Copyright © 1990 by Medical Economics Publishing
Reprinted with permission from the Sept 19, 1990, issue of
Medical Economics, a magazine written for physicians.
Explanations of medical terms have been added in brackets.
If you suspect that diagnostic shortcomings and
therapeutic abuses still plague the profession, you’re right.
With regard to the chiropractic profession, I suppose I’m a heretic. I’m concerned because there seems to be a growing misunderstanding of my profession by M.D.s. I can only ascribe this to lack of knowledge about chiropractic education, training, and practice patterns.
Some of you are beginning to consider chiropractors your peers, like osteopaths, or at least part of a separate scientific discipline. This view was encouraged by the U.S. Court of Appeals last February, when it upheld a lower court ruling that the American Medical Association, in violation of the antitrust laws, had conspired to boycott chiropractors.
But as I see it, despite my profession’s efforts to upgrade itself scientifically, we’re still well behind you. And as the barriers between the chiropractic and medical fields come down, I think M.D. s need to know to whom they refer patients.
No doubt other chiropractors will call these opinions self-serving. I’ve been doing utilization review for the past three years — helping businesses and health-care payers to determine the necessity of chiropractic services under the terms of their benefit plans. However, I’ve been outspoken about this issue for years, based on what I saw during a decade of private practice and three years as an instructor and clinician at a national chiropractic college.
I don’t mean to paint a totally dismal picture. I believe spinal manipulation is an important, bona fide therapy for selected patients with back, muscle, and nerve problems. I also believe there are many good chiropractors: They practice rationally, attend postgraduate courses, and read medical and chiropractic journals. But others don’t, and that hurts the profession.
We need to improve our image and patient care — by further documenting the efficacy of what we do and standardizing our services. Until then, I’d have to reluctantly agree that organized medicine’s perception of the diagnostic shortcomings and therapeutic abuses of chiropractic has generally been accurate.
Some D.C.s consider diagnosis unnecessary
A middle-aged woman went to a chiropractor with pain in her lower back and pelvis. She had a history of breast cancer with mastectomy. The chiropractor noted this in his records, but didn’t ask whether she was seeing an internist or oncologist, nor did he otherwise consider the patient’s history of cancer in his evaluation. He treated her with spinal manipulation and ultrasound several times a month for a year. When her pain didn’t subside, he sent her to the clinic at the chiropractic college where I worked.
Our X-rays revealed metastases to the L-4 region and right ischium [pelvic bone]. I don’t know whether her medical doctors had performed competently or not. The real point here is the failure of the chiropractor to establish a diagnosis. Instead, he rendered inappropriate therapy while the cancer spread.
In another case, an 83-year-old man saw a chiropractor for neck and low-back pain and constipation. He was treated for several months with spinal manipulation and colonic irrigation, then referred to our clinic.
When I examined him, I found pathological reflexes, clonus [rapid muscular contraction and relaxation], sensory deficits in his legs, and atrophy [wasting] of the hand muscles. An X-ray of the cervical spine revealed extensive osteoarthritis, and severe osteoporosis [bone thinning]. A CT scan showed bony bars impinging on the spinal cord. With any one of these conditions, spinal manipulation is very risky. It can cause irreversible neurological damage or compromise the vertebral arteries supplying blood to the brain.
Why did my colleagues overlook the obvious and endanger their patients? I think the answer has several components. For one thing, since they’re not trained in hospitals, chiropractic students are exposed to a limited range of pathology. For another, they’re taught diagnosis by instructors who learned diagnosis from other chiropractors. Many hardly consider diagnosis necessary. They still adhere to the theory, propounded by Daniel David Palmer in 1895, that virtually all disease is caused by pressure on the spinal nerves by off-centered vertebrae called subluxations. These practitioners feel that there’s no sense in focusing on the patient’s symptoms and complaints if the cure for everything is to align the spine.
The upshot is cursory histories, physicals, and X-ray interpretations.
The rule of thumb for M.D.s is that 80% of the diagnosis comes from the patient’s history, so you routinely inquire about the onset of symptoms, habits that can affect health status, illnesses that run in families, etc. Chiropractors, on the other hand, often do little more than record the patient’s chief complaint: e.g., “low-back pain for two months.” Consequently, it’s not surprising that a D.C. misses a serious problem-as when a 13-year-old patient experiences a weight loss of 10 pounds in one month, as happened in a case I reviewed.
The chiropractic physical exam typically includes testing reflexes, muscle strength, and range of motion. Relatively few practitioners check blood pressure, height, weight, temperature, pulse, or respiration, or palpate [feel] the abdomen. Under the old bone-out-of-alignment theory, all problems are considered mechanical; consequently, there’s no need to rule out organic pathology.
It’s the same with X-rays. In college, chiropractors learn how to spot organic pathology on film. In practice, though, the emphasis is on the identification of subluxated vertebrae. And chiropractors find subluxations that the rest of the medical community can’t. Is this a case of seeing what they want to see?
You’d probably describe a subluxation, on X-ray, as the shift of one bone over another by several millimeters, a decrease in disc space due to degenerative disease, or perhaps an abnormal overriding of the facet joints. That’s not necessarily the definition of subluxation that a chiropractor uses.
D. C. s employ a variety of elaborate X-ray marking systems and techniques to determine misalignments and make therapeutic choices. I know of no documentation supporting the validity of these systems, but here’s a description of a commonly used technique:
The practitioner takes a full spinal X-ray, compares it with an idealized version of the spine, then measures how much the patient’s vertebrae deviate from the ideal. After tallying the deviations — let’s say the total is 30 millimeters — the chiropractor determines the number of spinal manipulations the patient is supposed to receive: 30. To me, this lacks a rational basis, since there’s little evidence that slight postural distortions are correlated with back pain. The literature isn’t even clear on what the “perfect” spine looks like.
Treatments vary from accepted to absurd
The natural course of common back problems has been well-described in the medical literature. About 75% of patients with low-back pain return to work within a month. At the end of two months, it’s more than 90%. Only a small percentage go on to have unremitting chronic pain.
Chiropractic therapy tends to parallel the normal course of untreated back pain. The practitioner might see a patient three times a week for a month, twice a week for another month, then once a week for a third month. When the pain resolves, the patient attributes it to the treatment. And, in fact, scientific studies demonstrate that spinal manipulation can accelerate the resolution of such pain. But there are plenty of chiropractors who won’t stop treatment at that time.
Then there are those who tackle problems that may exceed their capabilities. For instance, one practitioner with whom I am familiar used spinal manipulation in an effort to correct a 47-degree scoliosis in a 17-year-old girl.
Others may choose to treat non-existent problems. They may recommend that patients visit once or twice a month, indefinitely, to prevent future disorders — organic as well as neuromusculoskeletal. This, too, stems from Palmer’s single-cause disease concept. I’m not aware of any scientific proof that spinal manipulations have a preventive effect, yet I’ve reviewed hundreds of cases in which patients received them without documented complaints of pain or significant objective findings.
“Practice builders” to D.C.s: Pump up the volume
Rather than verify the need for continuing care at each visit, chiropractors frequently tell patients at the outset that they’ll need a certain course of treatment. It’s not especially unusual for a chiropractor to recommend up to 100 manipulations for a simple back strain. Sometimes that’s based on practice habit or on what a colleague told them. Recently, however, a new trend has surfaced: The chiropractor may be following a “practice builder.”
Dozens of these practice builders serve our profession. Like medical practice management consultants, some just analyze office systems and teach techniques to streamline scheduling, improve billing and collections, etc. However, others advocate procedures in which quality of care clearly plays a secondary role to making money. Some advise their clients that “every patient needs a minimum of 30 visits,” and they also recommend a certain number of X-rays per patient.
Leaf through a few chiropractic publications, and you’ll find practice builders hawking “detailed steps to the $40,000-per-month practice,” and plans for boosting patient volume by 450 visits a month, or to more than 350 a day. Hundreds of practitioners subscribe to such programs. To help them sustain the money-making momentum, some practice-building firms actually hold meetings to give their clients awards based on increased practice profits.
Further complicating the treatment picture is a lack of generally accepted standards for clinical care. According to one researcher, more than 250 chiropractic techniques are in use.
There are chiropractors who use magnets, and others who use color therapy. There’s still a lot of colonic irrigation taking place, often without prior testing for blood in the stool.
There are chiropractors who continue to use the “activator technique,” which means they deliver measured thrusts to the spine with a spring-loaded hammerlike instrument. I’ve seen it used on the necks of patients who have bursitis of the shoulder.
Then there’s the theory of “applied kinesiology,” which holds, among other things, that weakness of certain muscles (such as the latissimus dorsi) can signal the need for nutritional support of an organ like the pancreas. Practitioners who employ this idea sometimes place vitamin or mineral tablets on the patient’s tongue, hand, or abdomen during testing. If the allegedly weak muscle gets stronger, it supposedly indicates the need for that particular dietary supplement.
While a small minority of D.C.s campaign for scientific demonstrations of therapeutic efficacy, practitioners on the whole don’t exhibit a very questioning attitude about what works. Possibly that’s because most low-back pain eventually resolves with or without treatment.
Another factor may be concerns that medicine will overwhelm chiropractic, since the chiropractor doesn’t really offer any specialized service that can’t be provided by other health practitioners.
Evidently, the fear of liability and regulation also prompts chiropractors to avoid the scientific mainstream. An executive of a chiropractic insurance company told me, for instance, that he opposed standardization of chiropractic procedure because it might increase our exposure to malpractice suits. From a patient-care standpoint, his reasoning struck me as untenable: “If they can’t define what we’re supposed to do, they can’t pin us down to having made a mistake. “
Still, M.D.s and D.C.s should cooperate
Having said all that, I’d encourage you to establish a rapport with at least one good chiropractor. Chiropractors frequently would like to be able to refer patients to M.D.s, but have trouble doing so because they aren’t personally acquainted with an appropriate specialist in family practice, neurology, orthopedics, or whatever. Better cooperation between M.D.s and D.C.s could only improve patient care.
Likewise, if you don’t guide your patients to a practitioner you trust, some patients will surely pick their own. And the message they may receive is, “We’re going to try to get you off those drugs,” which could mean the heart medication or diuretic you prescribed.
How do you locate a good chiropractor? One way is to check with colleagues who already have working relationships with D.C. s. Another is to get together with a nearby practitioner for a face-to-face discussion. Ask about his use of X-rays-what kind and how often? Some shoot repeated, full-spine films for localized complaints, such as neck pain. Inquire, too, about his notion of proper treatment for a condition like back sprain. He may say, “I use magnets,” or “I place vitamins on the tongue,” or “You know, sometimes these patients need up to 100 visits.” It shouldn’t take long to size up his competence, and ensure that undocumented therapies won’t be administered to your patients. And bear in mind that patients tend to respond sooner rather than later, and manipulation beyond a few weeks hasn’t been documented as efficacious.
Afterward, it’s wise to follow up by asking the patient about his response to the therapy, since whatever happens in the chiropractor’s office will be a reflection of your professional judgment and concern.