Complementary & Alternative Medicine

[Louisville04]

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What is the general feeling on complementary & alternative medicine when a patient asks about it? I work at a VA facility and have been asked if it is medically necessary.

1) Chiropractic Care.

2) Acupuncture.

3) Massage Therapy.

4) Hydrotherapy/Aquatherapy

The biggest problem I have is determining if it is medically necessary and how many sessions are needed. Should they be used for acute problems only or chronic/maintenance therapy as well? I've noticed some chiropractors keep requesting more sessions without an end in sight. For massage therapy, who wouldn't find it beneficial. Would water aerobics at the YMCA qualify as hydrotherapy/aquatherapy or does it need to be taught by a physical therapist in a specially heated pool?

 

[Ludicolo]

Don’t confuse hydrotherapy with aquatic therapy. Hydrotherapy is a passive modality; using hot/cold water, moist heat, or salt baths to treat pain. The mechanical action of moving water (i.e. whirlpool therapy) can also be used for things like wound debridement. Aquatic therapy is physical therapy/therapeutic exercise in a pool. Using water buoyancy to reduce stress on painful weight-bearing joints. Using water resistance as a form of strength training. Using water pressure to enhance proprioceptive sensory biofeedback. Water aerobics is a form of exercise, but not necessarily directed therapy for a specific diagnosis or impairment.

None of these treatments are “medically necessary”, although I can usually justify aquatic therapy to start, for the reasons listed above. Some patients do seem more motivated to get into a pool. Eventually though I would like to transition the patient to dry land training. Since, you know, that’s where we live.

Things like chiropractic adjustments and massage, like any passive modality, may help with pain temporarily. And if patients wish to pursue it, and I don’t see any medical contraindication, hey, it’s their money. But IMHO any pain relieving treatments – including medications or injections – should be used in conjunction with a rehab directed functional restoration program. With few exceptions.

Now I really don’t know enough about acupuncture to comment with any authority or certainty. While it’s probably the most thoroughly researched CAM intervention, most of the studies on acupuncture are rather poorly designed. But it is difficult to argue against thousands of billions of Oriental Patient Years. For all I know, redirection of chi is good for what ails you.

 

[facetguy]

Regarding chiropractic, numerous clinical practice guidelines recommend spinal manipulation for both acute and chronic neck and low back pain.

North American Spine Society just published this a few months ago regarding acute LBP: http://www.ncbi.nlm.nih.gov/pubmed/20869008

A review of 16 clinical practice guidelines published by governments or other medical organizations from around the world finds 14 of 16 recommend spinal manipulation for acute and chronic LBP:
http://www.ncbi.nlm.nih.gov/pubmed/20494814

Recent comparison study of manipulation, PT or back school. Finds manipulation best for short and long term (1 year) benefits:
http://www.ncbi.nlm.nih.gov/pubmed/20053720

Chronic LBP: finds similar results with manipulation and trunk stabilization exercise at 8 wks, 6 months and 12 months. http://www.ncbi.nlm.nih.gov/pubmed/17250965 Combining the 2 would be even better, as other literature shows.

Another 1 year follow-up study: http://www.ncbi.nlm.nih.gov/pubmed/15726029

From the American Pain Society and the American College of Physicians on low back pain: http://www.ncbi.nlm.nih.gov/pubmed/17909210
Spinal manipulation was the only non-pharma treatment recommended for both acute and chronic LBP (well, heat was also recommended for chronic LBP).

And there are others. The current literature supports referral for chiropractic care for acute and chronic spine pain, particularly if other forms of care are not effective for a particular patient, and we all know that not every patient responds to the same types of care.

And I agree with Ludicolo that rehab exercises should be a component of these treatment programs, especially the chronics.

 

[PMR 4 MSK]

"Medical Necessity" is relative. All that we do is elective. I give patients a choice in what I have to offer - meds, PT, injections, etc. I can write a LOMN, but it is relative, and the insurance can deny coverage.

Is Chiropractic have more scientific evidence for it's use than Accupuncture? Are ESI's more effective than PT?

It all depends on who you ask and what their bias is.

 

[facetguy]

"Medical Necessity" is relative. All that we do is elective. I give patients a choice in what I have to offer - meds, PT, injections, etc. I can write a LOMN, but it is relative, and the insurance can deny coverage.

Is Chiropractic have more scientific evidence for it's use than Accupuncture? Are ESI's more effective than PT?

It all depends on who you ask and what their bias is.

My point was that among those choices should be consideration for chiro care, since there is at least as much evidence for such care as for anything else out there. This is particularly true for low back pain. I've seen it said that spinal manipulation is THE most studied intervention for low back pain (disclaimer: I haven't personally counted the various studies myself 😉).

 

[lobelsteve]

I recommend listening to Mark Crislip's Quackcast podcasts.

www.quackcast.com

Acupuncture is not science
Chiro is not science

Either one is fine as far as symptom management but neither are medical care and should not be misconstrued as medical care.

 

[facetguy]

I recommend listening to Mark Crislip's Quackcast podcasts.

www.quackcast.com

Acupuncture is not science
Chiro is not science

Either one is fine as far as symptom management but neither are medical care and should not be misconstrued as medical care.

I went to the site but couldn't get any of the podcasts to play, at least not on this computer. I'll try again later from another computer and see if I have any luck.

From the descriptions of the podcasts, or Quackcasts I should say, it looks as though he may be critical of chiro history. I should hope that he isn't using 100+ year old theories to base his criticism upon.

What is the Quackcaster's main criticism of chiropractic? Subluxations? Does he get into any more modern models?

 

[lobelsteve]

http://moremark.squarespace.com/quackcast-list-mp3/

Or Search him on iTunes.

He does EBM and is critical of everything. But it is all based on current literature. He just likes crushing bad articles.

 

[facetguy]

http://moremark.squarespace.com/quackcast-list-mp3/

Or Search him on iTunes.

He does EBM and is critical of everything. But it is all based on current literature. He just likes crushing bad articles.

When you say "everything" and "bad articles", are you referring to all of healthcare, or just CAM (or chiro in this case)? Because as you know, there is plenty of "everything" and plenty of "bad articles" that pertain to medicine, or even pain management specifically for that matter. Does Quackcaster address them too?

I'll give his podcasts a try on a different computer.

 

[lobelsteve]

He goes after All CAM. He is an ID doc with no axe to grind, except for the vaccine idiots. Mostly the big journals screwing up by putting crap articles in.

 

[caedmon]

I never discourage my patients from going to a chiropractor, especially if it is effective for their symptom management. I do advise them that if their pain relief only lasts for an hour or so after they leave and they've been advised that they need 20-30 sessions and payment is required up front that they should run away.

not sure there's ever a reason for medical necessity for chiropractic.

My beef is that every patient has scoliosis that needs to be corrcted and maintained via manipulation (generally not much exercise involved). Then if they can actually get the x-ray from the DC's office it's a way under/over penetrated, angled, crappy image that you could really say anything about. Never seen a good quality image from a chrio office and I would like to be proved wrong. Very misleading to patients.

In general, I think there are great chiros out there and there are Quacks. We should get to know our local chiros so we can make informed recommendations for patients.

A buddy of mine is a former DC turned DO now physiatrist concentratin on spine who is VERY critical of chiropractic as a profession.

 

[PMR 4 MSK]

My beef is that every patient has scoliosis that needs to be corrcted and maintained via manipulation (generally not much exercise involved). Then if they can actually get the x-ray from the DC's office it's a way under/over penetrated, angled, crappy image that you could really say anything about. Never seen a good quality image from a chrio office and I would like to be proved wrong. Very misleading to patients.

Soooo true. 9/10 are worthless and the 10th is marginal. My guess is the informal training in it, or the lack of ability or desire to pay a rad tech to do them correctly.

 

[oreosandsake]

,

 

[jesspt]

When you talk about Chiropractic, are you talking specifically about spinal manipulation, or the Chiropractic approach in general? It seems to me that many of the previous posts treat them interchangeably.

Many other professions use thrust manipulation, mobilization with impulse, HVLA, or adjustments, but have a different view in how they should be used in the continuum of care for spinal pain.

 

[facetguy]

When you talk about Chiropractic, are you talking specifically about spinal manipulation, or the Chiropractic approach in general? It seems to me that many of the previous posts treat them interchangeably.

Many other professions use thrust manipulation, mobilization with impulse, HVLA, or adjustments, but have a different view in how they should be used in the continuum of care for spinal pain.

Sometimes 'chiropractic' and 'spinal manipulation' do get used interchageably. Since 94% of all spinal manipulation in North America is performed by chiropractors, it's easy to see why. But other providers do perform spinal manipulation also, it's just hit-or-miss when it comes to those other providers. Only small numbers of DOs or PTs, for example, use manipulation with any regularity, and (not to be inflammatory) the level of expertise likely varies greatly.

The emphasis on spinal manipulation stems from the way research studies get designed. It makes for a much easier intervention to study than the less homogeneous "chiropractic care" (although there are some studies for that too).

Of course, chiropractiic care in the broader sense includes more than just spinal manipulation. More and more chiros employ exercise as part of their treatment protocols now (which is mostly evidence driven), and attention to myofascial/soft tissue problems is also common among chiros. Other aspects of care, such as modalities and advice as to diet and other lifestyle modifications, postural counseling, use of proper body mechanics etc., are common during a chiro visit. We also provide an opportunity to refer patients to the appropriate medical folks when warranted. And not just because this is a PM&R forum, but I can say that physiatrists (and pain mgmt docs) are overall the most helpful providers to me and my patients in terms of diagnostics and treatment.

 

[PMR 4 MSK]

Some chiros have abandoned spinal manipulation.

Others now use that stupid electric thingy that gives them a map of how "subluxed" every single spinal level is (and every level seems to be subluxed on these reports) and then automatically electrically "manipulates" every level that "needs" it.

Some PTs are now incorporating high-velocity manipulation. Some MDs are taking DO courses in doing manipulation. All the lines are being crossed and blurred.

My first introduction to pain management in med school was with an anesthesiologist who also did acupuncture. I loved how he summarized his training - "I spent a week learning how to do acupuncture at a seminar, and then 6 months with a little old Chinese lady to learn when to do acupuncture."

 

[facetguy]

Some chiros have abandoned spinal manipulation.

Others now use that stupid electric thingy that gives them a map of how "subluxed" every single spinal level is (and every level seems to be subluxed on these reports) and then automatically electrically "manipulates" every level that "needs" it.

Some PTs are now incorporating high-velocity manipulation. Some MDs are taking DO courses in doing manipulation. All the lines are being crossed and blurred.

My first introduction to pain management in med school was with an anesthesiologist who also did acupuncture. I loved how he summarized his training - "I spent a week learning how to do acupuncture at a seminar, and then 6 months with a little old Chinese lady to learn when to do acupuncture."

There are some DCs using these 'mapping' things, but it's a small number. I've never looked into them, but I'm a skeptical. I think one of the more popular companies making these is having some financial problems so who knows the future for these things.

There is merit, however, to some other mechanical adjusting devices based primarily on the speed with which these devices deliver their thrust. They are way faster than a manually delivered manipulation thrust (perhaps up to 100 times faster), which helps get past stretch reflexes and increases mechanoreceptor firing. One would think that instrument-delivered manipulation also reduces risk of adverse events, tiny as these risks may be.