Dr stance on chiropractors

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I get a lot of patients with chronic low back pain. I've always wondered what should be the stance of a doctor on chiropractors to help alleviate this pain? Should we refer to chiropractors or avoid them like the plague? Is it shady to send patients to chriopractors or should they be an included part of a patient's regimen?

Not a residency-related topic. Moving to TIH.

Originally Posted by docu

I get a lot of patients with chronic low back pain. I've always wondered what should be the stance of a doctor on chiropractors to help alleviate this pain? Should we refer to chiropractors or avoid them like the plague? Is it shady to send patients to chriopractors or should they be an included part of a patient's regimen?

You should be sending them to other doctors that deal with this issue - specifically, physiatrists aka physical medicine and rehabilitation (PM&R) docs that specifically focus on spine/back pain issues.

I feel bad for PM&R's lack of awareness among other specialties when questions like the above pop up :/

Originally Posted by carml

You should be sending them to other doctors that deal with this issue - specifically, physiatrists aka physical medicine and rehabilitation (PM&R) docs that specifically focus on spine/back pain issues.

I feel bad for PM&R's lack of awareness among other specialties when questions like the above pop up :/

I dont think anyone refers to PMR unless they are in the hospital. I have outpatients and I usually refer them to physical therapy instead and most other doctors do the same.

However I was just wondering if chiropractors are legit. Some patients ask about them and I dont know what to say.

You will get the normal sdn response here, that you should avoid them like the plague.
However, if you are really interested then go find a local one and talk to him/her. It will become apparent in a very short time what type of Chiro you are dealing with.
There are good and bad ones just like everything else in life. Once you realize that your patients will see one whether you want them to or not, go find one you can trust. It will ultimately allow better overall compliance and patient understanding and can actually increase your referral base ( as you will get many more from them than the other way round)

Originally Posted by docu

However I was just wondering if chiropractors are legit. Some patients ask about them and I dont know what to say.

This is from the Cochrane Review:

Low-back pain is one of the most common and costly musculoskeletal problems in modern society. About 80% of the population will experience low-back pain at some time in their lives. Many people with low-back pain seek the care of a chiropractor. For this review, chiropractic was defined as encompassing a combination of therapies such as spinal manipulation, massage, heat and cold therapies, electrotherapies, the use of mechanical devices, exercise programs, nutritional advice, orthotics, lifestyle modification and patient education. The review did not look at studies where chiropractic was defined as spinal manipulation alone as this has been reviewed elsewhere and is not necessarily reflective of actual clinical practice. Non-specific low-back pain indicates that no specific cause is detectable, such as infection, cancer, osteoporosis, rheumatoid arthritis, fracture, inflammatory process or radicular syndrome (pain, tingling or numbness spreading down the leg).Twelve randomised trials (including 2887 participants) assessing various combinations of chiropractic care for low-back pain were included in this review, but only three of these studies were considered to have a low risk of bias.

The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias. Future research is very likely to change the results and our confidence in them. Well conducted randomised trials are required that compare combined chiropractic interventions to other established therapies for low-back pain.

http://www2.cochrane.org/reviews/en/ab005427.html

From what I have acquired, chiropractic manipulation of the spine is absolutely worthless for every known problem, except for non-specific low back pain. For non-specific low back pain, chiropractic manipulation is approximately as effective as a Tylenol. You could literally replace the entire field of chiropractors with a $2 bottle of Tylenol.

My problem with chiropractors is that the basis for their entire practice is unscientific. Daniel David Palmer literally walked outside and said "Ah ha! This is how disease is caused!" and invented the idea of subluxations of the spine being the root cause of disease in the body.

There's a big trend now where all of a sudden chiropractors are regarded as "health experts." They now try to run "wellness centers" and they prescribe "supplements." I find this ironic because they insult MDs because we prescribe "pills", but now they are prescribing pills! Except their pills have, for the most part, never been shown to be effective.

I'm sorry, but I simply would never listen to a chiropractor on health issues. Their entire practice is anti-science. If they are willing to stand by their practice, which means being diametrically opposed to reason, then I can not trust that they can ever analyze any data and present any meaningful information.

Two anecdotes, for fun: 1. I observed a chiropractor talking to a patient and he casually places his hand on their back, feels their spine, and starts saying how they have a subluxation of C7, or T5, etc. I couldn't believe the audacity of a person to make such a claim, when I would wager my entire life's savings that the chiropractor's hand wasn't within 2 spinal levels of the ones he was claiming to find pathology in.

2. My wife was told by a chiropractor, years ago (before we met!), that she had a severe curve in her spine, and that she had lots of spinal spurs. Years later, she was having a weird musculoskeletal pain in her posterior thorax and she ended up getting an xray. Spine was perfectly straight, no spinal spurs. And yes, the chiropractor took an xray! Individually, that chiropractor was a complete quack.

(I know anecdotes are worthless. Just my most recent experience with chiropractors. I'm sure they have their terrible doctor stories too.)

I apologize if I sound passionate this morning. Yesterday I had to listen to a women tell me how she practices Rekhi Healing ("Therapeutic Touch", it was disproved by a 9 year old named Emily Rosa many years ago) and she also practices Tuning Fork Healing (yes, she puts tuning forks on your body and heals you.) Then I had to listen to her call me closed minded because I don't believe in all that nonsense.

thanks. i've always felt that they are not good to use, because their back manipulations could mess the spine up even more from what i've heard. i've seen a chiropractor that owned a pain clinic where he hires doctors to rx narcotics and he sees them as patients too.

Originally Posted by docu

I get a lot of patients with chronic low back pain. I've always wondered what should be the stance of a doctor on chiropractors to help alleviate this pain? Should we refer to chiropractors or avoid them like the plague? Is it shady to send patients to chriopractors or should they be an included part of a patient's regimen?

I think you should entirely avoid chiropractors, for reasons already stated several times on SDN.

If you're interested in manual modalities for the chronic low back pain patient, your approach should include either referral for osteopathic manipulation with a DO comfortable with manipulation, or referral for physical therapy.

Originally Posted by docu

thanks. i've always felt that they are not good to use, because their back manipulations could mess the spine up even more from what i've heard. i've seen a chiropractor that owned a pain clinic where he hires doctors to rx narcotics and he sees them as patients too.

You can actually die from chiropractic manipulation of the cervical vertebra. It's called "vertebral artery dissection." The forces a chiropractor applies to the neck can actual damage the vertebral arteries that course through the cervical vertebra.

Info:

http://www.quackwatch.org/01Quackery...irostroke.html

There's a lot to say here. But I'll be brief.

Of course it's legit to refer to chiropractors. Don't refer your cancer patients; instead refer your neck and back musculoskeletal pain patients. Keep it simple until you get to know and trust a chiro in your area.

Spinal manipulation, particularly for neck and low back pain, is clearly evidence-based. If someone says otherwise, they don't know the literature (gee, that never happens here on SDN ).

From the North American Spine Society:
http://www.ncbi.nlm.nih.gov/pubmed/20869008
"Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone."

A review of worldwide clinical practice guidelines for the treatment of LBP:
http://www.ncbi.nlm.nih.gov/pubmed/20494814
Spinal manipulation is recommended for both acute and chronic LBP in virtually all guidelines (and I'm not talking about guidelines published solely by chiropractors; I'm talking about guidelines from medical societies and governmental bodies).

From the Americal Pain Society and American College of Physicians:
http://www.ncbi.nlm.nih.gov/pubmed/17909210
You'll note that spinal manipulation is the only non-pharma therapy recommended for both acute and chronic LBP.

And, just for future reference, anyone that tries to tell you that spinal manipulation is worthless and instead they've got all the answers for patients with neck and back pain, just do yourself a favor and walk away.

As to the Cochrane Review that was posted, read that more carefully. It concludes that chiro care is no better than anything else. That's quite a bit different than "worthless". Guess what? No discipline bats a thousand with these cases. Again, this gets back to the fact that these are often tough cases for whom nobody has a good answer. Anyone with experience working with these patients knows that.

Originally Posted by Shinken

I think you should entirely avoid chiropractors, for reasons already stated several times on SDN.

If you're interested in manual modalities for the chronic low back pain patient, your approach should include either referral for osteopathic manipulation with a DO comfortable with manipulation, or referral for physical therapy.

Medicaid doesn't pay for PT in my area, and my DO colleagues would slay me if I sent them all my non-specific back pain.

Originally Posted by LouisianaDoctor

I apologize if I sound passionate this morning. Yesterday I had to listen to a women tell me how she practices Rekhi Healing ("Therapeutic Touch", it was disproved by a 9 year old named Emily Rosa many years ago) and she also practices Tuning Fork Healing (yes, she puts tuning forks on your body and heals you.) Then I had to listen to her call me closed minded because I don't believe in all that nonsense.

Please tell me that you have watched Penn and Teller Bulls*** episode on new age medicine! They debunk/make fun of the above practices and it is AWESOME.

ChiroQuackers with their junior college degrees, if that, prior to attending quackery school, for 3 years, are great at separating pts from their money 3-5x aweek to stay healthy for the rest of ur life or until ur insurance runs out, but they take cash then. Unproven, no more useful than Tylenol, and dangerous. Find me a real study that says more effective than medical care? Doesn't exsist, see cochrane review above! I can't name all my pts that have suffered at their hands and promises that they'll get better. I use PT/OT or PMT, only. ChiroQuackery is a scam and lie.

Originally Posted by teamcox

ChiroQuackers with their junior college degrees, if that, prior to attending quackery school, for 3 years, are great at separating pts from their money 3-5x aweek to stay healthy for the rest of ur life or until ur insurance runs out, but they take cash then. Unproven, no more useful than Tylenol, and dangerous. Find me a real study that says more effective than medical care? Doesn't exsist, see cochrane review above! I can't name all my pts that have suffered at their hands and promises that they'll get better. I use PT/OT or PMT, only. ChiroQuackery is a scam and lie.

Sounds like an objective post. You appear to be very informed on this issue. Read much?

Hi docu,

I'm a student in chiropractic school and I appreciate that you even ask these questions.

The American Medical Association Code of Ethics states:

"It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic. (V, VI)" (http://www.ama-assn.org/ama/pub/phys...inion3041.page)

This is a very significant statement considering the organization's past opinions and actions against the chiropractic profession, which ultimately led to a supreme court ruling against the AMA (http://biotech.law.lsu.edu/cases/ant...wilk_v_AMA.htm). Relations since then have improved dramatically.

I would recommend taking an evidenced-based approach. Search the literature using databases such as PubMed and see what the current research says regarding the effectiveness of chiropractic for certain conditions. I believe the New England Journal of Medicine is a respected journal in the medical field. Here's an abstract of just one article in it regarding chiropractic: http://www.ncbi.nlm.nih.gov/pubmed/7...?dopt=Abstract

There is a lot more out there that draws empirical conclusions about the effectiveness and safety of chiropractic for certain conditions. I encourage you to please use more than anecdotal sources to draw a conclusion.

Research in the field is still in it's early stages due to historical battles and due in part to the fact that a significant portion of it must be funded by college tuition. Fortunately, the government and non-profits are increasingly providing grants to build a better research base. Due to the success of many studies regarding low-back pain, chiropractors are at almost every veteran's hospital and are covered under most insurance plans. I hope things like this don't happen just because of luck.

If you don't have access to any research databases, just contact me and I would be more than happy to send you a variety of articles.

Thanks again for the questions.

Edit/Addition: Also, someone posted the Cochrane Review, which is a very good article. I hope that folks will read the whole thing to get a full understanding of the conclusions drawn. Researchers found that chiropractic care for the back-pain related conditions studied had a statistically higher effect in terms of patient improvement compared to the other treatments. However, the researchers concluded that this only translates into a negligible difference clinically when compared to other treatments. The gray area is only whether statistical significance translates into better clinical outcomes.

If we take the Cochrane Review as the best evidence, it is fair to say that chiropractic care is at least as good as other treatments that a doctor or physical therapist would use. Knowing this, if I were a medical doctor, I would refer if the patient isn't getting anything from conventional medical treatment, or if prescription drugs are contraindicated or unnecessary. Please use your head, do your research, and stop bashing other professions based on emotion and anecdote. If it's an ego boost you want, you medical students are smarter. Please use those smarts ;-)

Originally Posted by rcarter14

Hi docu,

I'm a student in chiropractic school and I appreciate that you even ask these questions.

The American Medical Association Code of Ethics states:

"It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic. (V, VI)" (http://www.ama-assn.org/ama/pub/phys...inion3041.page)

This is a very significant statement considering the organization's past opinions and actions against the chiropractic profession, which ultimately led to a supreme court ruling against the AMA (http://biotech.law.lsu.edu/cases/ant...wilk_v_AMA.htm). Relations since then have improved dramatically.

I would recommend taking an evidenced-based approach. Search the literature using databases such as PubMed and see what the current research says regarding the effectiveness of chiropractic for certain conditions. I believe the New England Journal of Medicine is a respected journal in the medical field. Here's an abstract of just one article in it regarding chiropractic: http://www.ncbi.nlm.nih.gov/pubmed/7...?dopt=Abstract

There is a lot more out there that draws empirical conclusions about the effectiveness and safety of chiropractic for certain conditions. I encourage you to please use more than anecdotal sources to draw a conclusion.

Research in the field is still in it's early stages due to historical battles and due in part to the fact that a significant portion of it must be funded by college tuition. Fortunately, the government and non-profits are increasingly providing grants to build a better research base. Due to the success of many studies regarding low-back pain, chiropractors are at almost every veteran's hospital and are covered under most insurance plans. I hope things like this don't happen just because of luck.

If you don't have access to any research databases, just contact me and I would be more than happy to send you a variety of articles.

Thanks again for the questions.

Edit/Addition: Also, someone posted the Cochrane Review, which is a very good article. I hope that folks will read the whole thing to get a full understanding of the conclusions drawn. Researchers found that chiropractic care for the back-pain related conditions studied had a statistically higher effect in terms of patient improvement compared to the other treatments. However, the researchers concluded that this only translates into a negligible difference clinically when compared to other treatments. The gray area is only whether statistical significance translates into better clinical outcomes.

If we take the Cochrane Review as the best evidence, it is fair to say that chiropractic care is at least as good as other treatments that a doctor or physical therapist would use. Knowing this, if I were a medical doctor, I would refer if the patient isn't getting anything from conventional medical treatment, or if prescription drugs are contraindicated or unnecessary. Please use your head, do your research, and stop bashing other professions based on emotion and anecdote. If it's an ego boost you want, you medical students are smarter. Please use those smarts ;-)

the AMA have to say physicians can refer patients to chiropractors because they lost the lawsuit. evidence showed they were quacks (AMA Committee on quackery) but chiropractors sued the AMA for restraint of trade. the AMA has never really accepted chiros, they just have to pretend to. i will always discourage my pateints from throwing their money away on these con-artists. As a group they're more unethical than used car salesmen. if you want anyone to respect the field, stop pretending sublaxations exist, stop claiming to cure ear infections, and stop pushing unproven supplements. this is not how legit proffessionals behave.

Originally Posted by Trolking

the AMA have to say physicians can refer patients to chiropractors because they lost the lawsuit. evidence showed they were quacks (AMA Committee on quackery) but chiropractors sued the AMA for restraint of trade. the AMA has never really accepted chiros, they just have to pretend to. i will always discourage my pateints from throwing their money away on these con-artists. As a group they're more unethical than used car salesmen. if you want anyone to respect the field, stop pretending sublaxations exist, stop claiming to cure ear infections, and stop pushing unproven supplements. this is not how legit proffessionals behave.

Trolking,

Have you actually read the details of the case? If you did, you would find that the evidence did not point to that assertion and that the containment and elimination of market competition was a key motivator within the committee. Are you capable of doing non-anecdotal research? If you are, you would find that chiropractic is a viable healthcare alternative for some conditions and is more cost efficient than some other treatment forms.

You appear to be generalizing an entire profession based on your limited experiences and knowledge. That's akin to me believing that all medical doctors are "con-artists" or "unethical" just because a few defrauded Medicare for $295,000,000 (http://www.cbsnews.com/stories/2011/...20102766.shtml).

I won't do it because it doesn't make sense. If you want anyone to respect you as a professional, stop spreading false information, stop making claims without the supporting evidence, and stop setting a bad example for future professionals. That is not how legit professionals should behave.

Originally Posted by questiondoc

However, if you are really interested then go find a local one and talk to him/her. It will become apparent in a very short time what type of Chiro you are dealing with.
There are good and bad ones just like everything else in life. Once you realize that your patients will see one whether you want them to or not, go find one you can trust. It will ultimately allow better overall compliance and patient understanding and can actually increase your referral base ( as you will get many more from them than the other way round)

Sage advice, not all DC's practice with the same mindset and you may be surprised how many are completely patient centric. You will always find those with a clearly financial agenda sadly of course. Get to know an accomplished, treat and release paradigm DC and your patients will thank you for it.

Cochrane reviews have inherent problems, with regard to their data synthesis on the subject of spinal manipulation there are myriad issues including subsets of low back pain etiology, "manipulation" not specifically performed by a chiropractor etc.

Consider the following research and CPG guidelines (not included in the Cochrane review) and let your conscience and the tenet of putting your patients first be your guide:

http://www.ncbi.nlm.nih.gov/pubmed/20889389

CONCLUSIONS: This is the first reported randomized controlled trial comparing full CPG-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC in the treatment of patients with AM-LBP. Compared to family physician-directed UC, full CPG-based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.

http://www.annals.org/content/147/7/478.full

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).