Chiropractic Manipulation and Osteopathic Manipulation

[SleepIsGood]

What's the difference in the manipulation techniques?

Honestly, I dont know and would like to hear ideas, if there are any.

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[specepic]

What's the difference in the manipulation techniques?

Honestly, I dont know and would like to hear ideas, if there are any.

You can ask 3 people this questions and get 10 different answers. That being said:

1) The overall philosophy, classically speaking, is different. Chiro's are taught that manipulation ultimately targets the 'nervous system' and D.O.'s are taught that 'the rule of the artery is supreme', in other words, get tight tissues to loosen up, get the range of motion back, let the blood get in there, then leave it alone and let it heal.

2) Treatment plans tend to differ. For a really acute pt I might see them every 2 weeks, then quickly try to spread this out to q4-6 weeks. I was taught: 'find it, fix it, leave it alone'. Maintenance, if appropriate, would be like q2-3 months for a chronic. Chiros tend to treat more frequently, as often as daily, but I have seen 3x/week as typical for acute pts. They are taught this, but there are obvious financial implications. When a pt recently told me they asked their chiro if they could come in more often, and there were told no, thats not necessary, that chiros stock went up quite a bit for me.

3) As to how much PT will be involved is dependent on the D.O.'s training and specialty. Chiros may give stretches>exercises but referring to a PT is kind of referring to the competition. Again, very providor dependent on both sides of the aisle.

4) Types of techniques: in general chiros tend to do more of the 'wham, bam, thank you m'am' techniques. These are what most people think of as 'spinal manip'. These are HVLA (high velocity low amplitude). These are quick and pts feel like something is being done b/c they hear/feel things popping and usually feel different right away. A D.O. who specializes in manip is much more likely to do gentle techniques like myofascial release, muscle energy (contract/relax in the PT world), and other non-twisting/thrusting manuvers. There is a chiro technique called 'activator' which uses a hand held instrument and is very gentle. The problem with this technique is that many providers use the instrument as a 'find the sore spot and thump it' b/c this is quick and easy. This is not how it is designed to be used.

5) Indications: if I have a young, healthy, non chronic pt I anticipate seeing a chiro will help them recover from a MSK issue, especially spine, a bit quicker. Your FMS, elderly, chronic pts may prefer your local D.O. guru, if you are lucky enough to have one.

My bias: I'm a D.O. who does OMT. I did a fellowship in this specifically before doing residency/pain fellowship. It made me a better physician and gave me mind blowing palpatory skillz , yoda has contacted me about becoming a jedi. I have multiple family members, friends, including my best friend, who are chiros. I would send pts to some of them, and not others. Chiro admission standards are too low and the used car salesman bad apples get mixed in with the real pros. To be balanced the D.O. schools are expanding too rapidly now and the profession may have a similar problem as time goes on. That being said the hoops one has to get through to be a board certified D.O. are a whole different ballgame since there really is no true 'residency' for chiros.

sleep, I hope you weren't trolling on this one, b/c if you were and I just wasted some of my sunday a.m.--I will find you and execute an ancient osteopathic technique that will make you have bowel incontinence everytime to do a cervical injection, if that does not occur already.

 

[drusso]

Osteopathy historically pre-dates chiropractic. "Bone-setting" pre-dates them both. Practically speaking, there is no difference between the two systems of manipulation--biomechanics limits what forces you can introduce into a joint or soft tissue plane. Scientifically, the analgesic effects of all manual therapies are grounded in the physiology of "counter-irritation." Ditto for accupuncture, massage, rolfing, and other physical modalities.

For more information, I recommend this particularly well-written book chapter on the topic.

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=altrehab&part=A4

 

[SleepIsGood]

You can ask 3 people this questions and get 10 different answers. That being said:

1) The overall philosophy, classically speaking, is different. Chiro's are taught that manipulation ultimately targets the 'nervous system' and D.O.'s are taught that 'the rule of the artery is supreme', in other words, get tight tissues to loosen up, get the range of motion back, let the blood get in there, then leave it alone and let it heal.

2) Treatment plans tend to differ. For a really acute pt I might see them every 2 weeks, then quickly try to spread this out to q4-6 weeks. I was taught: 'find it, fix it, leave it alone'. Maintenance, if appropriate, would be like q2-3 months for a chronic. Chiros tend to treat more frequently, as often as daily, but I have seen 3x/week as typical for acute pts. They are taught this, but there are obvious financial implications. When a pt recently told me they asked their chiro if they could come in more often, and there were told no, thats not necessary, that chiros stock went up quite a bit for me.

3) As to how much PT will be involved is dependent on the D.O.'s training and specialty. Chiros may give stretches>exercises but referring to a PT is kind of referring to the competition. Again, very providor dependent on both sides of the aisle.

4) Types of techniques: in general chiros tend to do more of the 'wham, bam, thank you m'am' techniques. These are what most people think of as 'spinal manip'. These are HVLA (high velocity low amplitude). These are quick and pts feel like something is being done b/c they hear/feel things popping and usually feel different right away. A D.O. who specializes in manip is much more likely to do gentle techniques like myofascial release, muscle energy (contract/relax in the PT world), and other non-twisting/thrusting manuvers. There is a chiro technique called 'activator' which uses a hand held instrument and is very gentle. The problem with this technique is that many providers use the instrument as a 'find the sore spot and thump it' b/c this is quick and easy. This is not how it is designed to be used.

5) Indications: if I have a young, healthy, non chronic pt I anticipate seeing a chiro will help them recover from a MSK issue, especially spine, a bit quicker. Your FMS, elderly, chronic pts may prefer your local D.O. guru, if you are lucky enough to have one.

My bias: I'm a D.O. who does OMT. I did a fellowship in this specifically before doing residency/pain fellowship. It made me a better physician and gave me mind blowing palpatory skillz , yoda has contacted me about becoming a jedi. I have multiple family members, friends, including my best friend, who are chiros. I would send pts to some of them, and not others. Chiro admission standards are too low and the used car salesman bad apples get mixed in with the real pros. To be balanced the D.O. schools are expanding too rapidly now and the profession may have a similar problem as time goes on. That being said the hoops one has to get through to be a board certified D.O. are a whole different ballgame since there really is no true 'residency' for chiros.

sleep, I hope you weren't trolling on this one, b/c if you were and I just wasted some of my sunday a.m.--I will find you and execute an ancient osteopathic technique that will make you have bowel incontinence everytime to do a cervical injection, if that does not occur already.

Hey man thanks for the heads up. Not trolling by the way. Just wondered since both you and the chiros use the term "manipulation". I couldnt find anything that flushed out exactly the differences b/w the manipulations.

 

[axm397]

Osteopathy historically pre-dates chiropractic. "Bone-setting" pre-dates them both. Practically speaking, there is no difference between the two systems of manipulation--biomechanics limits what forces you can introduce into a joint or soft tissue plane. Scientifically, the analgesics effects of all manual therapies are grounded in the physiology of "counter-irritation." Ditto for accupuncture, massage, rolfing, and other physical modalities.

For more information, I recommend this particularly well-written book chapter on the topic.

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=altrehab&part=A4

I don't trust the authors - well especially one of them. i mean that's a lot of initials after the name! D.O., M.P.H., M.S.?? jeez how much schooling does one need?

 

[Ligament]

Excellent so we have at least two DOs answering this post that did an OMT fellowship.

For those of you not familiar: One can do a fellowship in OMT. It is one year long and occurs after the fourth medical school year, before internship and residency. The fellow does OMT all year. Russo has done two fellowships therefore; OMT and Pain Medicine after PMR residency.

 

[masterofmonkeys]

excellent post. Of course more in favor of OMT than chiro. But then again, so am I lol.

Should be noted that there are a number of chiros who are well-versed in and trained with an OMT philosophy, many directly under DOs.

It can certainly be argued that a chiro trained in DO techniques is not the same as a DO when it comes to manipulation. I'm an MD standing outside of the whole discussion, so I can't comment on that.

I'm only in my infancy as a future pain doc, but I have to say that I think that there are some situations in which HVLA thrusting is indicated (namely thoracic), but quite a few more where muscle and myofascial techniques are better.

Anyone here familiar enough with Active Release Technique to comment on it? It's all the rage with athletes.

 

[jpb26]

Just curious; why do so few DOs practice OMT once they are out? There is only 1 guy in my area who will do it as far as I know and he only does it as a complimentary tx on his own pts.

 

[SleepIsGood]

Just curious; why do so few DOs practice OMT once they are out? There is only 1 guy in my area who will do it as far as I know and he only does it as a complimentary tx on his own pts.

1) To labor intensive and I hear the labor/time spent isnt worth the $$

2) It's a temporary fix. From what I hear you have to repeat it multiple times. Insurance companies aren't too thrilled to do that.

I'm sure there are other reasons..

 

[facetguy]

A DC chiming in here. I agree with much of Specepic's response, although I'd change a few things.

You can ask 3 people this questions and get 10 different answers. That being said:

1) The overall philosophy, classically speaking, is different. Chiro's are taught that manipulation ultimately targets the 'nervous system' and D.O.'s are taught that 'the rule of the artery is supreme', in other words, get tight tissues to loosen up, get the range of motion back, let the blood get in there, then leave it alone and let it heal.

The historical tenets of either profession, while interesting, don't have a whole lot to do with modern day practice. But point taken.

2) Treatment plans tend to differ. For a really acute pt I might see them every 2 weeks, then quickly try to spread this out to q4-6 weeks. I was taught: 'find it, fix it, leave it alone'. Maintenance, if appropriate, would be like q2-3 months for a chronic. Chiros tend to treat more frequently, as often as daily, but I have seen 3x/week as typical for acute pts. They are taught this, but there are obvious financial implications. When a pt recently told me they asked their chiro if they could come in more often, and there were told no, thats not necessary, that chiros stock went up quite a bit for me.

In my practice, treatment plans vary widely. A really acute patient is likely to be seen 2 or 3 days/week for 2-3 weeks, although that too depends on the case. I may be able to restore their function in a couple of visits. All depends. Overall, however, I do agree that a patient is likely to be seen more frequently initially by a chiro than a DO (but the same can be said for PT treatment, and you guys all refer to PTs).

I can recall hearing that old line "find it, fix it, leave it alone" in school too.

3) As to how much PT will be involved is dependent on the D.O.'s training and specialty. Chiros may give stretches>exercises but referring to a PT is kind of referring to the competition. Again, very providor dependent on both sides of the aisle.

The amount of active rehab utilized by chiros has been increasing over recent years. New grads today get more of this training than I did, but there are lots of post-grad classes available. Historically, chiros didn't focus as much on the active component, that's true. As far as PTs being the competition, I guess due to the overlap in practices, there may be some truth to that in general. Myself, I have several good friends who are PTs, and I have no problem referring to them, especially for cases needing more active rehab and particularly knees, ankles, etc. They feel the same way (a PT I don't know told a mutual patient just last week "maybe you should go see your chiropractor and get adjusted"). Some chiros have more extensive in-house rehab areas.

4) Types of techniques: in general chiros tend to do more of the 'wham, bam, thank you m'am' techniques. These are what most people think of as 'spinal manip'. These are HVLA (high velocity low amplitude). These are quick and pts feel like something is being done b/c they hear/feel things popping and usually feel different right away. A D.O. who specializes in manip is much more likely to do gentle techniques like myofascial release, muscle energy (contract/relax in the PT world), and other non-twisting/thrusting manuvers. There is a chiro technique called 'activator' which uses a hand held instrument and is very gentle. The problem with this technique is that many providers use the instrument as a 'find the sore spot and thump it' b/c this is quick and easy. This is not how it is designed to be used.

I think this is mostly a misunderstanding of what chiros do. Specepic has friends who are DCs, so I know s/he comes at this with some background knowledge; and HVLA is a big part of many chiro practices. BUT, having said that, there are lots of different techniques that chiros can utilize, depending on training and personal preference/experience. I would say that I don't "crack" probably 50% of my patients (at least). And I use various soft tissue/myofascial techniques on probably 90% of patients.

It's my biased opinion that there isn't even a comparison in manual skills between chiros and DOs (perhaps an exception can be made for the fellowship trained DOs, I'm not sure). Chiros get WAY more training time, and quality focused training time at that than DO students. Many of the DO students don't even want to be in OMT class (just read the many forums here on SDN and you'll quickly see how true that is), let alone give it a real effort. Chiro students know 100% for sure that they will be using the skills they are learning in school; I think the % of DO students who can say the same is in the single digits. That makes a big difference during training years. For chiro students, it's why they are there. For DO students, it's a blow-off and waste of time. And chiro students are exposed to virtually any manual technique that a DO will learn; DO techniques aren't some ancient Chinese secret or anything.

Not to pick on DO students, but when I was applying to DO school last year, after interviews, a group of us were taken on a tour by two 2nd year DO students. At one point, we arrived at the OMT lab and they asked if we wanted to see a demonstration of HVLA. All the kids eyes lit up and everyone said yes. Let me just say, it was not impressive, to say the least. Yes, I understand they were only 2nd year students, but it was real clear that their skills would have been considered below sub-par in a chiro school setting.

5) Indications: if I have a young, healthy, non chronic pt I anticipate seeing a chiro will help them recover from a MSK issue, especially spine, a bit quicker. Your FMS, elderly, chronic pts may prefer your local D.O. guru, if you are lucky enough to have one.

This too varies widely. I see younger athletic patients along with elderly ones. Do I treat them the same? Of course not. I vary my techniques and recommendations to the patient. And chiros in general end up seeing lots of chronics if for no other reason than these patients have already been everywhere else and show up at the chiro office as a last resort.

My bias: I'm a D.O. who does OMT. I did a fellowship in this specifically before doing residency/pain fellowship. It made me a better physician and gave me mind blowing palpatory skillz , yoda has contacted me about becoming a jedi. I have multiple family members, friends, including my best friend, who are chiros. I would send pts to some of them, and not others. Chiro admission standards are too low and the used car salesman bad apples get mixed in with the real pros. To be balanced the D.O. schools are expanding too rapidly now and the profession may have a similar problem as time goes on. That being said the hoops one has to get through to be a board certified D.O. are a whole different ballgame since there really is no true 'residency' for chiros.

Chiro schools do need to beef up admission standards. Quality of chiro education has improved considerably over the last couple of decades however.

sleep, I hope you weren't trolling on this one, b/c if you were and I just wasted some of my sunday a.m.--I will find you and execute an ancient osteopathic technique that will make you have bowel incontinence everytime to do a cervical injection, if that does not occur already.

I hesitated to even respond because it was Sleep who was asking. So, the same goes for me!

 

[drusso]

How about this for an answer: Most of the manual medicine literature, theory, and practice is just garbage. Not completely void of any value whatsoever, but really a 19th century solution for a complex 21st century problem. Most DO's don't practice OMT consistently just as most DO's don't perform surgery or obstetrics consistently. For DO's OMT is one tool as opposed to *THE* tool. If you don't do it consistently, your skills will deteriorate. Frankly, unlike DC school students, DO's students are also pre-occupied learning "real medicine." It's no small thing...

Other reasons: Manipulation doesn't work for chronic pain beyond a temporary fix. At my medical school's manual medicine clinic we would see patients who have been coming in for YEARS to get manipulated, rubbed down, or get their head held silently for 40 minutes. No one really got better. So what are we trying to accomplish here??

Other reasons: There's no evidence that manual treatment has treatment effects beyond placebo, but that may be a moot point. Afterall, placebo's can be used therapeutically. It unclear how one would even design a credible manual placebo in order to estimate the effect size of manual interventions. So, we're all kind of in the woods...

http://www.jaoa.org/cgi/content/full/106/8/457

I still refer patients for manual treatment. I also perform it myself from time to time. I'm sure that if I "opened the flood-gates" and marketed myself as a manual medicine guy I could make a decent living at it, but there would be an element of self-deception in that endeavor as I believe most manual treatment is over-utilized, of limited value, and more appropriately used as part of a multi-modal rehab for acute or sub-acute injuries only.

The DC's I observe in my community seem to never discharge patients from their practice preferring to keep them on as an annuity. Meanwhile, these patients just can't understand why their SI joint keeps "coming out" and always needing to be put "back in." I've got patients with SIJ's just flapping in the wind. It's amazing that their whole pelvis doesn't just explode. However, one appropriately performed, image-guided, SIJ injection usually fixes these patients. The amount of de-programming they require after years of chiropractic or manual PT therapy is immense...thank God I've got a good psychologist in our practice for that.

 

[facetguy]

How about this for an answer: Most of the manual medicine literature, theory, and practice is just garbage. Not completely void of any value whatsoever, but really a 19th century solution for a complex 21st century problem. Most DO's don't practice OMT consistently just as most DO's don't perform surgery or obstetrics consistently. For DO's OMT is one tool as opposed to *THE* tool. If you don't do it consistently, your skills will deteriorate. Frankly, unlike DC school students, DO's students are also pre-occupied learning "real medicine." It's no small thing...

When I mentioned the differences in manual training between chiro students and DO students, I didn't mean to imply that the DOs weren't doing anything else outside of OMT lab. Of course their plates are full with learning "real medicine", but they still for the most part don't give a crap about OMT. As to the literature, "garbage" may be a bit strong.

Other reasons: Manipulation doesn't work for chronic pain beyond a temporary fix. At my medical school's manual medicine clinic we would see patients who have been coming in for YEARS to get manipulated, rubbed down, or get their head held silently for 40 minutes. No one really got better. So what are we trying to accomplish here??

Your implication here is that something other than manual treatment WILL help these people. Sometimes, that may be true. But other times, nothing helps these people, especially if by "help" we mean permanent fix. So what are we trying to accomplish? I'd start with improving mobility and functional capacity, and perhaps reducing (although not likely eliminating) the need for meds. I think that's something worth pursuing. As to the school clinic patients, I'm not too sure that they represent a true sample of chronic pain patients though.

Other reasons: There's no evidence that manual treatment has treatment effects beyond placebo,

Not true, but we've already gone through this.

...but that may be a moot point. Afterall, placebo's can be used therapeutically. It unclear how one would even design a credible manual placebo in order to estimate the effect size of manual interventions. So, we're all kind of in the woods...

http://www.jaoa.org/cgi/content/full/106/8/457

For you anesthesiology guys, perhaps you will be playing a role in future manipulation research when it comes to placebos:
http://www.ncbi.nlm.nih.gov/pubmed/19236995 (the lead author is a DC).

I still refer patients for manual treatment. I also perform it myself from time to time. I'm sure that if I "opened the flood-gates" and marketed myself as a manual medicine guy I could make a decent living at it, but there would be an element of self-deception in that endeavor as I believe most manual treatment is over-utilized, of limited value, and more appropriately used as part of a multi-modal rehab for acute or sub-acute injuries only.

The DC's I observe in my community seem to never discharge patients from their practice preferring to keep them on as an annuity. Meanwhile, these patients just can't understand why their SI joint keeps "coming out" and always needing to be put "back in." I've got patients with SIJ's just flapping in the wind. It's amazing that their whole pelvis doesn't just explode. However, one appropriately performed, image-guided, SIJ injection usually fixes these patients. The amount of de-programming they require after years of chiropractic or manual PT therapy is immense...thank God I've got a good psychologist in our practice for that.

Can we bash psychologists here someday?

 

[SleepIsGood]

A DC chiming in here. I agree with much of Specepic's response, although I'd change a few things.



The historical tenets of either profession, while interesting, don't have a whole lot to do with modern day practice. But point taken.



In my practice, treatment plans vary widely. A really acute patient is likely to be seen 2 or 3 days/week for 2-3 weeks, although that too depends on the case. I may be able to restore their function in a couple of visits. All depends. Overall, however, I do agree that a patient is likely to be seen more frequently initially by a chiro than a DO (but the same can be said for PT treatment, and you guys all refer to PTs).

I can recall hearing that old line "find it, fix it, leave it alone" in school too.



The amount of active rehab utilized by chiros has been increasing over recent years. New grads today get more of this training than I did, but there are lots of post-grad classes available. Historically, chiros didn't focus as much on the active component, that's true. As far as PTs being the competition, I guess due to the overlap in practices, there may be some truth to that in general. Myself, I have several good friends who are PTs, and I have no problem referring to them, especially for cases needing more active rehab and particularly knees, ankles, etc. They feel the same way (a PT I don't know told a mutual patient just last week "maybe you should go see your chiropractor and get adjusted"). Some chiros have more extensive in-house rehab areas.



I think this is mostly a misunderstanding of what chiros do. Specepic has friends who are DCs, so I know s/he comes at this with some background knowledge; and HVLA is a big part of many chiro practices. BUT, having said that, there are lots of different techniques that chiros can utilize, depending on training and personal preference/experience. I would say that I don't "crack" probably 50% of my patients (at least). And I use various soft tissue/myofascial techniques on probably 90% of patients.

It's my biased opinion that there isn't even a comparison in manual skills between chiros and DOs (perhaps an exception can be made for the fellowship trained DOs, I'm not sure). Chiros get WAY more training time, and quality focused training time at that than DO students. Many of the DO students don't even want to be in OMT class (just read the many forums here on SDN and you'll quickly see how true that is), let alone give it a real effort. Chiro students know 100% for sure that they will be using the skills they are learning in school; I think the % of DO students who can say the same is in the single digits. That makes a big difference during training years. For chiro students, it's why they are there. For DO students, it's a blow-off and waste of time. And chiro students are exposed to virtually any manual technique that a DO will learn; DO techniques aren't some ancient Chinese secret or anything.

Not to pick on DO students, but when I was applying to DO school last year, after interviews, a group of us were taken on a tour by two 2nd year DO students. At one point, we arrived at the OMT lab and they asked if we wanted to see a demonstration of HVLA. All the kids eyes lit up and everyone said yes. Let me just say, it was not impressive, to say the least. Yes, I understand they were only 2nd year students, but it was real clear that their skills would have been considered below sub-par in a chiro school setting.



This too varies widely. I see younger athletic patients along with elderly ones. Do I treat them the same? Of course not. I vary my techniques and recommendations to the patient. And chiros in general end up seeing lots of chronics if for no other reason than these patients have already been everywhere else and show up at the chiro office as a last resort.



Chiro schools do need to beef up admission standards. Quality of chiro education has improved considerably over the last couple of decades however.



I hesitated to even respond because it was Sleep who was asking. So, the same goes for me!

Hmm...so let me guess this.

You think Chiros are better than DOs
You apparently applied to DO school last year.

So either you are lying and NOT a chiropractor and are just a chiro student. OR you are very unsuccessful at what you do and wnt to be a real doctor?

Hey you wrote it, not me.

 

[facetguy]

Hmm...so let me guess this.

You think Chiros are better than DOs
You apparently applied to DO school last year.

So either you are lying and NOT a chiropractor and are just a chiro student. OR you are very unsuccessful at what you do and wnt to be a real doctor?

Hey you wrote it, not me.

I don't think chiros are better than DOs.
I did apply to DO school last year.

I am not lying. I am a chiropractor. I am not a chiro student. I am successful at what I do. I did want to go to DO school for a time.

Yes, I did write it.

 

[SleepIsGood]

I don't think chiros are better than DOs.
I did apply to DO school last year.

I am not lying. I am a chiropractor. I am not a chiro student. I am successful at what I do. I did want to go to DO school for a time.

Yes, I did write it.

READ YOUR POSTs...you did write that YOU thought chiros are better at manipulation.


A little confused huh...well atleast it explains some of your delusional thinkings.

 

[facetguy]

READ YOUR POSTs...you did write that YOU thought chiros are better at manipulation.


A little confused huh...well atleast it explains some of your delusional thinkings.

You said "better than DOs", not "better at manipulation/manual therapies than DOs". I believe the latter, not the former.

And not for nothin', but I think it's pretty clear to anyone who reads along with these threads just who is confused, delusional, etc. and who isn't. The more you write, the better I look. Clearly, you must have some intelligence and at least some drive, or you wouldn't be where you are, and I commend you for that. And maybe you just don't come across well in the written form. But, really man, your posts could be mistaken for those of a grade-schooler.

 

[specepic]

You said "better than DOs", not "better at manipulation/manual therapies than DOs". I believe the latter, not the former.

And not for nothin', but I think it's pretty clear to anyone who reads along with these threads just who is confused, delusional, etc. and who isn't. The more you write, the better I look. Clearly, you must have some intelligence and at least some drive, or you wouldn't be where you are, and I commend you for that. And maybe you just don't come across well in the written form. But, really man, your posts could be mistaken for those of a grade-schooler.

I apprecaite your reasonable and thoughtful reply to my post. I would respectfully disagree on the matter of manual med skills chiro vs. D.O. Let me be specific on this. Who would I want to do manip on me, a chiro or a average D.O. who does not do it often: chiro. But, chiro vs. OMT fellowship and/or OMT residency tranied D.O.: the D.O. for sure.

 

[facetguy]

I apprecaite your reasonable and thoughtful reply to my post. I would respectfully disagree on the matter of manual med skills chiro vs. D.O. Let me be specific on this. Who would I want to do manip on me, a chiro or a average D.O. who does not do it often: chiro. But, chiro vs. OMT fellowship and/or OMT residency tranied D.O.: the D.O. for sure.

Admittedly, I don't know much about the OMT fellowship, and I can imagine that that extra training puts you well above the "average" DO in terms of manual skills. There was no disrespect intended.

 

[Pain Applicant]

N Engl J Med. 1999 Nov 4;341(19):1426-31.
A comparison of osteopathic spinal manipulation with standard care for patients with low back pain.
Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S.

http://www.ncbi.nlm.nih.gov/sites/entrez



Out of curiosity, what are your guys thoughts on this?

 

[facetguy]

N Engl J Med. 1999 Nov 4;341(19):1426-31.
A comparison of osteopathic spinal manipulation with standard care for patients with low back pain.
Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S.

http://www.ncbi.nlm.nih.gov/sites/entrez



Out of curiosity, what are your guys thoughts on this?

Here's the direct link to the full text:
http://content.nejm.org/cgi/content/full/341/19/1426

And full text letters to the editor regarding the above study:
http://content.nejm.org/cgi/content/full/342/11/817

 

[Eta Carinae]

Hmmm, so

First they recruited only patients with back pain for <3weeks- acute by any definition of back pain. And how many of those are attempted to be treated by medicine (I mean actual MD or DO[minus OMT] medicine). Most patients present with chronic back pain.

Then they excluded patients with any actual medical diagnosis or even those with psychiatric diagnoses contributing to their low back pain :

“We excluded patients with nerve-root compression (dermatomal pain distribution, neurologic deficit, or both), a systemic inflammatory disorder, scoliosis, a serious medical illness such as cancer, recent myocardial infarction, diabetic neuropathy, neurovascular disease, alcohol or drug abuse, or a known psychiatric or psychological illness, as well as those with no lesion that could be manipulated. We also excluded patients who were pregnant, were involved in active litigation or receiving workers' compensation, had undergone manipulation treatment in the previous three weeks, or were considered unable to follow the protocol for any reason.”

This would be like testing a new flavor, say cream mint, of ice cream in people who are lactose-intolerant vs those who have love mint and frequent ice-cream bars habitually.

And finally they randomized them to either OMT or what they term “allopathic” medicine- meaning NSAIDs, physical therapy, antiinflammatories, muscle relaxants.

These ARE patients for whom medical treatment should not have been sought in the first place and who might have benefited from yoga, pilates, abdominal muscle strengthening/conditioning exercises and exercises to correct posture. The study should have compared OMT to those interventions or even to placebo. That would have been a much better comparison.

Their glaring failure to control for confounding is obvious in Table 1:
The group which received OMT was much younger (<30) than the group which received “standard care” (pushing 40).

And then finally, NONE, I mean NONE of their outcomes was statistically significant. P-values were huge and Confidence Intervals all crossed 0 and were also huge.

So the study was biased in selecting for patients who should not have been eligible for the medical treatments they compared OMT to in the first place. And then the so-called “results” they showed mean nothing?

I want to know how this got published .

PS: I wrote a paper in high school on how blue pens produced better outcomes when used in patient documentation than black pens and I want to know why it wasn’t published

 

[facetguy]

First they recruited only patients with back pain for <3weeks- acute by any definition of back pain. And how many of those are attempted to be treated by medicine (I mean actual MD or DO[minus OMT] medicine). Most patients present with chronic back pain.

It looks like they recruited patients with back pain of at least 3 weeks but less than 6 months.

And finally they randomized them to either OMT or what they term “allopathic” medicine- meaning NSAIDs, physical therapy, antiinflammatories, muscle relaxants.

These ARE patients for whom medical treatment should not have been sought in the first place and who might have benefited from yoga, pilates, abdominal muscle strengthening/conditioning exercises and exercises to correct posture. The study should have compared OMT to those interventions or even to placebo. That would have been a much better comparison.

I'm not sure where you live, but where I live, virtually ANYONE with back pain for at least 3 weeks but less than 6 months is prescribed, as you say, allopathic medicine (NSAIDS, muscle relaxors, PT). You may be right, though, that these patients would have benefitted from yoga, Pilates, or postural exercises. There are some studies comparing manipulation to a number of other interventions; these may be of interest.

Their glaring failure to control for confounding is obvious in Table 1:

The group which received OMT was much younger (<30) than the group which received “standard care” (pushing 40).

From the authors:
"There is an error in Table 1 of our article. The mean (±SD) age of patients in the osteopathic-treatment group was 40.0±10.6 years, not 28.5±10.6, as printed. "

Just a typo.

 

[Eta Carinae]

It looks like they recruited patients with back pain of at least 3 weeks but less than 6 months.

3 weeks to 6mos of back pain, excluding patients with any actual medical diagnoses, even extending as far as patients with psychiatric diagnoses seems like an attempt at chicanery to me.

I'm not sure where you live, but where I live, virtually ANYONE with back pain for at least 3 weeks but less than 6 months is prescribed, as you say, allopathic medicine (NSAIDS, muscle relaxors, PT). You may be right, though, that these patients would have benefitted from yoga, Pilates, or postural exercises. There are some studies comparing manipulation to a number of other interventions; these may be of interest.

Anecdotal report, albeit point well taken.

From the authors:
"There is an error in Table 1 of our article. The mean (±SD) age of patients in the osteopathic-treatment group was 40.0±10.6 years, not 28.5±10.6, as printed. "

Just a typo.

Indeed, in their subsequent letters they make this correction.

I find more recusive, the inability to produce any statistically significant differences between the groups. Indicating that, inspite of their attempts at subterfuge, the results mean little to nothing.


PS: I found some of the responses to the article interesting and insightful. I've copied them below:

In comparing osteopathic spinal manipulation with standard care for patients with low back pain, Andersson et al. (Nov. 4 issue)1 fail to recognize that many patients may have improvement with minimal or no treatment. This might have been evident had the authors included a control group of patients who received minimal or no intervention for back pain. Cherkin et al. compared the outcomes for patients with low back pain who received physical therapy, chiropractic treatment, or an educational booklet.2 There was only a marginally better outcome in the physical-therapy and chiropractic-treatment groups than in the booklet group. Improvement with minimal or no treatment would also explain the similar outcomes reported by Carey et al. in their comparison of treatments by primary care practitioners, chiropractors, and orthopedic surgeons.3 The only substantial differences in the results of these studies seem to be in the area of patient satisfaction and cost. Therefore, it would be erroneous to conclude from the study by Andersson et al. that either standard care or osteopathy is superior to the placebo effect. It is evident that in most cases, back pain resolves over time, regardless of the treatment used.

The emboldened statements above again reiterate my initial assessment of the article as failing to compare two equivalent treatment modalities, and labelling physical therapy as "allopathic"/"standard" treatment.

The repetitive claims of the uniqueness of osteopathic medicine, in these letters and elsewhere, are reminiscent of the classic bellman's fallacy in Lewis Carroll's wonderful nonsense poem "The Hunting of the Snark." At the outset, the bellman needs to convince his fellow travelers that they have arrived at the proper place. To do so, he says three times that they have landed correctly and then claims, "What I tell you three times is true."1 However, demonstrating a statement's truth by repeating it multiple times worked only to a limited extent in Lewis Carroll's 19th-century fantasy world and should not be mistaken for evidence-based argument in our 21st-century medical discussions.

the statements in bold, in particular, resonate with my exact sentiments on appraisal of this article and of the justifications for OMT as a valid practice in modern day medicine in general.

My knowledge and experience of the field (OMT) are limited, so attach however little weight to my opinion as you wish, however, I affirm the belief that the teaching of these practice should emphasize their place in antiquity, perhaps?

 

[masterofmonkeys]

Other reasons: Manipulation doesn't work for chronic pain beyond a temporary fix. At my medical school's manual medicine clinic we would see patients who have been coming in for YEARS to get manipulated, rubbed down, or get their head held silently for 40 minutes. No one really got better. So what are we trying to accomplish here??

For people with chronic pain secondary to anatomic dysfunction, why should we expect anyone to get better? For someone with radiculopathy secondary to bulging disc with associated narrowing of the neuroforaminal canal secondary to uncovertebral hypertrophy and osteophyte formation, why should we expect anyone to get better without surgery (and its intendant risks and long-term consequences)?

Could manipulation (DC or DO) not play a role in management of pain and dysfunction? So what if the patient has to come back weekly or monthly for manipulation? If that allows them a reasonable degree of pain relief and restoration of function and quality of life, why is that not in and of itself an accomplishment to be lauded?

Surely if manipulation reduced or eliminated the use of opioids/AEDs, the need for more invasive procedures, delayed surgery, and improved functional status, that in and of itself could be considered a good thing?

Personal story here, but I went weekly to a chiro who used a lot of soft tissue techniques for relief of cervical and thoracic radiculopathy and a lot of ribhead-derived pain. My MRIs look disastrous. I paired this with an extensive approach to self-PT derived directly from basic kinesiology and exercise science. But with this treatment and the time in the gym I have never touched an opioid or AED, never had a needle stuck in me, have no thoughts of pursuing multilevel fusion, and am able to maintain a very active lifestyle that includes weekend warrior sports with dramatically reduced pain between treatments. I consider this a therapeutic success, despite the fact that his manipulations haven't magically cured my anatomic disease and without the time in the gym things can go quickly south.

 

[ampaphb]

For people with chronic pain secondary to anatomic dysfunction, why should we expect anyone to get better? For someone with radiculopathy secondary to bulging disc with associated narrowing of the neuroforaminal canal secondary to uncovertebral hypertrophy and osteophyte formation ... could manipulation (DC or DO) not play a role in management of pain and dysfunction?

So let's tale your example. Clearly mechanical. Please explain the mechanism by which manipulation of any kind is likely to improve this structural issue. If we attribute the patient's symptoms to the pathology you described, doesn't the the treatment need to resolve or diminish the bio-mechanical etiology?

 

[facetguy]

So let's tale your example. Clearly mechanical. Please explain the mechanism by which manipulation of any kind is likely to improve this structural issue. If we attribute the patient's symptoms to the pathology you described, doesn't the the treatment need to resolve or diminish the bio-mechanical etiology?

Is it your contention that any attempted treatment must alter structure? I said this before to you: You sound more like a surgeon than a pain guy.

 

[ampaphb]

Is it your contention that any attempted treatment must alter structure? I said this before to you: You sound more like a surgeon than a pain guy.

My question was not addressed to you. I am hopeful masterofmonkeys practices rationally, and addresses pathology. If you do not tailor your treatment to the structural lesions that are present, then why bother obtaining imaging in the first place (other than because the lawyer who refers you accident cases expects you to)?

We pain guys and gals address specific pathology. We don't have the luxury of treating imaginary "subluxations" in order to justify our particular course of treatment.

If requiring a rational basis for my treatment protocol is a surgical approach (which it clearly isn't) then I suppose most of my colleagues and I are guilty of what clearly is a faux pas to your way of thinking.

 

[facetguy]

My question was not addressed to you. I am hopeful masterofmonkeys practices rationally, and addresses pathology. If you do not tailor your treatment to the structural lesions that are present, then why bother obtaining imaging in the first place (other than because the lawyer who refers you accident cases expects you to)?

We pain guys and gals address specific pathology. We don't have the luxury of treating imaginary "subluxations" in order to justify out particular course of treatment.

If requiring a rational basis for my treatment protocol is a surgical approach (which it clearly isn't) then I suppose most of my colleagues and I are guilty of what clearly is a faux pas to your way of thinking.

Addressing specific pathology is different than altering structure.

 

[ampaphb]

If you do not tailor your treatment to the structural lesions that are present, then why bother obtaining imaging in the first place?

You have stated several times that you frequently can not identify a particular etiology for your patient's pain. I presume you still go ahead and manipulate these patients. I am unclear how you chose your specific course of treatment, and what level to focus your efforts on.

If a patient presents with a pristine MRI and a normal physical exam other than complaints of low back pain, I personally do not move forward with procedures. Would you manipulate such a patient? When a patient falls outside my area of expertise, I refer elsewhere.

Most chiropractors in my area would advise the above described patient undergo a regimen of manipulations/massage/PT/nutrition counselling, provide them with a back brace, and sell them vitamins.

 

[facetguy]

If you do not tailor your treatment to the structural lesions that are present, then why bother obtaining imaging in the first place?

Diagnostic imaging, as you know, is obtained for a number of reasons. And who said decision making, including treatment, isn't affected by imaging findings?

You have stated several times that you frequently can not identify a particular etiology for your patient's pain. I presume you still go ahead and manipulate these patients. I am unclear how you chose your specific course of treatment, and what level to focus your efforts on.

What I said was that for many uncomplicated cases of neck or back pain, the primary pain generator is never officially 100% confirmed, because it doesn't have to be because the condition resolves with a course of conservative treatment. Of course there is a suspected target of treatment, say a facet joint, which we believe to be the primary pain generator. Manipulation is performed on these patients if there are no contraindications to doing so. The level of focus is based on the history and exam. (Is what I am saying really that foreign a concept??)

If a patient presents with a pristine MRI and a normal physical exam other than complaints of low back pain, I personally do not move forward with procedures. Would you manipulate such a patient? When a patient falls outside my area of expertise, I refer elsewhere.

A few issues here. First, I guess we'd have to define what a "normal physical exam" is. If I can't reproduce a patient's pain with specific exam procedures, or if the history suggests non-MSK etiology, I don't treat them without further info. Second, we've known for some time now that imaging morphology doesn't always correlate with pain. So, a pristine MRI rules things out, sure, but doesn't mean the patient can't be experiencing pain. This is where you and I have differed over the structural vs. functional sources of pain. You seem to feel that there must be some altered structure and that any real treatment must alter that structure. How does an epidural alter an osteophyte? And yet epidurals can be pretty darn effective sometimes, right? As to referring patients elsewhere, I do it every day.

Most chiropractors in my area would advise the above described patient undergo a regimen of manipulations/massage/PT/nutrition counselling, provide them with a back brace, and sell them vitamins.

A course of conservative treatment may be an effective strategy for our hypothetical patient. As to nutrition, I wouldn't necessarily expect you to agree that nutritional counseling has any value; as previous discussions suggest, let's say I wouldn't look to you for nutritional expertise.

 

[masterofmonkeys]

So let's tale your example. Clearly mechanical. Please explain the mechanism by which manipulation of any kind is likely to improve this structural issue. If we attribute the patient's symptoms to the pathology you described, doesn't the the treatment need to resolve or diminish the bio-mechanical etiology?

Sorry if I trip over my fingers here, but as a reply to both of your posts, I would say that a good chiro or DO can benefit from the use of imaging to inform their treatment approach. I am not a manual therapist and so am coming at this from the view of an outsider, so I doubt my answer will be 100% satisfactory.

First of all, one of the reasons I used my chiropractor is because he has never once used the word 'subluxation' and instead approaches from the much more rigorous world of PT (he was one before he went to DC school), and osteopathy. I realize many allos, interventionalists, and orthos do not necessarily buy into the DO research into mechanical dysfunction and pain. I personally do as I find it has a lot of corroboration from the kinesiological literature, as well as from exercise science.

A lot of pain and dysfunction related to mechanical problems may actually be secondary to the way in which the body adapts and attempts to compensate for injury. For instance, it isn't uncommon for an individual to 'splint' at the level of a bulging disc, and then end up with symptoms above or below the level of the actual mechanical injury due to hypermobility or overuse in compensation. Similar mechanisms have been well described in response to hypermobile segments (in which the tendency is for the other segments to become more and more rigid) as well as for segments at which there is significant rotation, which can lead to hip and shoulder pathology as a result.

And then there is the whole can of worms of muscle imbalances, as a result of nerve damage itself, poor posture, compensation for pain and/or weakness, and the aforementioned mechanisms. These can by well understood mechanisms lead to significant periscapular and rib pain as well as hip and knee pain.

A good DO or chiro can, by working on these muscles relieve a lot of these secondary symptoms.

And the role of traction in alleviating back and neck pain has been well described. Of course, one of several mechanisms by which it does so is stretching and lengthening of the muscles, which techniques like trigger point therapy, PNF, and muscle energy can also achieve. In my case, the results were better than they were with traction, despite the fact that I am one of those individuals who is quite good at relaxing the involved musculature during traction.

No imaginary subluxations. No fixing of discs or magical dissolution of osteophytes. But by limiting secondary dysfunction, improving posture and alignment, I do believe that there is a valid role for manipulative therapies in patients with joint and disc disease.

 

[SleepIsGood]

So facet guy...suppose you have facet arthropathy contributing to facet related pain at L3/L4. How do you manipulate just that facet joint? You guys are not using fluro and typically you are 'cracking backs' relying on bony landmarks. What about patient variability. For example, Tuffier's line may not be at L3/L4...it may L4/L5.

Is your quackery going to just 'manipulate' the entire back (ie from T12 to L5). That's what AMPA is trying to tell you. You chiros can not 'isolate' pathology.

What you are doing is equivalent to someone injecting the facet joints b/l from t12-L5. If someone was to do that in medicine, we would call that quackery. Medicine unlike chiropractics has high standards for isolating pathology and being SPECIFIC about tx. Sure diagnostic methods maybe 'broad'. But when it comes to TREATMENT it's usually specific. It's the right thing to do and plus for billing reasons/insurance reasons it's important.

 

[facetguy]

So facet guy...suppose you have facet arthropathy contributing to facet related pain at L3/L4. How do you manipulate just that facet joint?

Or is your quackery going to just 'manipulate' the entire back (ie from T12 to L5). That's what AMPA is trying to tell you. You chiros can not 'isolate' pathology.

What you are doing is equivalent to someone injecting the facet joints b/l from t12-L5. If someone was to do that, we would call that quackery. Medicine unlike chiropractics has high standards for isolating pathology and being SPECIFIC about tx. Sure diagnostic methods maybe 'broad'. But when it comes to TREATMENT it's usually specific.

We try to be as specific as we can with manipulative treatments, using short-lever contacts instead of long-lever, more generalized manipulation. Having said that, it is difficult to be perfectly sure that one is moving only a single facet articulation, and I would say that more than one joint is often affected by HVLA manipulation. But there is no harm in motioning adjacent segments with manipulation. Now and previously you have tried to compare spinal manipulation to spinal injections. It's apples and oranges. Spinal manipulation is a low cost, extremely low risk, non-invasive treatment modality. Spinal injections are high cost, invasive procedures with at least a fair degree of risk to the patient. So manipulating a few lumbar motion segments is not at all like injecting from T12-L5. I am in complete agreement that you guys are able to be more specific by using diagnostic injections; in fact, that's a primary reason for referring patients to you (which I do fairly regularly, by the way) and I explain that to patients. Perhaps you need to stop thinking of chiropractors as your competition; we don't do what you do and you don't do what we do. Why is that so hard?

For what it's worth and with regard to spine pain, in my view you guys enter the picture either when a patient's condition is so fired up that we can't even give conservative care a go, or after a reasonable course of conservative care has failed to improve the patient as much as we'd like. I think that is very reasonable. Do you see it differently?

PS: You must have been editing while I was responding; there are a new points in there. As far as billing goes, I don't get paid any more or any less if I adjust a single facet joint or the entire lumbar spine; chiro codes are for either 1-2 regions (e.g., cervical and thoracic), or 3-4 regions, or 5 regions. We don't bill by each spinal joint. As to using fluro, well you've tried to make that argument before and quite frankly I don't get it.

 

[SleepIsGood]

We try to be as specific as we can with manipulative treatments, using short-lever contacts instead of long-lever, more generalized manipulation. Having said that, it is difficult to be perfectly sure that one is moving only a single facet articulation, and I would say that more than one joint is often affected by HVLA manipulation. But there is no harm in motioning adjacent segments with manipulation. Now and previously you have tried to compare spinal manipulation to spinal injections. It's apples and oranges. Spinal manipulation is a low cost, extremely low risk, non-invasive treatment modality. Spinal injections are high cost, invasive procedures with at least a fair degree of risk to the patient. So manipulating a few lumbar motion segments is not at all like injecting from T12-L5. I am in complete agreement that you guys are able to be more specific by using diagnostic injections; in fact, that's a primary reason for referring patients to you (which I do fairly regularly, by the way) and I explain that to patients. Perhaps you need to stop thinking of chiropractors as your competition; we don't do what you do and you don't do what we do. Why is that so hard?

For what it's worth and with regard to spine pain, in my view you guys enter the picture either when a patient's condition is so fired up that we can't even give conservative care a go, or after a reasonable course of conservative care has failed to improve the patient as much as we'd like. I think that is very reasonable. Do you see it differently?

PS: You must have been editing while I was responding; there are a new points in there. As far as billing goes, I don't get paid any more or any less if I adjust a single facet joint or the entire lumbar spine; chiro codes are for either 1-2 regions (e.g., cervical and thoracic), or 3-4 regions, or 5 regions. We don't bill by each spinal joint. As to using fluro, well you've tried to make that argument before and quite frankly I don't get it.

Buddy, believe me YOU are not my competition. You and your colleagues may think you are.

So we do agree that chiropratics is like 'throwing the kitchen sink' at a problem. You are not specific in your treatment. It's almost like saying, when a patient has abdominal pain and a surgeon goes in to take the gall bladder, he just takes the appendix out too (it's an appendage that has no real use). Do you know in medicine you can not do that. A high degree of suspicion needs to be there for you to take out the appendix.

How can chiropractics address or assuage problems without specificity to pathology. Again, how can HVLA be of any additional use then non-specific massage at a spa? Both are non specific, expensive, and transiently soothing.

 

[facetguy]

Buddy, believe me YOU are not my competition. You and your colleagues may think you are.

Please remove this thought from your mind. How can we be competing with each other? We do very different things.

So we do agree that chiropratics is like 'throwing the kitchen sink' at a problem. You are not specific in your treatment. It's almost like saying, when a patient has abdominal pain and a surgeon goes in to take the gall bladder, he just takes the appendix out too (it's an appendage that has no real use). Do you know in medicine you can not do that. A high degree of suspicion needs to be there for you to take out the appendix.

The next time you prescribe a medication for a patient, be sure and whisper to each pill to go to and affect ONLY the left L3/4 facet joint and nowhere else. And when you refer a patient for PT, be sure to tell the PT to only work on the left L3/4 facet joint and only those muscle fibers in that specific area and none others. And on your next MRI order, tell the tech to just image that one level. Please...you are being goofy when you imagine "medicine" being specific. Yes, your injections are usually very specific. But many times "medicine" is anything but.

How can chiropractics address or assuage problems without specificity to pathology. Again, how can HVLA be of any additional use then non-specific massage at a spa? Both are non specific, expensive, and transiently soothing.

We've already done this.

 

[SleepIsGood]

Please remove this thought from your mind. How can we be competing with each other? We do very different things.



The next time you prescribe a medication for a patient, be sure and whisper to each pill to go to and affect ONLY the left L3/4 facet joint and nowhere else. And when you refer a patient for PT, be sure to tell the PT to only work on the left L3/4 facet joint and only those muscle fibers in that specific area and none others. And on your next MRI order, tell the tech to just image that one level. Please...you are being goofy when you imagine "medicine" being specific. Yes, your injections are usually very specific. But many times "medicine" is anything but.



We've already done this.

Some the truth hurts. I call them how I see them. it's not called being 'goofy'.

 

[jenny07]

Chiro's don't do manipulation, they do adjustment of spine or bones