Archives for September 2011

5 things that need to change in chiropractic (in my opinion)

This post was inspired by the following top 5 list from a physical therapy blog http://blog.myphysicaltherapyspace.com/2011/07/the-top-5.html and it appears the idea originating from an article published in the Archives of Internal Medicine (Vol. 171 No. 15, Aug 8/22, 2011) http://archinte.ama-assn.org/cgi/content/short/archinternmed.2011.231

As we think about various professions there are certain common negative aspects that come to mind.  I know that when we think of lawyers, car salesman, police officers, chiropractors, and many others there are certain images or negative stereotypes that come to mind.  Despite those aspects, we know that the majority of the people in these professions are talented, dedicated, and ethical people.  For those reading this, I challenge you to come up with the list of 5 things you would like to see changed about your profession. Here are 5 things I would love to see change within mine (in no particular order):

1. Do not rely too heavily on imaging (x-rays/MRIs) to justify treatment and do not use ‘common’ findings as scare tactics or reasons to justify ‘restorative’ care.  There is little evidence this truly matters. Imaging should be used to find ominous pathology, fractures, and instability.  Not finding these pathologies should be reassuring and framed in a positive light for the patient.  (See prior imaging findings discussion)
2. Do not schedule several months of care in advance or have people prepay for months of care.  We need to understand and respect individuality.  There should be an appreciation that methods of treatment, results, outcomes, and patients needs/goals vary. There is no cookie cutter solution.
3. Avoid putting someone on ‘maintenance’ or ‘wellness’ care when their issue is not yet solved.  It’s unfair to the patient… see # 4&5 for what else to do.  All patient issues and concerns should be addressed to the greatest possible extent.
4. Get your patients more help when they need it.  Refer within (& outside) the profession when necessary.  We are fairly good at referring outside the profession to other specialties, but often forget to refer to other chiropractors who have specializations (neuro, pediatric, rehab, nutrition, …) that may help our patients.  Be confident in your expertise, but be sure to recognize others as well.  So many patients can benefit from appropriate referral and/or comanagement.
5. Limited or no instruction in active care. Also, carelessly chosen corrective exercise. Research is numerous showing need for active interventions, I don’t understand why we continue to fail at this?  (This problem goes beyond the chiropractic profession to physicians who prescribe medication with no form of active care or self-management and extends into physical therapy as well where at times active is utilized haphazardly with poorly chosen exercises or stretches.)  Patients should be encouraged to be responsible for their health, exercise (appropriately), manage stress, and strive for a healthier lifestyle.

These are just my thoughts, feel free to post your comments or additions to this list.

Is your telephone ringing???

It is common for patients to call or enter the office for their first appointment proclaiming that they have a degenerating disc.  It is also fairly common for people to tell me they can’t do certain things because they have degenerating discs.  The blunt truth is who cares. (at least in most cases)

The best analogy I’ve heard (and unfortunately I forget where I heard it first, so I cannot give appropriate credit) is that having an MRI is like having a picture of a telephone.  By looking at the picture you can tell me the color, size, shape, relative age, apparent damage, and type of telephone.  Is it a cell phone, cordless phone, or rotary phone?  However, you cannot tell me the most important thing… is it ringing?  Pictures of spines (MRIs, x-rays, CT scans) do not show pain, just as pictures of phones do not show ringing.

We have a society where we want answers and we want them quickly. We expect science and our health care providers to give these answers to us.  With regards to back pain this often comes in the form of an MRI (which is too frequently requested by patients and often ordered too early in care by doctors).  This is not to say that MRIs aren’t necessary or valuable tools in some cases, but it is to say that they are over utilized and that we hold them to a higher standard than they deserve.  They are simply one more piece of a the clinical picture.  This is evidenced clearly by a study performed by Bigos, and an associated chart from Management of Pain.  The chart below shows prevalence of disc findings in normal, asymptomatic subjects.

Disc findings in normal subjects

Note: The frequency of degenerative change seen on x-ray is comparable to the patients age.

Immediate imaging for low back pain is necessary in cases of severe trauma, progressive neurologic symptoms, suspicion of cancer, instability, and cauda equina syndrome.  Beyond that it should often be done after a failed course of conservative management.  When it is ordered early in care it often creates psychosocial factors (yellow flags) which complicate care.  There is almost always something ‘wrong’ on the MRI and this can facilitate fear/pain avoidance behaviors in patients, it can also lead to unnecessary (and costly) medical procedures if the imaging findings are treated rather than the patient.  MRI findings must be carefully considered and compared to the patient’s condition, and examination findings.  Functional assessment should also be performed and addressed in most cases of back pain, sciatica, radicular symptoms prior to considering aggressive intervention, when possible.

For further reading, a well referenced, article on this topic from Craig Liebenson, DC entitled The Emperor Has New Clothes.