Gross, A.R., et al., A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Disorders. Spine, 2004. 29(14): p. 1541-1548

    A review published in the British Medical Journal concluded that, “Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.”Korthals-de Bos, I.B.C., et al., / Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial / Commentary: Bootstrapping simplifies appreciation of statistical inferences. BMJ, 2003. 326(7395): p. 911-914.

  3. PalMD– thank you for an extremely well written and well thought out post. I can bet my entire life’s savings, and then some (which is not inconsiderable) that 90% or more of those with a VAD will tell you to stay away from chiropractors and, particularly, neck manipulations. Until you know what it is like to shuffle your way out of the hospital (and being told that they are surprised you can even walk), it’s moot to cite studies that are likely funded by pro-chiropractic association. The risks are not worth the supposed possible pain relief benefits.

    Other countries require that chiropractors clearly state the risks, including that of a major stroke and death. Thankfully, these laws are either in progress, or being passed in the US. From a person who is still waiting for her dissection to heal, if it ever heals at all, VAD’s are real, do exist, and happen to young and otherwise healthy people but if not for some sort of trauma to their neck.

    Given that chiropractors only need, at the minimum, a 2 year ASSOCIATES degree before going to chiropractic school, and there is no rigorous “residency” training, I would rather bet my life on a doctor’s diagnosis over that of “chiropractic care”.

    Let’s put it this way– My back can continue to hurt when I have PMS. I would rather be alive and mobile.
    ,

  4. Old Geezer

     /  October 2, 2011

    I strongly believe that coincidence does not mean causation, but when the stakes are death or paralysis maybe it is well to pay attention to some of those coincidences. I had a serious set of injuries in an automobile accident in 1957 that has left me with muscle, nerve and disc injury in my cervical, thoracic and lumbar spine. I just cannot accept that being pushed about for five or ten minutes on a table will help overcome all of that damage. The only time I went to a chiropractor, I was in bed for three days afterward. The chiropractor just couldn’t explain it!

  5. luba petrusha

     /  October 3, 2011

    AP Kurt: according to D.D. Palmer, the founder of chiropractic, subluxation of the spine interferes with the body’s ability to heal itself, and causes all sorts of diseases, from acne and hemorrhoids to bed wetting and cancer. Correcting these misalignments of the spine will thus cure these diseases. This chart is an example: http://www.burreschiropractic.com/spinalchart.asp

    Is that what your list of articles is referring to?

    Or is it to the fact that some studies have found some benefit from chiropractic manipulation to the spine that is not inferior to other therapies for back pain (which are,for the most part, pretty useless)?

    Chiropractic is mostly bunk. It is not scientific, just like homeopathy. But at least homeopathy won’t actively kill you.

    Oh, and Stephen Barrett, of course: http://www.quackwatch.com/01QuackeryRelatedTopics/chiro.html

    • Karen

       /  October 3, 2011

      In my limited experience, chiropractic as practiced is an odd mix of effective physical therapy and ineffective bunk. When my father was nearly immobilized by back pain, I got a look at his X-ray, and there didn’t seem to be an uncompressed disk among the lot. He was bedridden, except to struggle to go see the doctor. (His MD was amazed he could even walk at all.) MD suggested a particular chiropractor — which surprised all of us involved in Dad’s care — but after about three months of therapy, Dad was up and about again. He never regained his old stride, but somehow he managed with that back (and with some light pain meds) almost until his death six years later at age 93; he needed a walker for stability in the last month of his life.

      So, I don’t dismiss chiropractors out of hand… but I’m still deeply suspicious of all this “manipulation” business for ordinary back or neck pain. I take ibuprofen for a few days and it tends to sort itself out, as Pal says.

    • You say : “Is that what your list of articles is referring to?” How about you READ the references. They are published peer-reviewed scientific studies.

      Instead of actually reading the science or providing science to support your point, you’d prefer to talk about what some chiropractors were doing at the turn of the century. The humor site Cracked covered some of the things that medical doctors have done in the past. http://www.cracked.com/article_15669_the-10-most-insane-medical-practices-in-history.html

      I showed you “science and facts” and you responded with silliness. It’s good for a laugh, but I’m not going around bashing medical doctors because they used to believe some wacky stuff.

      I recognize that MDs are generally well trained and most are doing their level best to help their patients. I don’t have an axe to grind against MDs. I’m just asking that our profession be treated fairly and that people like yourself actually read the scientific evidence objectively.

      Then again, thank you for proving the point I made following your original post. “you can argue with them all you want, bring up science and facts, but in the end it doesn’t matter.”

      • I’m a little confused, Kurt. People did respond with citations and facts, they just are contradictory to yours. Maybe they’re right, maybe they’re not, but they seemed serious.

        For my own selfish curiosity, what is the whole deal with chiropractic neck stuff? What is it supposed to do? I was always told I shouldn’t “crack” my neck.

        • Hi MonkeyPox. Which responses were those? Other than people who are in support of my point of view there has only been a single response from either of these threads that has included peer-reviewed research: Mark Crislip October 2, 2011 at 3:24 pm.

          He referenced two peer-reviewed sources and one of his sources actually made conclusions that support my position. The other source has been disputed in the literature because of serious methodological flaws:

          Spine (Phila Pa 1976). 2010 Apr 1;35(7):840.
          Spine (Phila Pa 1976). 2009 Oct 15;34(22):2476; author reply 2476-7.
          Spine (Phila Pa 1976). 2010 Feb 15;35(4):467-8.

          In contrast, I have provided more than 20 peer-reviewed studies to support my position which is this:

          Point 1: For chronic neck pain, the preponderance of evidence suggests that spinal manipulation has been found to be at least as safe and at least as efficacious as alternative treatments. Therefore people who bad-mouth chiropractors and spread fear about the treatments they offer are both unjustified and unprofessional. You’ll notice that I have not bad-mouthed the medical profession in any way. I think most MDs are quality people genuinely trying their best to help their patients.

          Imagine you have worked your way through 9 years of college and studied very hard to obtain a professional degree. You go to work every day with the sincere intention of helping people. You make every effort to keep abreast of current research and apply this research to the safety and benefit of your patients. You build relationships with teaching institutions, local doctors, and community leaders based on a reputation of integrity and genuine care for your patients.

          Then despite a decade of helping literally thousands of people without a single injury, despite significant peer-reviewed evidence demonstrating that the treatments you offer are safe and effective, despite peer-reviewed evidence that your education is on par with your colleagues in your area of expertise, there remains a group of people who are very vocally bad-mouthing your profession. You can imagine that might make you a little angry. Especially when you consider point 2:

          Point 2: And this is related to my insistence on peer-reviewed references: Often the same people who are bad-mouthing chiropractors claim that they are justified because they are “evidence-based”. However, they are unwilling to view the scientific evidence that disagrees with their preconceived notions in an objective manner. Or they cherry-pick a paper here or there without considering the evidence in total. This is the antithesis of “evidence-based”. If you read all of my posts you will see that after reviewing the evidence I was willing to concede that “I will be applying more mobilization procedures and fewer manipulations in my acute neck pain patients.” I feel that this is a rational response to a consideration of the evidence.

          So that’s that. I feel like I’ve made myself heard so I will stop commenting on this post. Thank you to PalMD for allowing me to make my point in this impromptu forum. I genuinely wish the best for him and his patients in the future.

      • luba petrusha

         /  October 6, 2011

        Right, “in the past” is the point when it comes to the cracked article. Most “allopaths” have moved on since. But that spinal poster is still used by many chiropractors (which how I came across it in the first place, by seeing ads with similar ones included). And how do you defend regular prophylactic adjustments in children, which are performed and recommended by many chiropractors?

        Yes, there was (and still is) much bunk and quackery involved in medicine. But at least there are institutes dedicated to research into developing new treatments and assessing old ones. Chiropractic? Not so much.

  6. MonkeyPox

     /  October 4, 2011

    Thanks for the response, but I’m still curious about how this stuff works.

    • Interesting question. I can point you to some resources, but maybe one of the chiropractors can give you a better explanation.

  7. APKurt

     /  October 4, 2011

    I said I wouldn’t post again, but I’m happy to answer your question. Here’s a brief overview of our current understanding. Despite clinical evidence for the benefits of spinal manipulation the biological mechanisms underlying the effects of spinal manipulation are still being studied. For brevity I will not include specific references but you are welcome to contact me if you’d like the references or more details here http://advancedphysicalhealth.blogspot.com:

    First mechanism: Spinal manipulation increases joint mobility by producing a barrage of impulses in muscle spindle afferents and smaller-diameter afferents ultimately silencing facilitated γ (gamma) motoneurons as proposed by Korr. This theory is supported by several recent studies by the Pickar lab and by findings that low back pain patients have altered proprioceptive input from muscle spindles. Recent work has also shown that that spinal manipulation modifies the discharge of Group I and II afferents. This has been accomplished by recording single-unit activity in muscle spindle and Golgi tendon organ afferents in an animal model during manipulation.

    A second mechanism is that spinal manipulation, by mechanically opening the intravertebral foramina (IVF), decreases pressure on the dorsal roots. Substantial evidence shows that the dorsal nerve roots and dorsal root ganglia are susceptible to the effects of mechanical compression. Compressive loads as low as 10 mg applied to dorsal roots increase the discharge of Group I, II, III and IV afferents. This compression can also alter non–impulse-based mechanisms (eg, axoplasmic transport) and cause edema and hemorrhage in the dorsal root. Spinal manipulation mechanically decreases the pressure in the IVF by gapping the facet joints and opening the IVF. For instance, the synovial space of the lumbar facet joints increases by about 0.7 mm in individuals receiving manipulation. This doesn’t seem like much, but as with any therapy there is usually a course of care involved. Even in moderate stenosis patients we typically see significant pain reduction following a period of 1-2 weeks of treatment.

    A third mechanism is based on findings that persistent alterations in normal sensory input resulting from an injury can increases the excitability of neuronal circuits in the spinal cord. Spinal manipulation works by applying non-noxious mechanical inputs to these circuits. This involves mechanisms similar to the pain-gate theory proposed by Melzack and Wall wherein activation of A-α and A-β fibers can reduce chronic pain and increase pain threshold levels. This is supported by studies where spinal manipulation of the lumbar region decreases central pain processing as measured via pin-prick tests. Additional studies have shown a reduction in central pain sensitivity after spinal manipulation using graded pressure and noxious cutaneous electrical stimulation.

    A fourth mechanism involves β-endorphin mechanisms. Studies have shown increases in β-endorphin levels after spinal manipulation but not after control interventions. This is still being debated because results have been variable and a recent study failed to show increased β-endorphins even though subjects had decreased pain.

    Fifth mechanism: Substantial evidence also shows that spinal manipulation activates paraspinal muscle reflexes and alters motoneuron excitability. These effects are still being studied and appear to differ depending on whether performed on patients in pain or pain-free subjects.

    A sixth mechanism involves inhibition of somatosomatic reflexes by alterations in muscle spindle input produced by spinal manipulation. It is thought that spinal manipulation may normalize spindle biomechanics and improve muscle spindle discharge.

    Lastly, in humans, manual therapies can decrease heart rate and blood pressure while increasing vagal afferent activity as measured by heart-rate variability. Manual therapies in rats have been shown to produce an inhibitory effect on the cardiovascular excitatory response and reduce both blood pressure and heart rate. Manual therapies such as massage have been shown to impact behavioral manifestations associated with chronic activation of the HPA axis such as anxiety and depression, while decreasing plasma, urinary, and salivary cortisol and urinary corticotropin releasing factor-like immunoreactivity (CRF-LI). Manual stimulation in rats has been shown to significantly increase glucocorticoid receptor gene expression which enhanced negative feedback inhibition of HPA activity and reduced post-stress secretion of ACTH and glucocorticoid.

    I know some of this is pretty technical, but I’d be happy to explain in detail if you contact me at the link above. Come to think of it, perhaps I will post a video link that explains these things better in layman’s terms. Cheers.

    • APKurt

       /  October 4, 2011

      I just remembered this paper which is the most comprehensive review of the literature on the mechanisms involved in spinal manipulation:

      http://www.ncbi.nlm.nih.gov/pubmed/17142166

      It’s five years old now and there has been a significant amount of research since then. However, it gives a nice overview of the areas of strengths and weaknesses in basic science research related to chiropractic as of 5 years ago.

  8. APKurt

     /  October 5, 2011

    One last thing, I promise. I forgot to add this: Everybody wants to focus on spinal manipulation when it comes to chiropractic, but that’s not all we do. Think of everything a physical therapist would do; we do all of those things too. In my office I perform treatments like ultrasound when appropriate, soft-tissue techniques, joint mobilization, post-isometric stretching, McKenzie protocols, athletic taping, etc. For a lot of patients I don’t even manipulate the spine. And, I have a complete exercise rehabilitation facility where we work on everything from core strengthening to shoulder and knee injuries.

    And, we are trained and licensed to diagnose. I perform complete health histories and physical exams. For example, in my headache patients I perform opthaloscopic exams and check cranial nerves. I also perform standard orthopedic test and do things like palpation, auscultation, and percussion. I also perform pre-employment physicals. I routinely order X-rays, MRI, MRA, CT, blood work, diagnostic ultrasounds, etc. I occasionally give nutritional advice, but I don’t sell any vitamins in my office and I only recommend things that are well-researched.

    For non-musculoskeletal conditions I refer to internists or specialists. For musculoskeletal conditions that are beyond my scope or are not responding as expected I obtain orthopedic consults.

    So that’s how chiropractic “works”. I’m sorry to disappoint the haters out there, but there’s no voodoo, no “belief” systems, no sales pitches, no magic wands, and no “pseudoscientific bunk”. And, I don’t keep people coming back for ever and ever just to pad my pocketbook. The vast majority of my patients improve very quickly and are released from care within a week or two at the most.

    Yes, there are some wacky chiropractors out there, just as there are some wacky MDs, and wacky attorneys, and wacky school teachers, and wacky dentists, etc. And, yes 110 years ago chiropractors believed things that we know now are not true; the same can be said of MDs. Most of what we do these days is backed up by solid scientific research and more research is being published every year.

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