Twenty years ago Doctors in the US did not have a good word to say about chiropractic now more are recognising that chiropractic is effective for back pain yet many chiropractors dismiss this as a medical conspiracy to restrict scope of practice. I don’t believe the average GP is bothered about chiropractic and certainly not as antagonistic as many of the sceptics. Like chiropractors GPs are seeing to help their patients, its the pharmaceutical industry thats principal duty is
to make money for its share holders.
Originally posted: August 4, 2009
A medical doctor’s view of chiropractic care
As both a chiropractor and medical doctor, Dr. Ralph Gay has an unusual perspective on the legendary rift between the two professions. He took some time out of his busy schedule as the director of the Spine Biomechanics Research Group at the Mayo Clinic to shed some light on what chiropractors can do for back pain and to address some common misconceptions for my story, "Chiropractors: Beyond the spine."
Q: Chiros are best known for treating back and neck pain, but some say they can treat all disorders, since "the spine and nerve system is the master system, controlling everything in the body." Please talk a little about whether you think chiropractors can and should be treating conditions such as ear infections, asthma, insomnia and cancer.
A: Traditional chiropractic theory posits that by correcting spinal abnormalities (subluxations) a chiropractor can effect all organs of the body. It is a good theory and there is some experimental work in animals that tends to support the premise. But, there is little evidence in the literature that chiropractic is effective for problems other than musculoskeletal conditions.
Q: How does chiropractic care work?
A: Good question but not a straightforward answer. Why does any form of treatment work?
Q: What are the main criticisms of chiropractic care?
A: The chiropractic profession has taken a lot of criticism during its existence. The criticisms it faces today are often generalizations that are not necessarily based in reality. Some of the common criticisms are:
Chiropractors have an inferior education: Chiropractic has a highly developed educational system that is regulated and standardized to a great degree. Although some portions of a curriculum may lack rigor, most are of good quality. The weakest part of chiropractic education is the clinical post-doctoral period…there is no requirement for an internship or residency prior to licensure as there is in medicine and osteopathy.
Chiropractic does a poor job of self policing: Although state boards regulate chiropractic practice in all 50 states, most chiropractors have a solo practice. This lack of "rubbing shoulders" with colleagues provides little incentive for practitioners with a typical behavior to change.
Chiropractors just want you to keep coming back: There is some truth to this. The chiropractic practice model suggests that multiple treatments over a period of weeks to months is necessary to get a maximal benefit. But this is not unlike physical therapy, acupuncture or massage practice. Although some chiropractors let their business model dictate treatment more than clinical evidence, most limit treatment to what is needed for each individual patient based on their response to care.
Q: How can consumers be sure they find a good chiropractor and what conditions should they consider seeing one for?
A: Chiropractors do a reasonably good job of treating back and neck pain and there is limited evidence that some lumbar radiculopathies (or sciatica) may benefit from their treatment. A good chiropractor will explain why treatment is indicated, and suggest a trial period of treatment (for example 6 to 8 visits) to determine if it is going to help. I suggest that patients beware of chiropractors who suggest initial treatment of more than 3 to 4 weeks duration, lump sum payment, or treatment for a condition that is not related to the spine or other common joints/muscle conditions.
Q: How solid is the evidence behind the efficacy of chiropractic care? Does human touch have a role, even without adjustments?
A: The evidence supporting spinal manipulation for back pain (regardless of who renders it)is very good. The evidence in neck pain is good but less convincing. You must realize that the treatment effect for all types of treatment for back pain is relatively small. Chiropractic treatment of back pain with spinal manipulation has just as much evidence supporting it as any medical treatment for back pain.
Human touch plays a role in all health care encounters where it occurs. These "non-specific" effects are hard to measure in clinical studies.
Q: How did MD’s view chiros five years ago and has that changed? If so, how?
A: I think the medical view of chiropractic is slowly changing. The biggest impediment to change is the lack of interaction between the professions. Medical doctors who refer to chiropractors do so usually because they know the chiropractor personally and trust them to take good care of their patients, not because they have a chiropractic degree.
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Comments
Dear Julie,
Thanks for another good article on the subject of chiropractic medicine. I think either you misunderstood, or Dr. Gay misstated one thing. You quote Dr. Gay as saying "The weakest part of chiropractic education is the clinical post-doctoral period…there is no requirement for an internship or residency prior to licensure as there is in medicine and osteopathy."
Actually, that is not correct. There IS a requirement for an internship of one academic year PRIOR to licensure. In allopathic or osteopathic medicine, this is followed by a POST licensure residency and therein lies the difference. While there ARE post licensure residencies in chiropractic medicine such as radiology or family practice, they are limited. National University of Health Sciences now also offers an accredited post graduate Master of Science Advanced Practice degree for those who wish to take advantage of this additional education. It is clear to me, as president of National that residency training will be a given in the future of chiropractic education.
I recall clearly when allopathic medicine criticized chiropractic education for being inadequate because its programs and institutions were not accredited – we remedied that by getting regional and programmatic accreditation. Then the criticism turned to undergraduate education – we remedied that by requiring the baccalaureate for admission to the chiropractic doctorate – now it is post-professional education. We are in the process of remedying that as well. What will they criticize next, or will we finally actually get a seat IN the bus?
Jim Winterstein, DC
President
National University of Health Sciences
Posted by: James Winterstein | Aug 4, 2009 12:38:07 PM
Dear Julie,
Thanks for the interesting article and the forthright answers from Dr Gay … and the on-target post comment from Dr. Winterstein. The chiropractic profession has really come a long way and there are still a lot of misconceptions about them … there are some really great chiropractors out there who treat with evidenced-based medicine – others are money grubbing charlatans … as in ANY profession.
Similarly, the naprapathic profession has also attempted to gain legitimacy over the years as it is a sister profession to both chiropractic and osteopathic. Naprapaths too are wondering when we will get a seat IN the bus? (Starting with a little bit of newspaper coverage? Hint!) However, our Alma mater must realize that they must be the ones to begin that legitimization process! Accreditation is the mandatory first step for NCNM! Get with it folks before the bus leaves town!
Posted by: Naprapathic Medicine | Aug 4, 2009 4:58:11 PM
A recent study conducted by the University of Chicago Medical Center has shed interesting light on theories developed and practiced by chiropractors for a century.
Namely: that correcting neck problems with small specific forces can affect abnormal body functions. It seems that your GP and your chiropractor may indeed be talking the same language…at last!
The report stated:
A Chicago-area study of 50 individuals with a misaligned Atlas vertebra (located high in the neck) and high blood pressure showed that after a one-time specialized chiropractic adjustment, blood pressure decreased significantly
If that wasn’t fascinating enough the journal New Scientist went on to say:
…the finding could explain why blood pressure and heart rate sometimes change when the neck muscles are injured – through whiplash, for example.
These studies are largely ignored by the medical community, but I commend your article’s author for at least being honest and impartial and up with the literature on chiropractic care.
Reference: Journal of Human Hypertension (2007), 1 – 6
& 2007 Nature Publishing Group. www.nature.com/jhh
Posted by: Joe Ierano DC | Aug 4, 2009 8:28:44 PM
As a field Chiropractor I appreciate Dr. Gay’s research based perspective. I can speak for many field Chiropractors that we appreciate his validation of “touch” and the intangibles it brings to the doctor patient relationship. As is often the case, clinical and academic settings can be different. With this in mind, I would like to offer slightly different thoughts from a more clinical perspective, rather than the research/academic based one presented by Dr. Gay.
Q: How does chiropractic care work?
We explain the complex dynamics of neurology like an electrical system. Basically your nerves are wires through which impulses (electricity) flows. Each vertebra acts as a switch; in one position the power is “on” and in another it is “off.” When the power is off, the body doesn’t function well. When it is on, it does function well. If you turn “off” the power to a nerve that supplies a muscle, it can have poor movement or pain. If the “off” nerve supplies an organ it can result in poor function, such as asthma in the lungs. There is plenty of medically based research to support this Chiropractic premise, much of which you can find on Medline.
Chiropractic does a poor job of self policing: Most chiropractors are in solo practices, but “rubbing shoulders” occurs more than stated, at least where our practice is. All states have state professional organizations which offer continuing education which field Chiropractors are required to attend. Many attend seminars and meetings or belong to private professional organizations in addition to those offered by the state organizations. Many are happy being in “general practice” and do not wish to over burden family lives to pursue further professional degrees. Personally, I find this admirable. It is not the letters after your name that determine how good one is, but the CARE they provide to those they serve.
Chiropractors just want you to keep coming back: Its not that we want people to come back, it is that they recognize the benefit of doing so. Much like in dentistry, patients go in for routine check-ups, have their teeth cleaned professionally, speak with the doctor about how their teeth are, what they can do, receive advice, discuss what to watch out for, etc. Chiropractic patients often do the same for their spine and nerve system. Chiropractors are well versed in what to do to get well and stay well. It is our experience that is what people want in our day and age.
With regards to what “A good chiropractor” is, I have to directly disagree with Dr. Gay. He states “a good Chiropractor will suggest a trial period of treatment (for example 6 to 8 visits) to determine if it is going to help. I suggest that patients beware of chiropractors who suggest initial treatment of more than 3 to 4 weeks duration, lump sum payment, or treatment for a condition that is not related to the spine or other common joints/muscle conditions.” Although Dr. Gay’s advice is documented in research, one thing I have learned from working with people is that they reserve the right to take as long as necessary to get relief. To tell them that a trial of 6-8 visits over 3-4 weeks is enough isn’t telling the truth. We have seen a number of people who do not receive relief in 6-8 visits over 3-4 weeks, but continue their care and receive help within 6 or sometimes 12 months. We have also seen one adjustment provide the help the patient is looking for. The truth is that a broad range is possible and in my opinion should be stated to the patient as such. People should be allowed to accept the level of care they are comfortable with and proceed accordingly with continued dialogue with their Chiropractor. Professionally, the Chiropractor needs to be up front with all possibilities regarding time and frequency.
As for lump sum payments, there is no harm to the patient to accept such an offer from a Chiropractor. Let’s face it, finances are a part of patient’s lives and we live in a society where many American’s find they’re paying out of pocket for health care or with insurance plans that have high deductibles or high copayments. If their doctor is working within the parameters of their state law, why not receive a doctor’s offer to save money? Especially if it gets the patient the care they want or need. Obviously consumers need to use common sense as to what they are willing to do or what seems reasonable to them. But also be diligent enough to know a bargain when one presents itself.
Dr. Gay’s views on how the medical community is opening up to Chiropractic are in line with that of our own personal experiences. MDs are coming around and as with any health care setting; trust is of utmost importance, as it should be. Chiropractors have succeeded in helping others for many years without the support of the medical community or research and will continue to do so with or without them. Service with results has always been the mantra of the Chiropractor.
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