During my 20+ years of practice, primary care physicians have expressed four main areas of concern. I would like to address these concerns in this newsletter.


1. What type of education does a chiropractor have?
Chiropractors are required by the state of Maryland to have a four-year undergraduate degree to obtain a license. Chiropractic school is a four year program consisting of 4800 hours of classroom, laboratory, and clinical study, including anatomy, physiology, chiropractic technique, radiology, biochemistry, toxicology, biomechanics, nutrition, diagnosis and physical examination, and a clinical internship consisting of one year of hands on clinical experience and training in a professional clinical setting. The Department of Health and Human Services classifies doctors of Chiropractic as category 1 providers, just like medical doctors, osteopaths, and dentists.



2. Can a chiropractor really diagnose?
One case I will never forget illustrates the importance of proper diagnosis in chiropractic practice. When I first started practice, a 45-year-old woman presented in severe lumbar pain. Examination showed clubbing of every digit. The woman was a smoker and had been examined three months prior, but the clubbing was dismissed. Lumbar X-rays showed destruction of the pedicles in two vertebrae and chest films showed a large metastasis to the lung. She was immediately referred to an oncologist.
Over the years, patients have presented with the following disorders: disc herniations, ectopic pregnancy, breast cancer, ankylosing spondylitis, aortic aneurysm, congenital torticollis, and carpal tunnel syndrome.
All examinations include vital signs, orthopedic testing, reflexes, ROM, muscle strength testing, dermatomal sensation, and posture evaluation. X-rays and lab work are done as indicated.

3. Is chiropractic safe?
A number of literature reviews of serious occurrences from chiropractic adjustments have been documented. The most exhaustive study discussed 113 cases of vertebro-basilar accidents following spinal manipulative therapy, from 1934 to 1987, a period of 53 years. Of the cases documented 66 were chiropractic, 18 medical, 9 osteopathic, 2 physical therapist and the remaining 13 were divided between "wife," "self," and "unknown".

Let's put these numbers in perspective. There were 66 chiropractic cases in 53 years; a little more than one per year. There are currently about 52,000 chiropractors in practice treating, on average, about 100 patients per week. That works out to 5.2 million adjustments per week or 286 million adjustments per year. This works out to 1 to 2 cases of stroke, paralysis or death per 286 million adjustments. Maigne has stated, "there is probably less than one death of this nature out of several tens-of-millions of manipulations." No matter how one interprets the results, more people die from complications of drugs and surgery in one single afternoon than in decades of cervical adjustments. As a comparison to the risk of manipulation, the risk of paralysis from neurosurgery of the cervical spine is 15,000 cases per million.

4. Don't chiropractors keep you coming forever?
Our goal is to correct problem, i.e., decrease pain; increase ROM, increase muscle strength, correct any biomechanical abnormalities of joint function, and allow proper nervous system function. Initial care may be frequent- 1-3 times per week for a few weeks. Then care will taper and include nutrition, exercise (stretching and strengthening), and ergonomic advice. Maintenance care will be performed if the patient wishes. The patient will always be referred back to the primary care physician for general health care.

5. Do Chiropractors treat muscles? YES! Active Release Techniques® (ART) and Graston Technique (GT) are treatments specifically designed to treat muscles. Most of the time when muscles (tendons and ligaments also) are injured they actually tear. Pulls, strains (sprains are ligament tears), and ruptures are really tears of the muscle. Think of each muscle fiber as a single hair on your head. Did you cut (tear) one hair, all the hairs, or some portion of the hairs? What most people call a pull or strain is a tear of some of the muscle fibers, but not all, that make up the muscle. When a muscle tears, the first response in the body is an inflammation that may or may not cause significant swelling. The texture of the muscle changes and after the initial inflammation the muscle tissue feels taut like a guitar string and bumpy like gravel. Have you ever kneaded bread dough or pottery clay and tried to get the lumps out to make it smooth? This is like what treating an injured muscle feels like. This "adhesion" or scar tissue must be broken up or kneaded away. This can be accomplished with both ART and GT. This cannot be accomplished with anti-inflammatory medicines like ibuprofen (Advil, Motrin, Nuprin), naproxen (Aleve), Celebrex or Vioxx. These medications can help with the initial inflammation and pain, but they can disrupt and prevent proper healing of the muscle tissue. Also significant are the side effects, especially gastro-intestinal bleeding which kills thousands of people each year.

Most problems that present to my office are a combination of muscle injury, joint dysfunction and nerve irritation. That is why it is important to address all the components of the injury during treatment. Loosening up the muscle and removing the adhesions before making the adjustment to restore proper function to the joint is critical to proper and speedy healing. Many nerve injuries can be the result of torn muscles, tendons and ligaments adhering to nerve fibers and causing nerve irritation, e.g. carpal tunnel syndrome. If this is the case the nerve irritation can be removed by removing the adhesion of the muscle to the nerve. Proper stretching and strengthening are then added to the treatment program. ART and GT may allow the injured area to become pain free during regular daily activities, but only proper rehabilitative strengthening and stretching will allow the area to sustain the added forces of sports or rigorous training.

Common "muscular" injuries treatable by ART and GT include rotator cuff tears, frozen shoulder, tennis/golfer's elbow, carpal tunnel syndrome, ilio-tibial band syndrome, patellar tendonitis, shin splints, sprained ankles, Achilles tendonitis or rupture, plantar fasciitis, arthritic joints and common "pulls" like in the hamstrings. ART and GT work very well when combined with chiropractic adjustments for spinal problems as well.


Chiropractic -- A Medical Doctor's Perspective
By David Perlmutter, M.D.
Naples, Florida

"Recently I wrote an article for the Naples Daily News, Chiropractic Medicine -- Effective Alternative for Pain, Studies Show. The response that followed was surprising.

Predictably, I received several complimentary letters and phone calls from chiropractors in the community. On the other hand, my physician colleagues were obviously less than pleased with my portrayal of chiropractors as being conscientious and effective health care practitioners.

It is our duty as health care providers to give our patients the very best care available. If a physician is unable to provide a modality which may be effective in the treatment of a medical problem, then, without question, the patient should be referred to someone who may be able to offer this type of treatment. Clearly, "If your only tool is a hammer, every problem looks like a nail." This is why I frequently refer patients to chiropractors as well as acupuncturists, massage therapists, osteopaths, or to any one I feel may have something to offer my patient.

In researching chiropractic, I was pleased to learn that chiropractors receive a considerable amount of training in nutrition during their six years of chiropractic education. This contrasts significantly with medical school. It is estimated that only one-fifth of the medical schools in this country require courses in nutrition. What this seems to indicate is by encouraging an understanding of nutrition, chiropractic is more attuned with disease prevention rather than simply disease treatment.

As a neurologist and medical director of a physical rehabilitation facility, a large part of my practice deals with various syndromes. Some patients do well with straightforward medical treatment, using non-steroid, anti-inflammatory medications, etc. Other patients seem to do well after a course of physical therapy involving both active and passive modalities. Frequently, I refer patients for chiropractic evaluation and treatment and more often than not I am gratified by the response that my patients get.

Perhaps this article should have been published in a medical doctor's journal as opposed to "DC." In my experience, chiropractors have always known when it was appropriate to obtain consultation on a patient from another specialty. Medical doctors, however, have always seemed unlikely to refer patients to chiropractors, and this is not only unfortunate but also unfair since it deprives patients of a potentially useful modality.

There is no one discipline that has a corner on the market of techniques useful in patient care. No one discipline has all the tools. Hopefully, with time my medical colleagues will learn to concentrate on the ultimate goal of providing patients with the best chance of feeling better and realize that chiropractic has a lot to offer."


Chiropractic Recognized by Orthopedics Today

An orthopedics publication may not seem a likely place to find an article praising chiropractic, but perhaps Orthopedics Today has started a trend. The February 2003 issue of the magazine dedicated to "current news in musculoskeletal health & disease" featured an article entitled, "Time to Recognize Value of Chiropractic Care? Science and Patient Satisfaction Surveys Cite Usefulness of Spinal Manipulation."1 The article includes powerful commentary in support of spinal manipulation from Scott Haldeman, DC, MD, PhD, co-author of the Mercy Guidelines2 and several studies on the safety of spinal manipulation;3,4 Jack Zigler, MD, orthopedic spine surgeon with the Texas Back Institute; and Andrew Cole, MD, associate clinical professor of rehabilitation medicine at the University of Washington and recent past president of the American Academy of Physical Medicine and Rehabilitation.

"There are a lot of myths about chiropractic care," says Zigler. "I decided to look into each of these myths, and what I found is that chiropractic education, side-by-side, is more similar to medical education than it is dissimilar."

The article notes that Drs. Zigler, Haldeman and Cole joined other spine experts in attempting to debunk misconceptions about spinal manipulation5,6 at the North American Spine Society's 17th Annual Meeting, and also references a recent Harvard University study in which low back pain patients who received conventional and "alternative" treatment, including spinal manipulation, were significantly more satisfied with alternative than conventional care.

"About 10 to 12 international guidelines have suggested that there is some benefit to manipulation," says Dr. Haldeman. "If we look at their basic guidelines, manipulation has consistently been accepted by independent government and scientific bodies as being a valid form of treatment." Dr. Haldeman also mentions that several other studies demonstrate that the potential side-effects of spinal manipulation are short-term and relatively common for "new" patients, and that no direct relationship links spinal manipulation to any increased risk of stroke.

Dr. Cole offers perhaps the most striking endorsement of chiropractic, suggesting instances in which spine surgeons should refer patients to DCs. He emphasizes that manipulation can provide short-term pain relief for acute low back pain and modest relief for chronic low back pain. According to the article, his endorsement goes a step further: "Cole said that, overall, manipulation has the advantage of reducing pain, decreasing medication, rapidly advancing physical therapy and requiring fewer passive modalities." "Chiropractors work for us as screeners for surgical pathology," Dr. Zigler adds. "They can do the same work-up and send the patient who has already gone through his conservative treatment and had all his diagnostic work done to the surgeon."

The article in Orthopedics Today is significant not only because of its positive depiction of spinal manipulation and chiropractic, but because it comes at a time when several other media sources have portrayed DCs in much less favorable light.7,8 It's encouraging to see good news for a change, particularly in a publication that describes itself as "a monthly medical newspaper for orthopedic surgeons."

References

Time to recognize value of chiropractic care? Science and patient satisfaction surveys cite usefulness of spinal manipulation. Orthopedics Today February 2003:23(2), pp14-15.
Haldeman S, Chapman-Smith D, Petersen DM Jr. Guidelines for Chiropractic Quality Assurance and Practice Parameters. Proceedings of a consensus conference commissioned by the Congress of Chiropractic State Associations, held at the Mercy Conference Center, Jan. 25-30, 1992. Gaithersburg, MD: Aspen, 1993.
Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. Canadian Medical Association Journal 2001:165(7), pp905-906.
Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999:24(8), pp785-794.
Haldeman S, Cole A, Zigler J, et al. Spinal manipulation in spine care: who? why? when? Presented at the North American Spine Society 17th Annual Meeting, Oct. 29-Nov. 2, 2002, Montreal.
NASS learns about chiropractic. Over 2,400 surgeons and other specialists learn how to work with DCs. Dynamic Chiropractic, Dec. 16, 2002: www.chiroweb.com/archives/20/26/13.html.
Plane and Pilot editorial grounds chiropractic. Dynamic Chiropractic, March 24, 2003: www.chiroweb.com/archives/21/07/26.html. Penn and Teller take cheap shot at chiropractic, alternative medicine. Dynamic Chiropractic, March 24, 2003: www.chiroweb.com/archives/21/07/17.html


Chiropractors in the Hospital Setting
See Division of Chiropractic Medicine Established at Philadelphia Hospital


What is the research on Chiropractic? For extensive information on Chiropractic, see the AHCPR Publication Chiropractic in the United States: Training, Practice, and Research

My goal is to find ways we can work together to foster better health care for our patients. I welcome any questions and will be happy to provide care to you, your staff and your patients.