D
Here's what I found on google.
http://www.palmer.edu/PCC_Clinics/Residencies.htm
The Palmer College of Chiropractic Radiology Residency is a three-year program. This in-house program provides the additional education, training and experience in chiropractic radiology and specialized imaging. The resident is then eligible to sit for the board examination administered by the American Chiropractic Board of Radiology. The radiology residency is based in the Clinic Radiology Department. One new resident is accepted each year.
http://www.palmer.edu/PCC_Clinics/Residencies.htm
The Palmer College of Chiropractic Radiology Residency is a three-year program. This in-house program provides the additional education, training and experience in chiropractic radiology and specialized imaging. The resident is then eligible to sit for the board examination administered by the American Chiropractic Board of Radiology. The radiology residency is based in the Clinic Radiology Department. One new resident is accepted each year.
D
deleted6669
apparently several other chiro programs have similar residencies as well.....
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It's more than a little sketchy. There are also chiropractic "neurologists" and "orthopodists"... -- residency trained and "boarded." 
I wonder if the answer to every question on the exam is "subluxation"?
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If the real radiologists hadnt fallen asleep at the switch, this never woulda happened.
But the MDs were too worried about making money to pay attention to what the crazy quack chiros are doing.
But the MDs were too worried about making money to pay attention to what the crazy quack chiros are doing.
Huh?! We have no control over what Chiropractors do radiologically. They have their own licensing boards and we can't do anything to stop them from having their own Radiology programs or their own imaging centres. It's not a 'turf battle' as it can be within Medicine.
From what I can tell, the Chiro Radiology programs are pretty legit. I think that they are 3 year programs geared largely towads MSK stuff. A Chiro who was a personal trainer at my gym went to Southern California to do Chiro Radiology, and it's my understanding that her residency includes time with Bone Radiology guru Donald Resnick in San Diego.
I doubt that they could get away with half-assed programs as they would be exposing themselves to serious medico-legal issues.
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I disagree. It's like saying the real neurologists, PTs and orthos fell asleep too! People are free to choose whatever type of "alternative" provider they want. If they want to pay hundreds of dollars for "homeopathic" medicine (tap water), we can't stop them, and I hardly consider that a turf battle lost with IM/pharmacy!!
All we can do is ensure that allopathic medical care meets the standards we set out.
I also disagree with the poster that states that chiro rads programs seem legit. First of all, there is no standardization like there is in medical radiology, and second of all, there is a vested interest for these guys to read in subluxations. Subluxations are a diagnostic entitity which have not been validated in any meaningful way. Sure, SOME chiro rads may be good, but the more important question is how good the average and "worse" graduates are... Just beacuse someone somewhere rotates with Resnick does not make them legit.
How do you know that? I can't say that I have the answer---I'm only going on my impression.
I'm pretty sure that Chiro Radiologists aren't calling everything a 'subluxation'. I've seen bits and pieces of some of their texts, and they look quite a bit like our MSK Radiology texts.
I agree 100%. But, as I said, I don't think that Chiro Radiologists are there to diagnose subluxations.
Agreed. But if they are lousy, they're probably spending quite a bit of time in court as a result of their misses.
True.
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Russellb is right, and the chiropractic radiology programs are legit. It has nothing to do with reading films to diagnose ?chiropractic subluxations?. Coming from a medical radiologist (Russellb) it is quite a compliment. The residency is quite demanding and the testing is very rigorous. Most of the candidates who sit for the examination do not pass the first time. Not only does it cover plain film it covers MRI, CT ultrasound and most all other imaging modalities. I utilize both medical and chiropractic radiologists. I have never had a chiropractic radiologist diagnose a ?chiropractic subluxation?.
For more information visit this site http://www.accr.org/
For more information visit this site http://www.accr.org/
I've worked at several Spine Centers in Boston and I've had the opportunity to see some films that have come from a chiropractor's office. My opinion was that they've often been of poor quality (usually because an older machine was used), were inappropriately protocoled, and the impressions were often of little value (limited differentials, diagnoses that suggest the need for chiropractic manipulation, vague descriptions, etc.). The patients either didn't even need that study to begin with, we'd ignore the impression, or we'd order another set.
The reason that these chiropractic radiologists don't get sued more could be because the patients have most likely been pre-screened already. Patients who were suspected of having an infection, tumor, or neurological compromise (cauda equina, infarction, transverse myelitis, Grade III/IV spondylolisthesis, etc.) were hopefully already referred to a spine surgeon. My assumption is that patients that wind up getting films from a chiropractor usually get them after their back pain has been deemed safe by a PCP (and hopefully a spine specialist) or the patient has gone on their own to a chiropractor who ordered them. Even if this weren't the case, the percentage of LBP (without any other systemic symptoms) due to a tumor or infection is very small. Most of the time a patient with LBP will have Modic changes, L4, L5, or S1 paracentral bulge, disk dessication, HIZ, spondylolysis, etc. and it's not really hard to pick these things up if you've seen enough of them. Given that most LBP is safe and is usually due to the changes above, I'm sure they are on top of things most of the time. You could train a lot of people without medical backgrounds to pick these things up. What worries me is the other 1% that a chiropractic radiologist is even less likely to see because they don't usually get these patients through their office. Also, the fact that they have not gone through medical school, internship, and their radiology training is 2-3 years shorter than a MSK radiologist is quite concerning as well. Without the above training that a MSK radiologist gets, the differentials will be much more limited.
Chiropractors can pretty much do what they want and order what they want once they get the patient. However, if something significant gets missed and it's because a Physician referred the patient to a chiropractic radiologist and relied on their findings, I'm guessing that the patient's lawyer will likely try and go after the Physician too. I'm not sure how successful they would be, but I do wonder what the position of the ACR, AMA, NASS, ASSR would be. I'm not sure that many Physicians are even aware that such training programs exist and that they are reading MRIs and CTs too. Just because they are certified by the Chiropratic Radiology board in and of itself doesn't really mean that much in my opinion. I'd be curious to hear what other Radiology residents have to say.
The reason that these chiropractic radiologists don't get sued more could be because the patients have most likely been pre-screened already. Patients who were suspected of having an infection, tumor, or neurological compromise (cauda equina, infarction, transverse myelitis, Grade III/IV spondylolisthesis, etc.) were hopefully already referred to a spine surgeon. My assumption is that patients that wind up getting films from a chiropractor usually get them after their back pain has been deemed safe by a PCP (and hopefully a spine specialist) or the patient has gone on their own to a chiropractor who ordered them. Even if this weren't the case, the percentage of LBP (without any other systemic symptoms) due to a tumor or infection is very small. Most of the time a patient with LBP will have Modic changes, L4, L5, or S1 paracentral bulge, disk dessication, HIZ, spondylolysis, etc. and it's not really hard to pick these things up if you've seen enough of them. Given that most LBP is safe and is usually due to the changes above, I'm sure they are on top of things most of the time. You could train a lot of people without medical backgrounds to pick these things up. What worries me is the other 1% that a chiropractic radiologist is even less likely to see because they don't usually get these patients through their office. Also, the fact that they have not gone through medical school, internship, and their radiology training is 2-3 years shorter than a MSK radiologist is quite concerning as well. Without the above training that a MSK radiologist gets, the differentials will be much more limited.
Chiropractors can pretty much do what they want and order what they want once they get the patient. However, if something significant gets missed and it's because a Physician referred the patient to a chiropractic radiologist and relied on their findings, I'm guessing that the patient's lawyer will likely try and go after the Physician too. I'm not sure how successful they would be, but I do wonder what the position of the ACR, AMA, NASS, ASSR would be. I'm not sure that many Physicians are even aware that such training programs exist and that they are reading MRIs and CTs too. Just because they are certified by the Chiropratic Radiology board in and of itself doesn't really mean that much in my opinion. I'd be curious to hear what other Radiology residents have to say.
Stinky Tofu: I like your avatar (I drive an M series vehicle 😀 )
I can't say as I've ever seen the work from Chirropractic imaging centres, so I can't comment on this.
At least some of those patients would probably find themselves in an ER rather than a Chiro Radiologist's office, so that would reduce the risk faced by the Chiro Rad.
A large % probably see their Chiro first, if I had to guess.
Agreed.
True, but it may be sufficient from the point of view of a Chiropractor in clinical practice. They may not need certain details that surgeons or internists require.
I can't imagine that very many MD/DO's refer their patients to Chiropractic imaging centres. Perhaps patients occasionally choose such centres on their own and have the results sent to their MD/DO. But my guess is that the vast majority of patients seen at a Chiro Rad centre are referred by Chiropractors.
As long as they stick to spines and basic MSK exams and are able to recognise and refer the more serious pathologic entities, then they would probably be fine. If they start trying to interpret abdominal ultrasound or CT, etc., then they are likely to make major mistakes because they have a shorter training period and are unlikely to be trained by experts in these areas or see enough cases outside of the MSK scope.
I only know about it because my gym is near the Chiropractic college here and I know a bunch of the students and recent grads.
I can't say as I've ever seen the work from Chirropractic imaging centres, so I can't comment on this.
At least some of those patients would probably find themselves in an ER rather than a Chiro Radiologist's office, so that would reduce the risk faced by the Chiro Rad.
A large % probably see their Chiro first, if I had to guess.
Agreed.
True, but it may be sufficient from the point of view of a Chiropractor in clinical practice. They may not need certain details that surgeons or internists require.
I can't imagine that very many MD/DO's refer their patients to Chiropractic imaging centres. Perhaps patients occasionally choose such centres on their own and have the results sent to their MD/DO. But my guess is that the vast majority of patients seen at a Chiro Rad centre are referred by Chiropractors.
As long as they stick to spines and basic MSK exams and are able to recognise and refer the more serious pathologic entities, then they would probably be fine. If they start trying to interpret abdominal ultrasound or CT, etc., then they are likely to make major mistakes because they have a shorter training period and are unlikely to be trained by experts in these areas or see enough cases outside of the MSK scope.
I only know about it because my gym is near the Chiropractic college here and I know a bunch of the students and recent grads.
So do I. 🙂 I currently drive an M3.
Well, I guess that's what concerns me. Is their training sufficient to distinguish serious pathologic conditions from benign ones? Do they know the limtations of their training or will they be constantly pushing to broaden their scope?
Same here. An '04--- got in November. I never thought that I could love a car this much 😛
Good points. My guess ( I don't have firsthand knowledge) is that they are aware of which 'red flags' to look for. They don't want to get themselves in trouble by missing serious pathology. They don't really have to give the full Dahnert style differential. As long as they recognise that something may be beyond their scope, that's probably good enough.
If they try to broaden their scope, then they're bound to run into trouble. That's when Radiology lobby groups (e.g. ACR) would probably step in. Moreover, broadening their scope exposes them to exponentially more medico-legal risk. They're most likely content to deal with low risk cases.
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Let me fill you in. Naturopaths, which are largely similar to homeopaths, have full prescription rights in 7 states.
That means they can prescribe anything YOU can.
The naturopaths had to go to the state legislatures to get these script rights. Where were the MDs when this happened?
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This is a joke right? All medical specialties, in all fields, ALWAYS strive to expand their scope.
Call that Macgyver's law: there has NEVER been a health profession that did not try to expand its scope.
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ACR wont get involved unless the chiro rads try to go for the grand slam homerun all at once.
Thats not how this thing will play out. Slowly but surely, the chiro rads will increase their scope. Small steps. It wont happen next year, but 5 or 10 years down the line, chiro rads will look A LOT different than it does now.
ACR and the other specialty organizations arent really paying attention to what other medical groups do anyways. They are self-absorbed and wont even notice what chiro rads are doing.
I can't speak for other medical organizations, but you're wrong to say that the ACR doesn't watch what other medical specialties are doing. Turf battles are common in Radiology and we continue (and will continue) to exist because our professional organizations are vigilant with regards to this issue.
I better make sure to save my money---the Chiro Rads will be handling all of my body imaging cases in 10 years 😛
Here's a question: are Chiropractic Radiologists permitted to do contrast enhanced studies? My guess is that there would have to an MD/DO on their premises in order to do so. After all, Chiropractors are not permitted to sign orders for the meds that would be used to treat any contrast reactions.
I'm sure that Chiropractic Radiologists do a good job within their scope and that practicing Chiropractors find them helpful. But they aren't a threat to MD/DO Radiologists and never will be. Nor are we a threat to them.
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Oh really?
Where was the ACR when rads PAs were fighting for independent diagnostic rights in 3 states?
Where was the ACR when chiros first proposed rads residencies?
Where was the ACR when chiros gained approval from state legislatures to serve as independent diagnosticians of MRIs?
Why is the ACR considering, at this very moment, a proposal to give overseas docs board certification without US training?
Face it the ACR is totally ignorant as to what the midlevels and other health care groups are doing.
Absolutely they can order contrast enhanced studies. Now, they are at increased legal exposure if something goes wrong, but they fought and gained state legislative rights to inject contrast agents into patients a long time ago.
Thats yet another time when the ACR failed to step in and oppose their moves. They have been increasing their scope slowly but surely, and the ACR hasnt done a damn thing about it.
Thats naive. If you think that chiros arent going to push for expanded rights, you're crazy, because EVERYTHING in their history suggests that they will do exactly that. Will they be successful? I guess that depends on MD radiologists and the ACR, and how willing they are to quit being so self-absorbed and actually open their eyes as to whats going on in other health groups.
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I've worked at several Spine Centers in Boston and I've had the opportunity to see some films that have come from a chiropractor's office. My opinion was that they've often been of poor quality (usually because an older machine was used), were inappropriately protocoled, and the impressions were often of little value (limited differentials, diagnoses that suggest the need for chiropractic manipulation, vague descriptions, etc.). The patients either didn't even need that study to begin with, we'd ignore the impression, or we'd order another set.
I agree that chiropractors probably take some of the worst x-rays. It's not really the machine but rather the processor. Also has to do with darkroom, chemicals exhausted etc. I would say the main problem is fog. I have requested x-rays from my fellow colleagues and was embarrassed to send it to the radiologist for a reading (unfortunately, we do have idiots that don't have their films read). My advice has always been, "if you can't take a freakin x-ray, then refer the patient to the hospital or an imaging center". I do this quite a bit with the large patients, as I don't want to blow my tube.
Unfortunately the attorneys make it to where we have to x-ray everyone. Has nothing to do with the proper protocols. When one uses manipulation on a patient, one has to makes sure there is nothing else going on. I do not x-ray everyone even though it is the chiropractic standard of care to do so and this is where the attorney's will nail you/me, that one time you decide not to x-ray and something happens.
The reason that these chiropractic radiologists don't get sued more could be because the patients have most likely been pre-screened already. Patients who were suspected of having an infection, tumor, or neurological compromise (cauda equina, infarction, transverse myelitis, Grade III/IV spondylolisthesis, etc.) were hopefully already referred to a spine surgeon.
The reason they don't get sued is they are competent in what they do. Believe me; many times the conditions you mention wander into my office. I refer them to the proper specialist. If I were to x-ray them and missed the DX the chiro rad would pick it up. I have that much faith in them to put my license on the line. I have used them for years and not once did they miss something. I also utilize medical radiologists as well. The reason I use chiropractic radiologists is they will also describe the biomechanical alterations. From my experience, most medical rads don't do this. It's "rule out the pathology and move on to the next case", not to mention the unleveled pelvis, leg length inequality and rotational malposition of L5. This is good if the patient is personal injury. I'm not talking about imaginary subluxations either!
My assumption is that patients that wind up getting films from a chiropractor usually get them after their back pain has been deemed safe by a PCP (and hopefully a spine specialist) or the patient has gone on their own to a chiropractor who ordered them.
This is laughable. The PCP 90% of the time sends the patient home with vitamin M and muscle relaxers and half the time they do not perform any neurological or orthopedic examination.
Chiropractic radiologists read films. I do not know of any of them having an "imaging center". Of course, there may be a few that have an imaging center. I don't send patients to a chiro rad for films as most of them do not take films even though they are trained to do so. I either take them myself of refer out for films.
I agree that chiropractors probably take some of the worst x-rays. It's not really the machine but rather the processor. Also has to do with darkroom, chemicals exhausted etc. I would say the main problem is fog. I have requested x-rays from my fellow colleagues and was embarrassed to send it to the radiologist for a reading (unfortunately, we do have idiots that don't have their films read). My advice has always been, "if you can't take a freakin x-ray, then refer the patient to the hospital or an imaging center". I do this quite a bit with the large patients, as I don't want to blow my tube.
Unfortunately the attorneys make it to where we have to x-ray everyone. Has nothing to do with the proper protocols. When one uses manipulation on a patient, one has to makes sure there is nothing else going on. I do not x-ray everyone even though it is the chiropractic standard of care to do so and this is where the attorney's will nail you/me, that one time you decide not to x-ray and something happens.
The reason that these chiropractic radiologists don't get sued more could be because the patients have most likely been pre-screened already. Patients who were suspected of having an infection, tumor, or neurological compromise (cauda equina, infarction, transverse myelitis, Grade III/IV spondylolisthesis, etc.) were hopefully already referred to a spine surgeon.
The reason they don't get sued is they are competent in what they do. Believe me; many times the conditions you mention wander into my office. I refer them to the proper specialist. If I were to x-ray them and missed the DX the chiro rad would pick it up. I have that much faith in them to put my license on the line. I have used them for years and not once did they miss something. I also utilize medical radiologists as well. The reason I use chiropractic radiologists is they will also describe the biomechanical alterations. From my experience, most medical rads don't do this. It's "rule out the pathology and move on to the next case", not to mention the unleveled pelvis, leg length inequality and rotational malposition of L5. This is good if the patient is personal injury. I'm not talking about imaginary subluxations either!
My assumption is that patients that wind up getting films from a chiropractor usually get them after their back pain has been deemed safe by a PCP (and hopefully a spine specialist) or the patient has gone on their own to a chiropractor who ordered them.
This is laughable. The PCP 90% of the time sends the patient home with vitamin M and muscle relaxers and half the time they do not perform any neurological or orthopedic examination.
Chiropractic radiologists read films. I do not know of any of them having an "imaging center". Of course, there may be a few that have an imaging center. I don't send patients to a chiro rad for films as most of them do not take films even though they are trained to do so. I either take them myself of refer out for films.
Interesting. Perhaps Chiro Rads are a bit too few and far between to set up Radiology clinics. Maybe they don't feel that the volumes would be sufficient to make an imaging centre financially viable, particularly if they're relying heavily on 'overreads' of films taken at other people's offices.
Other than describing scoliosis and degenerative changs, I don't think that we are trained to go into the biomechanical details that you might find useful in practice. I also have some questions regarding the validity of some of some of the findings re:biomechanics. I read through quite a bit of the indexed literature on this topic some time ago in relation to another thread on this site. There was a bit of a lack of rad-path correlation in this area, i.e. are the findings related to symptomatology in a reliable manner? This is just my observation, I'm not trying to be antagonistic 🙂 It's possible that I missed some important studies proving validity. In any event, the biomechanical details on the Chiro Rad's report may well be useful to you in clinical practice --- I'm certainly not in a position to give an opinion on the relevance of the findings to Chiropractic management of a patient.
You're probably right .
If they are of such poor quality, why do them in the office? Wouldn't it be better to send them to a local Radiology Center to get better quality films? Also, when I said protocoled incorrectly, I meant that the patient would get sagittals, but no axials; patients would get only one view on plain films when they really need more; sagittals would not go lateral enough so we couldn't see the neuroforamen; the contrast and brightness was usually off so it was difficult to detect subtle differences and hence pathology would be missed; when a S1 radic was suspected, we would only get images down to L4/L5; or none of the axial images would be angled through the disks. I'm not saying that all medical centers are that great either, but all I've ever seen from a Chiropractic Radiologist is terrible images. I don't really have a big problem with Chiropractors doing plain films, but it does bother me when patients and their insurance companies get charged for expensive MRIs that are essentially useless.
Aren't most of the things above detected by your physical examination? Are you ordering these imaging studies to confirm before you treat? If the imaging studies didn't correlate with the symptoms and your physical exam, would you still treat? Would you treat an unleveled pelvis or a rotated lumbar vertabrae in a patient that was asymptomatic? I'm sure if you took plain films on all of us you'd find something. Just like 20-30% of the population has an asymptomatic disc herniation. I just don't find these additional findings as enough justification to pick a Chiropractor over a Physician -- especially since the equipment and technicians used by a Chiropractic Radiologist usually produce suboptimal images. My understanding was that indications for manipulation are usually based on physical exam rather than imaging studies.
Believe me, I think most PCPs mismanage LBP and don't refer soon enough. Many of these patients could've gotten better quickly, but instead wind up developing pain-related disability, psychoscoial problems, or wind up becoming addicted to pain medications. What I meant was that their pain was often determined to be non-life-threatening and hence the referral to the Chiropractor. Even if PCPs can't do a proper Neuro or MSK exam, they certainly know that the following situations probably warrant a referral (hopefully 😉 ):
1. Patient has lost 60lbs in the past month, smokes 3ppd, and has severe LBP that wakes him up at night.
2. Patient with LBP suddenly develops saddle anesthesia as well as incontinence.
3. Patient with has begun to notice tingling pain shooting down his leg, tingling in his foot, and his foot drags when he walks.
4. Patient with cellulitis that was treated and resolved with Keflex develops LBP and a fever of 102.
My point was that Chiropractors do get patients that have been pre-screened and the patients they see are more likely to have things like annular tears, facet joints, malrotations, and radiculopathies as the source of their pain. Radiologists are less likely to be sued for missing these things than they would be for missing osteomyelitis, an abscess, cauda equina, tumors, etc.
I know how you feel! You bought it just in time for winter, huh? Did you drive your M3 in the snow? I bought 17-inch replicas and put Blizzaks on them.
Yeah, I've been driving it this winter. I bought 18" winter rims and I have Michelin Pilot 225's. It's not too bad in the snow, although it slides a bit when there's sleet or ice on the road. One of my colleagues has an M3 for the summer and an X5 for the winter--- pretty good combo. My plan is to get an Acura MDX for the winter eventually. It's better value for the money than an X5. The X3's are about the same price as MDX's , but they've got quite a bit less cargo space (for my hockey gear, etc).
If they are of such poor quality, why do them in the office? Wouldn't it be better to send them to a local Radiology Center to get better quality films? Also, when I said protocoled incorrectly, I meant that the patient would get sagittals, but no axials; patients would get only one view on plain films when they really need more; sagittals would not go lateral enough so we couldn't see the neuroforamen; the contrast and brightness was usually off so it was difficult to detect subtle differences and hence pathology would be missed; when a S1 radic was suspected, we would only get images down to L4/L5; or none of the axial images would be angled through the disks. I'm not saying that all medical centers are that great either, but all I've ever seen from a Chiropractic Radiologist is terrible images. I don't really have a big problem with Chiropractors doing plain films, but it does bother me when patients and their insurance companies get charged for expensive MRIs that are essentially useless.
I agree if a chiro can't manage to take good films they should either refer out or have a rad tech in the office. My films usually turn out fine. I'm using a single phase so it does have its limitations. I'm a little confused here. Are you saying you get MRI's that actually are done by a chiropractor? Where? Again, I never heard of any group of chiropractors owning imaging centers with magnets in them. On top of that the chiropractic radiologist wouldn't be the one taking the MRI; they would be the one reading it.
Aren't most of the things above detected by your physical examination? Are you ordering these imaging studies to confirm before you treat?
Yes, most is detected through history and examination. Ordering imaging goes both ways, sometimes I do it to confirm dx but many times I do it to exclude or rule something out.
If the imaging studies didn't correlate with the symptoms and your physical exam, would you still treat?
Good question. Sometimes yes and other times no. It is very common to have symptoms and yet no test to actually confirm what is causing the problem. I have several patients with migraines that have had every test you can imagine and yet we (family doctor, neurologist and I) can't find what is causing them.
Would you treat an unleveled pelvis or a rotated lumbar vertebrae in a patient that was asymptomatic?
Yes. Just like a medical doctor would treat an asymptomatic patient with high cholesterol. It would be a preventative measure. We know that high cholesterol with time will lead to future problems. A patient with an unleveled pelvis and a rotated L5 will with time develop muscle weakness, his/her spine will begin to tower to one side, and the body will compensate and put a compensatory curve somewhere in the spine, it may be lumbar it may be thoracic. This with time will lead to abnormal function, abnormal wear and will result in the patient having back pain.
I'm sure if you took plain films on all of us you'd find something. Just like 20-30% of the population has an asymptomatic disc herniation. I just don't find these additional findings as enough justification to pick a Chiropractor over a Physician
As a PCP what are you going to do with a patient that has an asymptomatic disc? Are you going to educate them on proper posture, lifting etc? Are you going to design a strengthening program to strengthen the abdominals and the erectors to help stabilize the spine? This is part of what we do and I think in a case like this, a patient would have justification on choosing a chiropractor over a medical physician. Many doctors take the "wait and see" approach. Basically "let's wait until its bad enough" and surgery is your only hope. They do this with scoliosis patients all the time.
they certainly know that the following situations probably warrant a referral
1. Patient has lost 60lbs in the past month, smokes 3ppd, and has severe LBP that wakes him up at night.
2. Patient with LBP suddenly develops saddle anesthesia as well as incontinence.
3. Patient with has begun to notice tingling pain shooting down his leg, tingling in his foot, and his foot drags when he walks.
4. Patient with cellulitis that was treated and resolved with Keflex develops LBP and a fever of 102.
My point was that Chiropractors do get patients that have been pre-screened and the patients they see are more likely to have things like annular tears, facet joints, malrotations, and radiculopathies as the source of their pain. Radiologists are less likely to be sued for missing these things than they would be for missing osteomyelitis, an abscess, cauda equina, tumors, etc.
The chiropractors that practice similar to me and have graduated from what is considered a "good school" would see the red flags you mention. I know my limitations and would refer appropriately. Believe me; I wouldn't mess with anything you mentioned as my malpractice insurance carrier would say "get it the hell out of your office!"
1.)Smells like METS to me...send to PCP and let him decide what to do.
2.)Cauda equina syndrome send to ER or Neuro
3.) I'm thinking disc but could be a host of other problems send to ER or Neuro
4.) Infection send to ER or PCP
Are you a Rad resident? Just curious.
I see you guys are into bimmers. I traded my 528 (1998) in on a 540 (2002). It has the 285hp v8 with 6 speed manual. It has the M sport package (tuned suspension, bigger wheels yadda yadda) it's not a M5 but it will bake the tires with the traction control off. I bet that M3 moves! I'm looking at the CrossFire (basically a Benz)...only problem is I can't fit the kids in the damn thing!
I agree if a chiro can't manage to take good films they should either refer out or have a rad tech in the office. My films usually turn out fine. I'm using a single phase so it does have its limitations. I'm a little confused here. Are you saying you get MRI's that actually are done by a chiropractor? Where? Again, I never heard of any group of chiropractors owning imaging centers with magnets in them. On top of that the chiropractic radiologist wouldn't be the one taking the MRI; they would be the one reading it.
Aren't most of the things above detected by your physical examination? Are you ordering these imaging studies to confirm before you treat?
Yes, most is detected through history and examination. Ordering imaging goes both ways, sometimes I do it to confirm dx but many times I do it to exclude or rule something out.
If the imaging studies didn't correlate with the symptoms and your physical exam, would you still treat?
Good question. Sometimes yes and other times no. It is very common to have symptoms and yet no test to actually confirm what is causing the problem. I have several patients with migraines that have had every test you can imagine and yet we (family doctor, neurologist and I) can't find what is causing them.
Would you treat an unleveled pelvis or a rotated lumbar vertebrae in a patient that was asymptomatic?
Yes. Just like a medical doctor would treat an asymptomatic patient with high cholesterol. It would be a preventative measure. We know that high cholesterol with time will lead to future problems. A patient with an unleveled pelvis and a rotated L5 will with time develop muscle weakness, his/her spine will begin to tower to one side, and the body will compensate and put a compensatory curve somewhere in the spine, it may be lumbar it may be thoracic. This with time will lead to abnormal function, abnormal wear and will result in the patient having back pain.
I'm sure if you took plain films on all of us you'd find something. Just like 20-30% of the population has an asymptomatic disc herniation. I just don't find these additional findings as enough justification to pick a Chiropractor over a Physician
As a PCP what are you going to do with a patient that has an asymptomatic disc? Are you going to educate them on proper posture, lifting etc? Are you going to design a strengthening program to strengthen the abdominals and the erectors to help stabilize the spine? This is part of what we do and I think in a case like this, a patient would have justification on choosing a chiropractor over a medical physician. Many doctors take the "wait and see" approach. Basically "let's wait until its bad enough" and surgery is your only hope. They do this with scoliosis patients all the time.
they certainly know that the following situations probably warrant a referral
1. Patient has lost 60lbs in the past month, smokes 3ppd, and has severe LBP that wakes him up at night.
2. Patient with LBP suddenly develops saddle anesthesia as well as incontinence.
3. Patient with has begun to notice tingling pain shooting down his leg, tingling in his foot, and his foot drags when he walks.
4. Patient with cellulitis that was treated and resolved with Keflex develops LBP and a fever of 102.
My point was that Chiropractors do get patients that have been pre-screened and the patients they see are more likely to have things like annular tears, facet joints, malrotations, and radiculopathies as the source of their pain. Radiologists are less likely to be sued for missing these things than they would be for missing osteomyelitis, an abscess, cauda equina, tumors, etc.
The chiropractors that practice similar to me and have graduated from what is considered a "good school" would see the red flags you mention. I know my limitations and would refer appropriately. Believe me; I wouldn't mess with anything you mentioned as my malpractice insurance carrier would say "get it the hell out of your office!"
1.)Smells like METS to me...send to PCP and let him decide what to do.
2.)Cauda equina syndrome send to ER or Neuro
3.) I'm thinking disc but could be a host of other problems send to ER or Neuro
4.) Infection send to ER or PCP
Are you a Rad resident? Just curious.
I see you guys are into bimmers. I traded my 528 (1998) in on a 540 (2002). It has the 285hp v8 with 6 speed manual. It has the M sport package (tuned suspension, bigger wheels yadda yadda) it's not a M5 but it will bake the tires with the traction control off. I bet that M3 moves! I'm looking at the CrossFire (basically a Benz)...only problem is I can't fit the kids in the damn thing!
1. Patients have shown up with MRIs done by a Chiropractor.
2. You're right, technicians do that. The Physician or Chiropractor that is reading the images should go back and tell the technician if they are doing something wrong. Often the technician is just following the protocol that was set forth by the Radiologist. I think the main problem is that Imaging Centers owned by Chiropractors tend to have older machines that have weaker magnets and less sophisticated software.
1. I'm not a PCP, but I'd do nothing as far as medical interventions. If they are asymptomatic, they wouldn't of gotten the MRI to begin with.
2. No. There's no evidence that proper lifting techniques or posture decreases the incidence of LBP. There's a good review paper in Clinical Biomechanics (1999) by Dieen on the topic.
3. There's several good papers by Rainville in The Spine Journal as to what strengthening exercises patients should be doing. All of their recommendations are evidence-based and he has written several good articles on the subject if you are interested. Basically, he is much more agressive in terms of strength training.
4. The "wait and see" approach isn't always bad. You just have to know when you should do so.
I'm sure you would recognize these things. They weren't really meant to be clinical vignettes that I was looking for answers to. My original point was that Chiropractic Radiologists were less likely to miss these types of diagnoses (and hence get sued) because many of these patients were probably already referred by their PCP (despite not being able to do a good neuromusculoskeletal exam) to a surgeon.
No.
Is that a bad thing? 😉
In theory, this sounds snesible. The only problem is that I'm not certain how much hard evidence there is to back up this statement. I'm not saying that you're wrong (you may well be correct and there could be evidence that I'm not aware of), I'm just not sure whether or not your statement can be made with a high degree of certainty.
I have every reason to believe you. You seem to take a no-nonsense approach.
The '98 and '02 500 series bimmers were great. The new 500 series design is a bit hurting, though I've read that the performance is terrific. Have you considered an '05 M5 (I realise that they're quite pricey) ? The new M5s will be unreal. I'm not an Audi person, but the S6 might be worth considering.
The M3 can really move. Mine is suposed to do 0-60 in 5.2sec (haven't tried that yet), but the real power is felt when I accelerate in the passing lane on the highway. It takes no time to go from 50 to 80 mph.
They're apparently going to release a ZM4 in the near future (Z4 with an M3 engine). That car will be pretty sick.
I just did a case a few minutes ago which brings the thoughts above to mind.
55 y.o. white male with no significant PMHx comes to the ER with a 2 week hx of back pain (has not seen any other provider). Over the last 3-4 days , he has had increasing bilateral leg numbness, and over the last day he has developed mild urinary retention (able to void a little bit ,ER doc hasn't catheterised hom, so I don't know his residual). Referred for urgent MRI.
L2 is diffusely abnormal ( VB and posterior elements) and there is a soft tissue mass extending into the spinal canal, compressing the cauda equina and completely effacing the CSF space. My diff dx: myeloma, lymphoma, mets, and TB (less likely, but prevalent around here).
Tough break for the patient 🙁
In theory, this sounds snesible. The only problem is that I'm not certain how much hard evidence there is to back up this statement. I'm not saying that you're wrong (you may well be correct and there could be evidence that I'm not aware of), I'm just not sure whether or not your statement can be made with a high degree of certainty.
I assume you are talking about the pelvis/L5 issue. You are right. I have no evidence but my own experience in practice to fully support my view. I could check and see if actual research has been done but I'm too lazy right now.
The '98 and '02 500 series bimmers were great. The new 500 series design is a bit hurting, though I've read that the performance is terrific. Have you considered an '05 M5 (I realise that they're quite pricey) ? The new M5s will be unreal. I'm not an Audi person, but the S6 might be worth considering.
The M3 can really move. Mine is suposed to do 0-60 in 5.2sec (haven't tried that yet), but the real power is felt when I accelerate in the passing lane on the highway. It takes no time to go from 50 to 80 mph.
They're apparently going to release a ZM4 in the near future (Z4 with an M3 engine). That car will be pretty sick.
I agree as far as the new styling, looks like they shrunk a 7 series. The backend looks goofy to me. Anyway I would love a M5. They are truly an awesome machine. They are pricey and my wife would never allow me to buy one. Besides, I'm not rolling in the dough like you radiologists are. What about the new vette? or perhaps a viper?? The good thing is I could fit the kids in the M5. I'm happy with the 540 as it has plenty of power and it will get up and boogie when called upon. It's still a heavy vehicle. My 528 had heated seats and steering wheel. I miss that, as this one doesn't have it. I don't think I would ever spend more than 45-50k on a vehicle. Maybe if I wash your M3 you'll let me take it for a spin LOL. That thing has like 300 plus horse power.....I would probably kill myself in something like that! Z4 with the M3 engine? Now you're talkin.
I assume you are talking about the pelvis/L5 issue. You are right. I have no evidence but my own experience in practice to fully support my view. I could check and see if actual research has been done but I'm too lazy right now.
The '98 and '02 500 series bimmers were great. The new 500 series design is a bit hurting, though I've read that the performance is terrific. Have you considered an '05 M5 (I realise that they're quite pricey) ? The new M5s will be unreal. I'm not an Audi person, but the S6 might be worth considering.
The M3 can really move. Mine is suposed to do 0-60 in 5.2sec (haven't tried that yet), but the real power is felt when I accelerate in the passing lane on the highway. It takes no time to go from 50 to 80 mph.
They're apparently going to release a ZM4 in the near future (Z4 with an M3 engine). That car will be pretty sick.
I agree as far as the new styling, looks like they shrunk a 7 series. The backend looks goofy to me. Anyway I would love a M5. They are truly an awesome machine. They are pricey and my wife would never allow me to buy one. Besides, I'm not rolling in the dough like you radiologists are. What about the new vette? or perhaps a viper?? The good thing is I could fit the kids in the M5. I'm happy with the 540 as it has plenty of power and it will get up and boogie when called upon. It's still a heavy vehicle. My 528 had heated seats and steering wheel. I miss that, as this one doesn't have it. I don't think I would ever spend more than 45-50k on a vehicle. Maybe if I wash your M3 you'll let me take it for a spin LOL. That thing has like 300 plus horse power.....I would probably kill myself in something like that! Z4 with the M3 engine? Now you're talkin.
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Yeah, I was referring to it in the context of treating asymptomatic patients.
I respect your point of view. However, I would submit to you that it's very difficult to judge whether or not the treatment is actually preventitive no matter how experienced you may be. It's hard to predict when a patient would have eventually experienced symptoms. You generally need large volumes of long term data to prove a preventitive benefit, and I don't think that such studies have been done in this context (I can't find any , anyhow). That doesn't mean that you're wrong, but I'm sure that you understand why I'm skeptical about it.
Just to show you that I keep a skeptical eye on my own profession, though, I'm every bit as skeptical about the value of screening CT or MRI (with the possible exception of CT Thorax in smokers---- not enough long term data yet, though) as I am about spinal manipulation for asymptomatic patients. I admit that I'll always rely on cold, hard data as much as, if not moreso than, on my own experience. Experience, unfortunately, is subject to strong personal bias.
Agreed.
I'm single, so I get to spend my earnings on myself 😀
Not really my style. If I wanted a true 'sports car', I'd have probably gone for the Porsche 911. But that's more $$ than I wanted to spend on an investment that loses 10% once it's driven off of the lot. I suppose I could have purchased a used 911, but I wanted a new car. My previous car was a '97 Honda Civic.
The 540 is an excellent car. It's a nice combo of luxury and performance.
That's probably a good decision given that you're raising kids and I'm guessing that you have a mortgage to pay as well.
333 hp to be exact 😎 😀
My guess is that it will outperform the 911 Carrera by a significant margin, but at a lower cost. 911 still has the mystique, though.
I rarely would treat a patient that is asymptomatic just because they do not present to my office. It's good to be skeptical. I remember a while back that we had a discussion about "maintenance" care. I do not recommend maintenance or wellness care in the way many chiropractors do. That is, I do not tell a patient they would need to come in monthly so I can check them for subluxations. Or tell them I need to adjust them monthly to prevent the subluxation from returning.
Now I have patients (usually those who are elderly or construction workers) who come in once a month. This is their choice. Most say "I'm stiff and sore and just can't wait any longer" or "I felt it was time to come in". Of course this would be considered maintenance care. Either way the patient benefits from it. The difference is the patients are symptomatic.
What about abnormal pressure on the bone? Don't bones respond to abnormal pressure? If you have an unleveled pelvis and abnormal pressure within the spine it makes sense to me that with time (years) this would cause a degenerative process. Isn't one of the causes of osteoarthritis, excessive stress and strain on the joints? I would imagine there is some research out there somewhere that supports my view.
Yeah I have the mortgage to go along with it. I'm actually thinking of downgrading the car so I can free up some cash for having a house built. Plus, when this thing breaks down it costs a fortune to fix. Actually, I have not had any problems mechanically, but the CD player quit working and then the indoor outdoor temp sensor went bad, and the frickin ashtray broke. I'm not a smoker but I put change in it, it was $300 bucks to fix it as they had to take the console out. So down the road I think I will trade it or sell it outright and get a Accord or Altima maybe a used Maxima. I've had Accords in the past and have great luck with them. I need to start saving for the kids colleges as well. Sounds like you have it made.
Now I have patients (usually those who are elderly or construction workers) who come in once a month. This is their choice. Most say "I'm stiff and sore and just can't wait any longer" or "I felt it was time to come in". Of course this would be considered maintenance care. Either way the patient benefits from it. The difference is the patients are symptomatic.
What about abnormal pressure on the bone? Don't bones respond to abnormal pressure? If you have an unleveled pelvis and abnormal pressure within the spine it makes sense to me that with time (years) this would cause a degenerative process. Isn't one of the causes of osteoarthritis, excessive stress and strain on the joints? I would imagine there is some research out there somewhere that supports my view.
Yeah I have the mortgage to go along with it. I'm actually thinking of downgrading the car so I can free up some cash for having a house built. Plus, when this thing breaks down it costs a fortune to fix. Actually, I have not had any problems mechanically, but the CD player quit working and then the indoor outdoor temp sensor went bad, and the frickin ashtray broke. I'm not a smoker but I put change in it, it was $300 bucks to fix it as they had to take the console out. So down the road I think I will trade it or sell it outright and get a Accord or Altima maybe a used Maxima. I've had Accords in the past and have great luck with them. I need to start saving for the kids colleges as well. Sounds like you have it made.
I would have expected this to be the case. Your approach seems to be pragmatic.
Nothing wrong with that. These patients stand to derive benefit from your treatment. If my proneness to injury continues at its current pace, my physiotherapist will be able to retire based on my business alone 😛 (N.B.--my PT does a lot of manual therapy, including occasional SMT and active release. He also does acupuncture---I think you mentioned that you do that as well).
What you're saying may well be true. However, it doesn't really come particularly close to proving that SMT prevents the eventual degenrative changes. I can't find any long term data (I don't think that any is available) demonstrating the efficacy of SMT for the prevention of OA/DDD/etc...... That's why I'm giving you the gears 😀
I'm not arguing that you're wrong or that your ideas don't make sense. You could be right. I'm arguing from the perspective of a skeptic who likes to look closely at the evidence which supports or refutes a claim. My feeling is that at this time, the claim that SMT may prevent degenrative changes can be neither supported nor effectively refuted.
To be perfectly honest, if this topic is sudied rigourously, my guess is that SMT will prove to have a small benefit, if any, in the prevention of OA or DDD. But that's just my guess--- it's not fact. Your opinion is obviously diferent from mine and based on our previous discussions, I've come to respect your opinion, even though I may not agree.
The house is WAY more important than the car.
Tell me about it.......The M3 is full of computerised parts. The BMW mechanics are more like Information Technology guys. When one thing goes wrong, everything has to be reprogrammed. That happened last month when my tire pressure got too low on a very cold day and I had to take the car in.
Maximas are great cars. My dad has driven Maximas since 1990. I would definitely choose a Maxima over a 300 series BMW or an Audi A4.
My first car was an '86 Accord. I inherited it from my dad in '91. I loved it, but it hit the skids after 120 000 km.
Putting kids through college is also WAY more important than driving a BMW.
Keep in mind that my very favourable financial position is largely a result of my being single--- my expenses are really low. If I had started a family during residency, then the M3 would be a pipe dream right now.
I appreciate your honestly. I know you were not trying to argue or prove me wrong. We were always taught in school that SMT would prevent DJD or if a patient had DJD it would slow or stop its progression. I believe, or rather hope its true (I know I'm brain washed). Anyway, I guess we could also mention the use of glucosamine sulfate as a preventative or for repair and whether it works or not. I'm glad to get your point of view. I have always noticed that medical doctors seem to be pretty critical. Do most MD's do a lot of research in college? Is it part of the degree process? In chiropractic school we had to do a research project but it was a joke. It had three people per project and no one really took it seriously. Basically if you did the thing you got credit and that was it. We studied the effects of MSG on developing chicken embryos. They all died...whoops!
Anyway, you're in Canada right? I know the physical therapists (who go by physiotherapist) are pretty sharp up there. The ones who train in manipulation and are certified as manual therapists are really good and would give any chiropractor a run for their money (with regard to manipulation). I do not think there are a lot that specialize in manipulation, so I guess it's not much competition for the chiropractors. How do your friends (chiropractic ones) feel about the physiotherapists doing manipulation?
I do acupuncture from time to time for pain control and that's about it. Interesting to see physiotherapists doing it in Canada. From what I understand Physical therapy in the states is a lot different than in Canada.
Anyway, you're in Canada right? I know the physical therapists (who go by physiotherapist) are pretty sharp up there. The ones who train in manipulation and are certified as manual therapists are really good and would give any chiropractor a run for their money (with regard to manipulation). I do not think there are a lot that specialize in manipulation, so I guess it's not much competition for the chiropractors. How do your friends (chiropractic ones) feel about the physiotherapists doing manipulation?
I do acupuncture from time to time for pain control and that's about it. Interesting to see physiotherapists doing it in Canada. From what I understand Physical therapy in the states is a lot different than in Canada.
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if i get a chiropractic radiology residency, will i be taught how to use a Spine-O-Cylinder?
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No, you have to do a residency in chiropractic neurosurgery, chiropractic orthopedics or chiropractic neurology for that!!
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I have met several chiropractic radiologist, and have discovered that they go through a 3 year residency, which some schools are now changing to a 4 yr residency. It is mostly focused on pf but they do get exposure to MRI, CT, US and nuclear med. They are reconized by ACR, and there has been studies done comparing the evaluation of Lx films b/w med students, gen practicioners, chiro students, DCs, med rad resident, chiro rad resident, general radioligist, msk fellows and chiropractic radiologist. I believe the article was published in SPINE, it was co-written by Resnick, MD and Taylor, DC, DACBR.
To my understanding it is the only current chiro specialty that requires a min of 3 yr fulltime residency.
here are some websites
www.dacbr.com
www.acbr.org
To my understanding it is the only current chiro specialty that requires a min of 3 yr fulltime residency.
here are some websites
www.dacbr.com
www.acbr.org
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As a member of the ACR, I would like you to show me where you got this information.
Their website has nothing about chiropractors and radiology other than to state that HCFA clarified its policy that Medicare no longer reimburses for xrays ordered by chiropractors.
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im curious if residents who get new nice cars after they graduate medical school get any flak or feel guilt when they pull up next to their attending driving a beat up old car.
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No 😀
Besides, I bought my car after 1 1/2 years of practice (i.e. , after completing my fellowship). As well, plenty of my former attendings also drive nice cars and live in nice houses.
Most of the interns at my hospital drove better cars than the attendings -- especially the Internists and Surgeons. Over 50% of my class drove a BMW so I didn't feel as guilty. As a resident, I don't think anyone really knows what I drive. I have certain areas within the parking lot that I like to park in to minimize the chances of someone dinging my car and it tends to be pretty far away from where most people park. Frankly, I don't think most attendings know the difference between the M3 and a 325 so it probably wouldn't be a big deal if they saw my car. The medical students are usually the ones that make a big deal about my car, but who cares what they think. 🙂
