VIS Dr. Oz and Chiro adjustment

[trussett]

"It's garbage and a money grab as far as I can tell. The Tx goes something like this:

1) PT performs evaluation looking for "asymmetries, muscle imbalance issues and core stabilization issues"

2) Chiropractor performs evaluation and finds areas that require "alignments"

3) PT then works on the "muscles" to keep the spine "aligned"

4) PT is typically the dufus that hooks the patient up to some zapping gadget along the way."

Proud, I wouldn't disagree with you about multi-disciplinary practices, but it hasn't been my personal experience, but it was what my "bosses" expections were I think.

I recognized early on that too many practitioners at once is not beneficial to the patient, and so we got away from that years ago - despite pressure/heat I used to get from the company that used to own my clinic to do so (and this came from both PT and DC 'superiors' btw). Now that my wife and I own the clinic, we do things the way we like to without me having to hear it from some idiot every month.

We might co-treat chiro/massage, pt/massage . Rarely more than 1 practitioner simultaneously to be honest, unless requested by the referring MD.

Is this the best method, or even a better method than anyone else? Absolutely not - just how we roll.

In our clinic co-treatment might by more aptly put as - " I've seen this person 4-5 times with zero results, can you have a look dear wife and see what you think"

What usually happens is the patient gets a short, complimentary PT or DC mini-assessment, and if we (my wife, myself, the MD, and the patient think transferring practitioners is a good idea, we do so). We also make sure to point out that they are welcome to see practitioners outside our clinic if they would prefer.

It boils down to this for me. My wife is often better than me with certain conditions, and vice versa, so if someone books into see me, and I see something that she or our other PT would be better at treating, I say bye-bye, and refer, and we do not charge 2X for the two new assessments, so I don't think it's a money thing, talk to my accountant he'd agree.

If I was a money guy, I would have stayed in finance/economics/business or studied computers/engineering/a trade in school in or after university, as there are countless better ways to make money than what I do for a living.

I'd imagine some multi clinics are run as you describe, I've worked at 2 and neither were, but that's because the practitioners realized that no one can force them to practice in a certain way unless they give their consent to do so.

"I have to wonder Truss, if you practice manipulation without the nonsensical explanations....what are the PT's that you work with doing?"

Well I've worked with a Part A/B PT, so if you're from Canada that might help explain how he would explain his treatments, I've worked with 4-5 Western Ontario graduates - very mesodermal/orthopedic - but this all changes with post graduated courses does it not?

For example my wife graduated from Western, has taken her levels Upper/Lower 1-3, Butler courses, Diane Lee courses, Mulligan courses, McKenzie, APTEI courses etc etc....with each new course comes new explanations - right or wrong.

So everybody explained everything based on where their mindset was at during that point of their careers I guess.

As far as explanations go - I still employ many of the same physical techniques I always have, but since coming on here, I explain their mechanism much differently - Diane's articles on patient education have been excellent for this. I had used a 'technique' very similiar to the one decribed in her DNM manual for years that I learned from some chiro in Denver, who also talked about Melzack albeit incorrectly I think, but I adopted Diane's explanation for its mechanism once I understood that it was a far more likely explanation. The skin...never thought of that

So whichever practitioner they see, they get their personal interpretation of what they're doing based on their current level of education or whatever course they most recently took. For the most part we are on the same page at my clinic.

As it stands now, I think I explain pain more than anyone else at my clinic in a manner like what I've learned on this site, but who knows what will happen when new evidence makes it way to my caveman brain.

Apparently, truss, these two gals somehow adopted the subluxation thing after graduation from CMCC?


As far as these CMCC grads you and John referred to, I actually said I didn't go there, so I have no idea what they learned. I believe somewhere on this site a chiro student posted his curriculum while in some heated debate, but it's possible I dreamt this. Perhaps the PT/DC Greg would be better to talk to about this, and I believe he touched on this already.

As I said previously, most chiros I know practice non-subluxation chiropractic (manual therapy with likely a stronger emphasis on manipulation) and many I don't know practice subluxation-based chiro stuff - I don't know their personal motives and reasoning are for this, I know I just do not share it.

Where they come to believe the theory is beyond me, I remember meeting a family acquaintance from my youth who became a chiro who had been our high schools most brilliant student, went to my university for engineering on scholarship of some sort, switched to Kin and became a chiro eventually...and he became the straightest subluxation chiro I have ever met. Not sure why it happens.

I always think of George Costanza saying 'It's not a lie if you believe it", but I make it a habit of not assuming I know what goes on in any other person's head than my own...it's busy enough in my own, if the voices would only stop...

[Diane]

There is the silly side of chiro, then there's the tragic side of neck manip.

[trussett]

Since you always seem to want to throw something back at me, no matter what I write, I'll let you know that many moons ago when I figured out c-spine manips worked no better than mobilizations and read a study that seemed to say the same thing, I personally stopped doing them, plus I had enough sleepless nights worrying about VBAIs when I first graduated.

I'm curious though, does your scorn fall only onto manual therapists who kill people, or should I assume you have the same feelings for, let's say the makers and distributors of NSAIDS as well?

I'm sure this is a common chiro argument, but since I'm on board for ditching c-spine manips due to their unnecessary risk, and since I'm not fond of double standards, what is your take on things like adverse drug reactions (ADRs) and iatrogenic causes of deaths in other professions? Seems to me there is ample evidence to suggest many deaths a year can be attributed to ADRs, yet I never hear much outcry about it from you, maybe you have and I missed it.

Is it probable, if not likely, that some of these deaths may occur in people taking medications for nothing more than pain, so is the risk worth the reward in this case any more so than people treated with cervical manipulation seeking relief from simple HAs and neck pain? If I'm missing the point or my logic (or lack thereof) is way off, I apologize, as I said I am rather slow.

If you're going to use this as a means of saying - "see he's a typical chiro going on a an anti-MD rant" go nuts, but that's not what it is IMO, I have no problems with MDs.

I've been fortunate to have had great MDs patch me up in the past with things like RC repair and ACL reconstruction, a lacerated extensor pollicis longus last summer, my kids received their vaccines, hell I even have Advil for when I need to play hockey( although some RAND study from the early 90s that told me I had a 1/4000 chance of serious GI complication with even a single does always crosses my mind when I do, but I'm a bit paranoid, and I can't quit hockey even though the OA in my hips at 39 begs me to), I've taken anti-biotics etc etc.

Here's your ammunition, enjoy your kill shot.

[Barrett Dorko]

Is there ANY indication that thoughtless and dangerous care is tolerated by any member of this board no matter who practices it?

Why do you insist that overt criticism of anything means that it will be witheld otherwise?

[Diane]

Truss, I don't know why you have stepped into my line of fire. Get out of it. I have nothing against you, so there is no need for you to feel you have to defend yourself.
(I appreciate your self disclosure, and I accept everything you say about who you are, so you can stop feeling so edgy. )

Having said that, I will never stop taking aim at the killing and maiming of patients by idiocy. Sheer unadulterated human primate grooming idiocy. Patients who have put their own trusting, live, conscious hurting necks into the hands of someone who had the ignorant audacity to tell them that cracking their neck would help them.

It's the practice I abhor. And I abhor the profession that grew itself up around doing this to other humans, as a gimmick/sales promotion. Yes, I abhor that it is still entrenched in my own profession. And grateful that most don't bother with it.

I think it's unconscionable, despicable, that pain science is catching on so slowly that stuff like this still is ALLOWED to happen. I think neck manipulation should be banned from the face of the planet.
Any questions?

[Diane]

New post by Harriet Hall MD, "Chiropractors as family doctors? No way!"

[advantage1]

Can a chiropractor call themselves a physician? I see they are using the title 'chiropractic physician' in the article Diane posted. I wouldn't dream of calling myself a 'physiotherapy physician'. Why? Because I did not go to medical school.

[proud]

Ah the NSAIDS argument. Right.

So I think it's important to note that yes indeed there are problems with iatrogenic illness of which NSAIDS have been implicated in the literature. But lets make it clear that the bulk of the data on the adverse consequences of NSAIDS occur on already gravely ill people. The mis-use of NSAIDS was the final blow so to speak. That doesn't necessarily make it better but I think there is a distiction there:

1) Otherwise healthy, functioning person
2) recieves a treatment that not only has virtually no evidence to support it's use; most evidence supports NOT using it
3) Dies

versus

1) Rather ill person goes to hospital for treatment.
2) Has a multitude of complex medical issues and the medical team scrabbles to figure what is wrong. Is prescribed medication (in error)
3) dies

Unless I am mistaken, not much data exists where an otherwise healthy person walks into a doctors office with general run of the mill neck pain, is prescribed an NSAID....and dies.

I could be wrong.

[Bas Asselbergs]

Trussett, don't forget that most of our rants are against manual therapy "abuses", whether from DC, Osteo, PT, MT or other more creative titled people.
And yes, chiro receives its fair share - when considering the sheer amount of junk-therapy that is thrown at the public on a daily basis.

It is a rotten thing for people like you and Greg that the amount of marketing of garbage is higher in your profession than any other. Not your fault.

[Barrett Dorko]

proud, I think you're right.

Why do we always assume that the medical community is doing the wrong thing when they provide medication for pain? Isn't it our responsibility to convince them that other forms of treatment are more effective and reasonable?

Of course, if choreographed movement makes them worse and moist heat is essentially useless (and that's all the therapist knows to do) why would the doctor send them to us?

[proud]

Oh and I almost forgot. I attended a seminar once put on by a "pain doctor". He went on about medication use for pain and out of the blue...in an audience of perhaps 75-100, a fellow introduces himself as a local chiropractor and he brought up the medication versus neck manipulation thing as well ( I mean...where did that even come from).

Anyway...to me suprise, this pain doc was well prepared and he did cite some of the data that I mentioned above. But he also had a sharp tongued quip that silenced the poor fellow.

If I recall it went something like this:

The data supports that 99% of all adverse effects via medication are from patients using the medication incorrectly (despite built in safety nets such as physician explanation and pharamcy explanations)...whereas snapping someone's neck is all out of the hands of the poor unsuspecting fool who chose that mode of care....the patient has no locus of control in that scenario.

The NSAID comparison is a true strawman argument...

[Barrett Dorko]

proud,

Is it possible that this physician didn't know ANYTHING about the possible analgesic effects of corrective movement; that he really didn't know about the origins of pain?

Who's supposed to know about that?

My guess is that he equated all "passive" movement with manipulation. Once the referral source believes that we are, well, you know.

[proud]

Originally Posted by Barrett Dorko

proud,

Is it possible that this physician didn't know ANYTHING about the possible analgesic effects of corrective movement; that he really didn't know about the origins of pain?

I would say without a doubt he didn't know. He rambled on about pain medication primarily and gave a nodding approval of the Physiotherapist he works with who is "great at finding and correcting muscle imbalances"

He was clearly referencing thrust manipulation though when he spoke of that "mode of treatment".

[Greg Lehman]

I'm not defending neck cracking (I no longer do it) but thought everyone might be interested in this paper. They look at the invivo strain associated with neck manipulation and suggest that it can not influence the vertebrobasilar artery.

I am just the messenger. I don't have full access but below is the abstract.

http://www.sciencedirect.com/science...50641112000557

[advantage1]

The research on the likelihood of a stroke from manipulation is certainly mixed. Some saying no risk others indicating a small risk. Don't forget that there is research indicating that mobilizations are just as effective as manipulation without the risk.

There is recent research indicating that those cases of a patient having a stroke following a neck manipulation presented to the practitioner with early signs of a stroke. Therefore it is more important to try to identify those patients that are not appropriate for neck manipualtion and refer them to the ER. I'll track down the references. Have to get to the gym to prevent a stroke.

[Greg Lehman]

The paper is the Cassidy (2008) which was a follow up to a paper by Bondi and Rothwell. They suggested that individuals were already having a stroke when they want to the chiro or the MD, hence the correlation of having a stroke after a seeing a chiro or an MD was the same. Im pretty sure this paper has been debated before. The lead authors are chiros but they are not practicing and really identify themselves more as researchers. Their afiliations are to universities and hospitals not any chiro funders. Cote, one of the authors routinely annoys chiros with his research suggesting delays in recovery after whiplash if you see a chiro or a lawyer. He was one of the first to champion the idea that all VBI testing was useless to test as premanip screening and therefore unethical. I originally heard him argue that if they are going to have a stroke due to manips then there is no way to tell and it is a gamble (im paraphrasing). Of course, this statement was seven years befoe this paper came out. I dont know what he says now.

The paper is here. Dont ask me to defend it

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/

[John W]

They look at the invivo strain associated with neck manipulation and suggest that it can not influence the vertebrobasilar artery.

I'd have to see the study population and the number and training of the clinicians to draw any conclusions.

I hope their conclusion was not as general as you made it sound because there are far too many documented cases of vertebral artery dissection from spinal manipulation to support such a broad statement. Also, it's very dubious to assume that all of these people were having some kind of vascular event when they arrived for the manipulation. I suppose it is possible that some of them had developed chronic dissections from frequent manipulations, developed some pain of visceral origin, and then finally received the coup de grace that rendered them either brain-damaged or dead.

I originally heard him argue that if they are going to have a stroke due to manips then there is no way to tell and it is a gamble

I tend to agree with this. There are a certain percentage of the population with hypoplastic vertebral arteries, and the only way to identify the condition is by arteriogram. Persons with hypoplastic vertebral arteries are more susceptible to posterior circulation strokes regardless of having their neck cracked.

So, should we have arteriogram screenings in junior high school just in case someone gets a neck ache and needs their neck cracked? I wonder how much that would cost?

[Greg Lehman]

I'd have to see the study population and the number and training of the clinicians to draw any conclusions.

I actually think the training or experience is irrelevant. It assumes there is a correct way to crack a neck and that if we knew what this way was that we have a feedback mechanism during the training to correct the technique of the person being trained. Saying that you should avoid rotation or that it must be only high velocity and low amplitude assumes at least two things:

1. That we have biomechanical and tissue based studies that show that a lateral bend force is somehow safer and that no rotation even occurs at a segment with a "perfectly" delivered thrust.

2. There is no mechanism to quantify amplitude at a segmental level and no information to know what is a safe level.


While we can create force profiles that come from "expert" manipulators we should not conclude that more experience equals greater safety. The force data on manipulation suggests a huge variability across back crackers with comparable experience levels. Most of this work is done in the thoracic spine.

As an aside, the journal of emg and kinesiology is having a review edition of many of these areas this summer. Many papers are already published online. There is some very interesting stuff on manipulations influence on the nervous system.

Greg

[Diane]

No consideration is made of the blatant fact that everyone's anatomy is unique, that variations are normal, especially vascular anomalies, and no one knows for sure what dragons may lurk beneath the skin on anyone.

[Greg Lehman]

Yup. Unless n= the entire world we should be pretty hesitant to make a safety conclusion to the entire species. I can assess 30 people and clear them for high intensity sprint training, this doesnt mean the rest of population can do it.

Diane, do you know if they addressed your comments in the discussion. Walter herzog is known to be academically stringent. I know because i believe i disapponted him in 1997

Greg

[Diane]

I wouldn't know, Greg.

[John W]

Greg,
I wasn't referring to experience level, rather the number of different clinicians who were providing the test manipulations. This is important for the very reason you cited that a high degree of variability in force has been found with thrust manipulation techniques among different clinicians.

Also, by "training" I was referring to the level of standardization of the manipulative procedure used in the study, not how experienced or "well-trained" the neck crackers were or were not.

[Greg Lehman]

Thanks John,


Good points in that light. Regardless, thanks for Giving me a springboard to bring up some of the issues i mentioned. I've heard the idea of training in technique being an important variable in safety or effectiveness, by both chiros and physios, and i obviously think it is just so much bunk.

Greg

[trussett]

Proud,

I'll admit having to look up what 'straw man argument' meant, clever way of putting me in my place I guess. Congrats, people liked that comment to, good on you!

"A straw man is a component of an argument and is an informal fallacy based on misrepresentation of an opponent's position.[1] To "attack a straw man" is to create the illusion of having refuted a proposition by replacing it with a superficially similar yet unequivalent proposition (the "straw man"), and refuting it, without ever having actually refuted the original position.[1][2]"

However, where my use of the NSAIDs as a specific example may have been erroneous, that that particular class of meds resulted in ADRs wasn't necessarily my point - my point was that all potentially deadly medical/manual practices should be probably be abolished unless the alternative to their use is certain death. I believe there is some data suggesting ADRs, not necessarily from NSAIDS do occur in healthy people who were prescribed drugs correctly and taken in correct dosages, and still died or had had serious consequences. I mean for me the potential side effects mentioned in advertisements for pharmaceuticals are enough to want to avoid their use, but that's a personal choice.

This was the most recent article I had read on NSAIDS (which shows you how often I read journals, I come here to read synopses of articles by people much more clever than myself) and it probably validates your point more than mine anyways, as it did say the patients were hospitalized, however they were hospitalized for GI complications from NSAID use.

My expertise in reading Journal articles and Research Methods etc is about kindergarten level at best compared to most people on this site that I seem to get in the crosshairs of, so if this study sucks for some reason, please let me know why.

http://www.nature.com/ajg/journal/v1...g2005305a.html


http://jama.ama-assn.org/content/279/15/1200.full - this is the study I think al ot of chiros use and maybe got lodged in my subconscious - is it the article you're referring to?