Random Wednesday thoughts

I read with interest the comments from a chiropractor left on a recent series of posts.  It reminded me of a few things.  First, there are plenty of thoughtful, intelligent chiropractors.  Just because there are also a lot of wackos doesn’t mean many of them aren’t trying to do good.

But his presentation of evidence left me feeling a bit empty, as if more “modern” chiropractors are looking for a scientific basis for their practice but not yet finding much meat, at least compared to usual medical literature.  The starting point seems to be “well, we know this stuff works, but not yet why, and here are some plausible hypotheses, some of which we’ve tested.”  It seems a bit “wrong way ’round” scientifically.  In most of medicine, we come up with a hypothesis, either through reasoning from scientific plausibility or via serendipity, and test it before applying it.  The chiropractors that have moved away from the fantastical “subluxation complex” idea are working from an assumption that what they do actually works.

The sum of the literature at this point does not point to a strong effect from chiropractic for most situations, although it may be equal to usual care for back pain.  But it’s just not real strong evidence, the kind we would expect from a medical intervention. That isn’t to say real medicine has done much better for functional musculoskeletal pain, it’s just that chiropractic doesn’t appear to have additional benefit—at this point.  It would be better to find out if some sort of standardized chiropractic treatment actually worked consistently, and then look for a mechanism of action.

And just as in medicine we recognize a risk-benefit ratio associated with our interventions, chiropractors must learn to do the same.  It’s time for them to acknowledge that vertebral artery dissection, while quite rare, does appear to be associated with neck manipulation, and given the limited benefit of the intervention, it shouldn’t be done.

Perhaps some day, one or more specific, standardized chiropractic approaches will find a valid use, but after more than a century, we’re just not there.

In real medicine, we also need to clean house a bit.  Doctors need to take a look at the physical therapy centers they use.  Some are based on typical range of motion and strengthening maneuvers, but there are plenty of odd practices going on, such as reiki and cranial-sacral therapy.  “Consult PT” often leads to interventions you might not have intended.

In addition to warning my patients away from chiropractic neck manipulation, I also remind them that recovery from back and neck pain requires a great deal of patience.  Any doctor who claims to be able to entirely relieve their pain isn’t being honest.  And surgery is an option saved for those who have significant pain or weakness that a surgeon really thinks would respond to surgery.  If there is no impending spinal catastrophe, it’s always good to get a second opinion.

Lest you think me heartless, I’ve shared with you my own back troubles, and when I was at my worst, I just wanted to get better.  I thought about chiropractic, acupunture, anything, but my research led me away from it (especially given the huge hunk of disc sitting near my spine).  And like most patients, I improved spontaneously over time.  It’s hard to be patient when you hurt, but sometimes it’s still the best plan.

4 Comments

  1. Old Geezer

     /  October 5, 2011

    I’ll see your disc and raise you seven. In all seriousness, the orthopedic surgeons I have respected the most are the ones who have said, “Let’s not rush into surgery. We have found that there are a lot of things we can do before we start doing drastic stuff.” On the other hand, I’ve never met a manipulator who had any belief but that he could tweak it here and twist it there and all would be just fine. I’m with you Pal. Patience and good medicine is the way to go.

  2. ericdc77@gmail.com

     /  October 6, 2011

    Correct, these are random thoughts. I’m not sure what the point of the post is.

  3. Another thing we could use is some better way for patients to select physical therapists, occupational therapists, etc. when our doctors don’t have recommendations.

    I had PT some years ago: the orthopedic surgeon basically said “get your primary to write a prescription.” My primary care physician didn’t have a useful recommendation, so I just picked someone based on geography. He turned out to be quite good, but that was pure luck.

    More recently, she gave me a generic “you should see an occupational therapist,” and again I had no basis for choice, so went with geography (this time, someone near my office) combined with her self-describing as specializing in hands and arms. After a few sessions, I have concluded that either she is the wrong therapist for me, or OT isn’t what I need, but I’m not enthusiastic about starting over with someone equally random.

    (To be fair, my primary has offered me suggestions for, among other things, a cardiologist and a radiology facility.)

  4. MZ

     /  October 6, 2011

    I had a wonderful experience with PT in Australia last year. For the first time in my life, I had lower back pain; before that I had always been smugly self-righteous about all those sufferers. I had to go to the dr anyway to get some vaccinations for travel, and while there asked about my back. She asked me a few questions, had me move around while she looked at me, and then said, “why don’t you go to the physio (what physical therapists are called there)?” I asked her to write me a referral, anticipating lots of paperwork and long waits, and she looked faintly surprised and said I didn’t need one, I could just go, and what’s more, she told me, the one on campus was quite good and convenient.

    OK. I duly made an appointment for the next day, no fuss, and when I saw him, he also examined me, asked some questions, and concluded that the problem was the crummy mattress in the rented apartment I had just moved into a couple of months before. He said, “I can make the pain better now, but we need to figure out a way to prevent it from recurring.” In the end, he massaged/manipulated my back (not chiropractic), my husband and I flipped and turned the mattress, and presto. Pain gone. The bill was just over $60.

    I realize it was an easier fix than for many people’s back pain, but for me the moral of the story was that it was a much more effective approach than what I would have found here in the US, with a mandatory visit to a primary care physician, doubtless an X-ray (which I am sure they would have done in Oz had the pain persisted), a referral, and a lot more hassle and expense. Physical therapists there are much more free agents, and tons of people go to them for all kinds of help.

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