pmrmd

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Dont even try the 'young' guy training on me bud. No offense, but your knowledge of anatomy/physiology is likely an inkling compared to even an intern's from a US medical school. Not a pissing contest, just the facts.

Secondly, let's see..epidurals help with the inflammatory process associated with herniated discs. How again does your massaging or manipulaton do that again? You'll likely say something that give a massage say. "it increases blood flow and lymph flow and take the toxins away'.:rolleyes:

And since your name is facet..what does your manipulation do for facet arthropathy? How are you blocking pain that originates there?

Yah, I'll light a candle and sing Kumbaya and wait for your responses.
just because your posts are the most annoying i have ever read, i will answer this for you. facet arthropathy is irrelevant. arthropathy is common without symptoms. facet pain comes from the facet capsule, which is likely stretched a bit with manipulation, however this is difficult to prove. it is the reason why some people do great with manipulation. i am no fan of chiropractic, but there are multiple trials that show efficacy. its equivalent to p.t., which is in general a total sham the majority of the time. sleep you are a resident with a lot yet to learn. you ask questions like a resident who doesn't know a thing about actually treating a patient. you will not bat 1.000 treating pain. get some humility while you can because you need it badly.
 

lobelsteve

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just because your posts are the most annoying i have ever read, i will answer this for you. facet arthropathy is irrelevant. arthropathy is common without symptoms. facet pain comes from the facet capsule, which is likely stretched a bit with manipulation, however this is difficult to prove. it is the reason why some people do great with manipulation. i am no fan of chiropractic, but there are multiple trials that show efficacy. its equivalent to p.t., which is in general a total sham the majority of the time. sleep you are a resident with a lot yet to learn. you ask questions like a resident who doesn't know a thing about actually treating a patient. you will not bat 1.000 treating pain. get some humility while you can because you need it badly.
Amen.:thumbup:
 

dc2md

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Some of you guys are just plain ridiculous. The bottom line is that chiropractic AND PM&R/pain medicine are both lacking in good, quality studies to prove the effectiveness of many of things we do. But what chiropractic manipulations provides is a safe alternative for patients that choose to no take medication or undergo interventional pain procedures or surgery. What's wrong with that? And the proof....just ask the patients. We all know that much of what we do in treating pain is treating the psychological component of that chronic pain. So if a patient FEELS that chiropractic manipulation makes them better (more functional; better able to do ADLs), then that's exactly what it does.
 

algosdoc

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Chiropractic safety is in the eye of the beholder. That doesn't bode well for the patient here in my city that had their vertebral artery transsected by a quack manipulator a few years ago....has permanent injuries. I also have seen several others with permanently painful cervical facets after chiropractors manipulated their cervical spines in the absence of any pain in the cervical spine prior to the manipulation. The chiros decided to do this to improve their alignment. Chiropractic can be just as unsafe as any other treatment.
 

dc2md

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Do we really want to open that box? Errors and injuries from medical procedures and medications are prolific. Let's not go down this route.
 

algosdoc

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I am fine in not going down that road as long as people don't begin spouting off crap about chiropractic being a "safe alternative". It is not safe. Medications are not safe. Procedures are not safe.
 

lobelsteve

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Do we really want to open that box? Errors and injuries from medical procedures and medications are prolific. Let's not go down this route.
Depending on the complication and procedure, one is legitimate medical care and the other is pseudoscience quackery. I have an issue with HVLA. 4 fold increased risk of VBA dissection and CVA in folks 45 yrs old or younger.
 

facetguy

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Depending on the complication and procedure, one is legitimate medical care and the other is pseudoscience quackery. I have an issue with HVLA. 4 fold increased risk of VBA dissection and CVA in folks 45 yrs old or younger.
4 fold relative to what? Mobilization?
 

dc2md

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Steve, your forming of opinions based on a miopic picture of chiropractic extremists is unfortunate. It's sad really.

I just hope other physicians on this forum will actually open their minds and talk to local DCs and their patients about what the like.
 

lobelsteve

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Steve, your forming of opinions based on a miopic picture of chiropractic extremists is unfortunate. It's sad really.

I just hope other physicians on this forum will actually open their minds and talk to local DCs and their patients about what the like.
A local dc used my ss# and signed my name to a loan for $50k.
I have a low opinion of chiros for this and generally unscrupulous behaviors: neurometrx, vax-d, strip the pip. But little bothers me more than mua.
 

lobelsteve

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Steve, your forming of opinions based on a miopic picture of chiropractic extremists is unfortunate. It's sad really.

I just hope other physicians on this forum will actually open their minds and talk to local DCs and their patients about what the like.
4 fold relative to what? Mobilization?
4x more likely to stroke than folks not having hvla.
 

dc2md

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A local dc used my ss# and signed my name to a loan for $50k.
I have a low opinion of chiros for this and generally unscrupulous behaviors: neurometrx, vax-d, strip the pip. But little bothers me more than mua.
That's incredible!! What happened to that chiro?

We've spoken before about this; the chiros trained at Life University School of Chiropractic (in your neck of the woods) are THE most extreme. Unfortunately, those are the ones you're exposed to. In contrast, the schools in New York and outside Chicago (the one I graduated from) teach a VERY moderate version of chiropractic; one where students are thoroughly taught to look for those red flags that say, "hey, this back pain isn't of musculoskeletal origin...better send them to their PCP/ER". They also taught them to know their limitations.

What are they manipulating under anesthesia? Adhesive capsulitis? I really don't have enough experience with my patients getting that done to know its effectiveness in prolonged, resistant cases. Are you knocking MUA, or just MUA by chiros?
 

facetguy

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4x more likely to stroke than folks not having hvla.
Sorry to hear about the identity theft; but it's obviously unfair to project that upon all DCs.

The increased stroke association in those <45 was higher for those visiting a DC, but it was also higher for those visiting a PCP (the PCP group had increased association for those patients >45 as well.
http://www.ncbi.nlm.nih.gov/pubmed/18204390
This was the first time a study looked at chiro's association AND medical association with stroke, and found it was there for both practice types. The proposed theory is that the vertebral artery dissection may begin, causing neck pain for which the patient presents to either their DC or MD. That's not to say that sudden vertebrobasilar artery dissection can't occur suddenly due to HVLA. But the authors state "we found no evidence of excess risk of VBA stroke associated with chiropractic care compared to primary care."
 

lobelsteve

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Sorry to hear about the identity theft; but it's obviously unfair to project that upon all DCs.

The increased stroke association in those <45 was higher for those visiting a DC, but it was also higher for those visiting a PCP (the PCP group had increased association for those patients >45 as well.
http://www.ncbi.nlm.nih.gov/pubmed/18204390

This was the first time a study looked at chiro's association AND medical association with stroke, and found it was there for both practice types. The proposed theory is that the vertebral artery dissection may begin, causing neck pain for which the patient presents to either their DC or MD. That's not to say that sudden vertebrobasilar artery dissection can't occur suddenly due to HVLA. But the authors state "we found no evidence of excess risk of VBA stroke associated with chiropractic care compared to primary care."
from above: 818 CVA in 100M patient/years. Case control study, studies association, not causation. The conclusion from the abstract is completely unsupported by the paper. Read the article or listen to the critique of the conclusion. At timepoint 20:30 on the mp3 podcast. http://moremark.squarespace.com/quackcast-list-mp3/

If not convincing, at least entertaining. Dr. Crislip addresses your questions and concerns and pokes fun at you at the same time.
It was a chiro authored article with full spin.

Neurologist. 2008 Jan;14(1):66-73.
Does cervical manipulative therapy cause vertebral artery dissection and stroke?

Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM.

Division of Neurosciences, Faculty of Science, Loyola University, Chicago, IL, USA.

OBJECTIVE: Does cervical manipulative therapy (CMT) cause vertebral arterial dissection (VAD) and subsequent ischemic stroke? What is the best estimate of the incidence of CMT associated with VAD and ischemic stroke? METHODS: The questions were addressed with a structured evidence-based clinical neurologic practice review. Participants included neuroscience students, consultant neurologists, clinical epidemiologists, medical librarians, and clinical content experts. A critically appraised topic format was employed, starting with a clinical scenario and structured question. The participant group devised search strategies, located and compiled the best evidence, performed critical appraisals, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. RESULTS: The search yielded 169 citations, of which 55 were deemed most relevant. From this return, we selected 26 publications of the highest evidence available: 3 case-control studies, 8 prospective and retrospective case series studies, 4 illustrative case reports, 1 survey, 1 systematic review of observational research, 5 reviews, and 4 opinion and expert commentary pieces. Five of the applicable 7 criteria for causation were satisfactorily met and supported weak to moderate strength of evidence for causation between CMT and VAD and associated stroke, especially in young adults. Young vertebrobasilar artery territory stroke patients were 5 times more likely than controls to have had CMT within 1 week of the event date (OR 5.03, 95% CI, 1.32-43.87). No significant associations were found for those > or =45 years of age. The best available estimate of incidence is approximately 1.3 cases of VAD or occlusion attributable to CMT for every 100,000 persons <45 years of age receiving CMT within 1 week of manipulative therapy. CONCLUSIONS: Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy. Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT.

Spine J. 2002 Sep-Oct;2(5):334-42.
Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias.

Haldeman S, Carey P, Townsend M, Papadopoulos C.

Department of Neurology, University of California, 101 City Drive, Orange, CA 92868, USA. [email protected]

BACKGROUND CONTEXT: The growing recognition of cervical manipulation as a treatment of neck pain and cervicogenic headaches has lead to increased interest in potential complications that may result from this treatment approach. Recent surveys have reported that many neurologists will encounter cases of vertebral artery dissection that occur at various times after cervical manipulation, whereas most practitioners of spinal manipulation are of the opinion that these events are extremely rare. We asked the question whether these differences in perception could be explained in part by referral or selection bias. PURPOSE: To assess the effect of referral bias on the differences in perceived incidence of vertebral artery dissection after cervical manipulation between neurologists and chiropractors in Canada. STUDY DESIGN: This study was a retrospective review of cases where neurological symptoms consistent with cerebrovascular ischemia were reported by chiropractors in Canada. METHODS: An analysis of data from a chiropractic malpractice insurance carrier (Canadian Chiropractic Protective Association [CCPA]) and results of a survey of chiropractors was performed to determine the likelihood that a vertebral artery dissection after cervical manipulation would be reported to practicing chiropractors. This was compared with the likelihood that a neurologist would be made aware of such a complication. RESULTS: For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime. CONCLUSIONS: The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.


Y'all go listen to quackcast 27 from twenty minutes onward. Come back and report your thoughts. It's only 5-10 minutes- and well worth it.
http://moremark.squarespace.com/quackcast-list-mp3/
 
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facetguy

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from above: 818 CVA in 100M patient/years. Case control study, studies association, not causation. The conclusion from the abstract is completely unsupported by the paper. Read the article or listen to the critique of the conclusion. At timepoint 20:30 on the mp3 podcast. http://moremark.squarespace.com/quackcast-list-mp3/

If not convincing, at least entertaining. Dr. Crislip addresses your questions and concerns and pokes fun at you at the same time. It was a chiro authored article with full spin.
It was chiro authored. But we should also mention that these chiro authors weren't typical chiro clinicians but were members of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, an international multidisciplinary group of experts. We should also mention that their paper was published in Spine, which isn't exactly a shady chiropractic tabloid. Dismissing the paper because it was chiro authored isn't warranted in my view.

I'll try to listen to the mp3 you linked to, although I've already read similar critiques.

The 2008 Neurologist paper you cited concludes that there is a connection in timing between people having visited a DC and having a stroke within a week. There are a few similar papers out there. That's why the article I cited was important, because they also looked to see if the same timing association was present for visits to a PCP, and it was. One of the authors of the Task Force paper (Susan Bondy, PhD) had been an author of one of these earlier papers.
 

ampaphb

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So if a patient FEELS that chiropractic manipulation makes them better (more functional; better able to do ADLs), then that's exactly what it does.
Well, since it's all about the placebo effect, let's start handing out sugar pills - they're a heck of a lot cheaper than visiting the chiropractor 3x/wk for an unlimited duration of care
 

ampaphb

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I think many patients, those coming to see me anyway, are more in the 'functional problem' category, as opposed to just anatomical. I think if we can change someone's function, we can reduce their pain.
This is impressive. You have co-opted the physiatric concept of function for your own purposes. Only problem is, you do so without saying how you improve function. Again, every study you have cited to document chiropractic efficacy looks at "chronic low back pain", as though that could be addressed by what the underlying cause is. And, in fact, if you aren't trying to improve the underlying anatomic pain generator, but rather only improve function, you are right, it doesn't matter what the cause is. It's a once size fit's all, simplistic, dumbed down solution for a mutifactorial, multifaceted constellation of potential eitiologies.

I agree with you that muscle building is important, and that would be anatomical. But there's also the aspect of muscle firing patterns and enhancing stabilization that way, more in a neurophys way, along with looking for other biomechanical/functional faults.
Completely agree - this is why I send my patients to experts in the field of kinesiology - physical therapists.

So early conservative treatment is more about reducing myospasm,, and mechanical dysfunction (and all the related chemical/inflammatory soup).
What specific "mechanical dysfunction" are we speaking of, and how, exactly, does HVLA manipulation resolve these issues?
 
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facetguy

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This is impressive. You have co-opted the physiatric concept of function for your own purposes.
Chiropractic profession began in 1895.

Physiatry began when again? I'm pretty sure we beat you to the punch.:D

Only problem is, you do so without saying how you improve function. Again, every study you have cited to document chiropractic efficacy looks at "chronic low back pain", as though that could be addressed by what the underlying cause is.
Low back pain is where much of the research has been focused, mostly because it's a huge problem and chiros are pretty good at treating it. There are studies for both acute and chronic low back pain, as well as acute and chronic neck pain. And, yes, the clinical outcomes studies tend to look at "neck pain" or "low back pain"; don't blame me for that. We've already been through this.

Spinal manipulation has been repeatedly documented to improve range of motion, reduce pain, and reduce myospasm. Those are 3 obvious ways SMT improves function. There are other proposed mechanisms like improving motor programs, sympathetic effects, etc, but the research has not been as extensive for these yet (all in due time). Add in other treatment methods used by chiropractors, like strength/endurance exercises, myofascial treatments, educating patients about posture and ergonomics, use of various modalities (cold laser, ultrasound, e-stim, etc.), etc. and there are plenty of avenues to improve function.

And, in fact, if you aren't trying to improve the underlying anatomic pain generator, but rather only improve function, you are right, it doesn't matter what the cause is. It's a once size fit's all, simplistic, dumbed down solution for a mutifactorial, multifaceted constellation of potential eitiologies.
I'm not sure why you are taking this position. If I understand you correctly, you are saying that unless there is some anatomical change, say on an imaging study, then a patient can't have pain? You are a pain specialist; how can you say that?? Let's take facet mediated pain for example. Why does the anatomy of the joint have to be abnormal to cause pain?

You stated just above that I wouldn't try to improve the underlying anatomic pain generator. Why wouldn't I? Again, let's use facet pain as an example. Of course facet joints are a target of my treatment, but I'm looking to improve joint function, not anatomy. Do facet injections improve anatomical structure? No, yet they sometimes work.

As to the constellation of potential etiologies issue, truth is most cases of neck and back pain resolve without ever knowing 100% what the true pain generators were. I know you're not recommending a patient undergo a series of diagnostic injections for every episode of uncomplicated neck or back pain, right? No. History and examination allow us to form a working diagnosis and, in the absence of red flags or unusual findings, a trial of conservative care is begun. Many times that's all that's needed and the case is resolved, all without ever having a 100% iron-clad guarantee of exactly what was causing the pain. That's how it's done. You know that. And I would imagine with the ever-increasing cuts in healthcare, we won't have the nice fancy and expensive diagnostic studies for every patient, so if anything this approach will become even more common.

Completely agree - this is why I send my patients to experts in the fired of kinesiology - physical therapists.

What specific "mechanical dysfunction" are we speaking of, and how, exactly, does HVLA manipulation resolve these issues?
I guess the clearest example of mechanical dysfunction would be a loss of motion, either globally in a region of the spine or intersegmentally. This mechanical dysfunction is often, though not always, accompanied by pain. There is no requisite structural alteration but rather a functional (i.e., mechanical) change.

With all of your emphasis on structural and anatomic abnormalities, are you sure you aren't a surgeon??
 

ampaphb

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Chiropractic profession began in 1895.

Physiatry began when again? I'm pretty sure we beat you to the punch.:D
In 1895 Daniel Palmer, a Canadian grocer, first described "the cause of all ailments and its cure." While in his "magnetic studio" Palmer treated his janitor named Harvey Lillard, who had been deaf for seventeen years. Upon examining the man, Palmer was certain that there was something wrong with the man's back, and this could be a cause of his problem. The vertebrata was moved to its proper place, and miraculously the man could hear after being deaf for so long!

Palmer had a second success with a cardiac patient. With this N of 2, he concluded, "a subluxed vertebrata, a vertebral bone, is the cause of 95% of all diseases".​

So if that's the history you want to claim, you are welcome to it

Low back pain is where much of the research has been focused, mostly because it's a huge problem and chiros are pretty good at treating it.
This seems to be where we are talking past one another, so let me try again. Low back pain is not, in fact, one entity. It is a symptom, which can be produced by facet spondylosis, facet inflamation, facet capsular strain or disruption, an anular tear, disc protrusion, vascular and sinuvertebral nerves ingrowth into the anulus, leakage of nuclear proteoglycans, central canal stenosis, ligamentus hypertrophy, spondylolysthesis, SI Joint or ligament issues, myofacial disease, supratentorial factors, or a combination of these factors. The idea that you can treat any or all of these maladies with one therapy is naive.

I'm not sure why you are taking this position. If I understand you correctly, you are saying that unless there is some anatomical change, say on an imaging study, then a patient can't have pain? You are a pain specialist; how can you say that?? Let's take facet mediated pain for example. Why does the anatomy of the joint have to be abnormal to cause pain?

You stated just above that I wouldn't try to improve the underlying anatomic pain generator. Why wouldn't I? Again, let's use facet pain as an example. Of course facet joints are a target of my treatment, but I'm looking to improve joint function, not anatomy. Do facet injections improve anatomical structure? No, yet they sometimes work.
Here again you demonstrate my point. In order to treat the appropriate structure, you need to first diagnose it as the pain generator. If the issue is primarily discogenic, and you address the patients' facets, you are mis-targeting your efforts. Function does not independently go awry without an anatomic structure causing it to. Facets can be sagitally aligned. They can be inflamed. Their capsules can have been disrupted. But in some manner, their anatomy has been altered or disrupted in order to produce symptoms.

As to the constellation of potential etiologies issue, truth is most cases of neck and back pain resolve without ever knowing 100% what the true pain generators were. I know you're not recommending a patient undergo a series of diagnostic injections for every episode of uncomplicated neck or back pain, right? No. History and examination allow us to form a working diagnosis and, in the absence of red flags or unusual findings, a trial of conservative care is begun. Many times that's all that's needed and the case is resolved, all without ever having a 100% iron-clad guarantee of exactly what was causing the pain. That's how it's done. You know that. And I would imagine with the ever-increasing cuts in healthcare, we won't have the nice fancy and expensive diagnostic studies for every patient, so if anything this approach will become even more common.

I guess the clearest example of mechanical dysfunction would be a loss of motion, either globally in a region of the spine or intersegmentally. This mechanical dysfunction is often, though not always, accompanied by pain. There is no requisite structural alteration but rather a functional (i.e., mechanical) change.
Again, you make my point for me. The reason I send my patients for PT rather than chiropractic care is because chiropractors have far less understanding of spinal anatomy and biomechanics than PTs. McKenzie exercises are appropriate for back pain of certain etiologies. Williams flexion exercises are appropriate for others. Core strengthening for still other presentations. Ionto- and phonophoresis make sense when the appropriate medications being applied address the particular patient presentation.

Not all back pain should treated the same way. But when the issues you are treating are reduced to pseudoscientific diagnoses like "decreased function", "subluxation", "mechanical dysfunction" and "restoration of mechanoreceptive information" without a shred of histopathologic or pathophysiologic data, it is not surprising that one size fits all. That is why I for one, view the care you provide as a simplistic, generalized, non-specific, homeopathic placebo.
 
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In 1895 Daniel Palmer, a Canadian grocer, first described "the cause of all ailments and its cure." While in his “magnetic studio” Palmer treated his janitor named Harvey Lillard, who had been deaf for seventeen years. Upon examining the man, Palmer was certain that there was something wrong with the man’s back, and this could be a cause of his problem. The vertebrata was moved to its proper place, and miraculously the man could hear after being deaf for so long!

Palmer had a second success with a cardiac patient. With this N of 2, he concluded, “a subluxed vertebrata, a vertebral bone, is the cause of 95% of all diseases”.​

So if that's the history you want to claim, you are welcome to it

This seems to be where we are talking past one another, so let me try again. Low back pain is not, in fact, one entity. It is a symptom, which can be produced by facet spondylosis, facet inflamation, facet capsular strain or disruption, an anular tear, disc protrusion, vascular and sinuvertebral nerves ingrowth into the anulus, leakage of nuclear proteoglycans, central canal stenosis, ligamentus hypertrophy, SI Joint or ligament issues, myofacial disease, supratentorial factors, or a combination of these factors. The idea that you can treat any or all of these maladies with one therapy is naive.

Here again you demonstrate my point. In order to treat the appropriate structure, you need to first diagnose it as the pain generator. If the issue is primarily discogenic, and you address the patients' facets, you are mis-targeting your efforts. Function does not independently go awry without an anatomic structure causing it to. Facets can be sagitally aligned. They can be inflamed. Their capsules can have been disrupted. But in some manner, their anatomy has been altered or disrupted in order to produce symptoms.

Again, you make my point for me. The reason I send my patients for PT rather than chiropractic care is because chiropractors have far less understanding of spinal anatomy and biomechanics than PTs. McKinsey exercises are appropriate for back pain of certain etiologies. Williams flexion exercises are appropriate for others. Core strengthening for still other presentations. Ionto- and phonophoresis make sense when the appropriate medications being applied address the particular patient presentation.

Not all back pain should treated the same way. But when the issues you are treating are reduced to pseudoscientific diagnoses like "decreased function",
"subluxation", "mechanical dysfunction" and "restoration of mechanoreceptive information" without a shred of histopathologic or pathophysiologic data, it is not surprising that one size fits all. That is why I for one, view the care you provide as a simplistic, generalized, non-specific, homeopathic placebo.
Couldnt have conveyed it any better...
 
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just because your posts are the most annoying i have ever read, i will answer this for you. facet arthropathy is irrelevant. arthropathy is common without symptoms. facet pain comes from the facet capsule, which is likely stretched a bit with manipulation, however this is difficult to prove. it is the reason why some people do great with manipulation. i am no fan of chiropractic, but there are multiple trials that show efficacy. its equivalent to p.t., which is in general a total sham the majority of the time. sleep you are a resident with a lot yet to learn. you ask questions like a resident who doesn't know a thing about actually treating a patient. you will not bat 1.000 treating pain. get some humility while you can because you need it badly.
Hey PMR

I welcome your criticism, however, humility? Please drill it into the Chiropractor on here. Perhaps there's a disparity in the generations. You claim that chiropractics is essentially of no benefit, yet welcome Facet's arrogant comments about his chiropractics.

My generation doesnt like to put up with nonsense that these quacks like to perpetuate. Pain Medicine got a bad rep in the past because we have non fellowship trained docs and chiropractors claiming to be "pain docs' and essentially providing voodoo, magic medicine. Those people need to get weeded out.

This is a medical forum for medical docs. Feel free to have these quacks run all over you, I'm just not ok with that.

---------

Going back to the original thread. I didnt realize how big these North American Spine guys are. If you've flown recently on practically any airline, you will see their ads on the airline magazines. They must be doing well, ads arent cheap to place on those magazines.
 

pmrmd

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Hey PMR

I welcome your criticism, however, humility? Please drill it into the Chiropractor on here. Perhaps there's a disparity in the generations. You claim that chiropractics is essentially of no benefit, yet welcome Facet's arrogant comments about his chiropractics.

My generation doesnt like to put up with nonsense that these quacks like to perpetuate. Pain Medicine got a bad rep in the past because we have non fellowship trained docs and chiropractors claiming to be "pain docs' and essentially providing voodoo, magic medicine. Those people need to get weeded out.

This is a medical forum for medical docs. Feel free to have these quacks run all over you, I'm just not ok with that.

---------

Going back to the original thread. I didnt realize how big these North American Spine guys are. If you've flown recently on practically any airline, you will see their ads on the airline magazines. They must be doing well, ads arent cheap to place on those magazines.
sleep get ahold of yourself. i am not that much older than you. and i am no believer in chiropractic. in fact i can summarize even better than amp. chiropractic is a random treatment method. they will help some but not others. random treatment approaches get average outcomes, which is exactly what chiropractic has. i am a firm believer there is no science to it, but it is at least as effective as PT, another random treatment approach that you seem to like. perhaps because you don't understand it. dislike of chiropractic is not a new thing. the AMA tried to wipe them out years ago but some idiot judge intervened and the rest is history. i don't defend them at all and agree with everything that was written on this forum.

there is no question you have an exaggerated sense of who and what you are at this point in your career. i have seen many patients from the fellowship-trained physicians that you extol that got nowhere--overtreated with epidurals, p.t., meds, stim trials. finishing your training program and having done 1000 ESIs or 1000 SCS or whatever isn't important. a monkey can be trained to do it. knowing how to get a history and do a physical examination and knowing just a little bit of physiology separates the men from the boys.

i went out and started my own practice in a saturated market from day one. i have been successful treating the failures of others alot of times simply because there was no decent exam by the fellowship-trained guy before. in fact, sometimes i think it makes my double-board look bad. i am in the process of hiring another physician now. all i can say is you wouldn't make the end of my list.
 

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In 1895 Daniel Palmer, a Canadian grocer, first described "the cause of all ailments and its cure." While in his “magnetic studio” Palmer treated his janitor named Harvey Lillard, who had been deaf for seventeen years. Upon examining the man, Palmer was certain that there was something wrong with the man’s back, and this could be a cause of his problem. The vertebrata was moved to its proper place, and miraculously the man could hear after being deaf for so long!

Palmer had a second success with a cardiac patient. With this N of 2, he concluded, “a subluxed vertebrata, a vertebral bone, is the cause of 95% of all diseases”.
So if that's the history you want to claim, you are welcome to it
Usually included in such descriptions of DD Palmer are the ever-flattering "fish monger" and "phrenologist". You missed those!

And, as we all know, medicine hasn't changed or evolved a bit since 1895 either, right?

This seems to be where we are talking past one another, so let me try again. Low back pain is not, in fact, one entity. It is a symptom, which can be produced by facet spondylosis, facet inflamation, facet capsular strain or disruption, an anular tear, disc protrusion, vascular and sinuvertebral nerves ingrowth into the anulus, leakage of nuclear proteoglycans, central canal stenosis, ligamentus hypertrophy, spondylolysthesis, SI Joint or ligament issues, myofacial disease, supratentorial factors, or a combination of these factors. The idea that you can treat any or all of these maladies with one therapy is naive.
Do you think I don't consider all of these things? How about fracture, infection, or metastatic disease? Maybe that's where you are getting hung up. Perhaps you assume that chiropractors don't learn about all these things. Perhaps you assume that a diagnosis from a chiropractor is either "neck pain" or "back pain" without any thought given to the potential pain generators. The clinical outcomes research uses these general terms; what's going through my head as I'm evaluating a patient is obviously more specific.

As I stated earlier, when a patient presents to me with, say, low back pain, a history is taken to gather more info about the patient and his/her condition (as in anyone else's office). Then a physical exam is done to gather additional information (as in anyone else's office). All the while, I'm ruling things in or out (as anyone else would). Diagnostic imaging may or may not be ordered based on my impression (standard). If I'm satisfied that there are no red flags or ominous or unusual findings, I'll go ahead with treatment based on my working diagnosis (this is standard stuff).

In an ideal world, we would send every patient through the gamut of diagnostics. But we all know that's not reality. As a patient progresses further and further without improvement, the diagnostic scrutiny increases likewise. Perhaps your viewpoint is shaped by the fact that in your specialty you tend to get patients who have failed other treatment efforts. In those cases, sure, have at it with the invasive diagnostics. But the typical case presenting to the chiro office doesn't need to be referred on day one for a battery of interventional studies. (Is this surprising to everyone? I don't know. It seems like basic stuff.)

Here again you demonstrate my point. In order to treat the appropriate structure, you need to first diagnose it as the pain generator. If the issue is primarily discogenic, and you address the patients' facets, you are mis-targeting your efforts. Function does not independently go awry without an anatomic structure causing it to. Facets can be sagitally aligned. They can be inflamed. Their capsules can have been disrupted. But in some manner, their anatomy has been altered or disrupted in order to produce symptoms.
What happens if you address the patient's facets, but don't address the fact they have horrible posture or that they are deconditioned? How far are you going to get? What specific anatomic structure is posture? What anatomic structure is inflammation? Yes, a facet joint, as an anatomical structure, may be inflamed but is inflammation an anatomic disruption?

I think it's important to bear in mind that interventional treatments usually have a very localized point of effect, while treatments like mine will affect the region more generally. You think in terms of a very specific target for, say, an injection. I think in terms of correcting that same structure by also affecting how the whole region functions.

Again, you make my point for me. The reason I send my patients for PT rather than chiropractic care is because chiropractors have far less understanding of spinal anatomy and biomechanics than PTs.
That's your choice. PTs do nice work. I disagree, however, with your position on the DC's knowledge.

McKinsey exercises are appropriate for back pain of certain etiologies.
Yes they are. And it's McKenzie ( but that's ok, as long as your PTs know that).

Williams flexion exercises are appropriate for others. Core strengthening for still other presentations. Ionto- and phonophoresis make sense when the appropriate medications being applied address the particular patient presentation.
Yes, yes, yes.

Not all back pain should treated the same way. But when the issues you are treating are reduced to pseudoscientific diagnoses like "decreased function",
"subluxation", "mechanical dysfunction" and "restoration of mechanoreceptive information" without a shred of histopathologic or pathophysiologic data, it is not surprising that one size fits all. That is why I for one, view the care you provide as a simplistic, generalized, non-specific, homeopathic placebo.
I treat each of my patients as an individual. True, most of them get some type of manual treatment, be it mobilization, manipulation, traction-based treatments, myofascial work, PNF, etc. And we will most often discuss exercises, posture, ergonomics, and even diet/nutrition in an effort to deal longterm with their typically pro-inflammatory state. But how I approach each patient is case-by-case. I think that's another misunderstanding you have with chiropractors, perpetuating your belief that it's one size fits all. The discussion of mechanoreceptive factors and other neurophysiological points was to try to describe and understand how manipulation works. As stated at the beginning of this post, I'm thinking about all same potential pain generators you are, so I'm not sure how that makes me simplistic and non-specific.
 

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Hey PMR

I welcome your criticism, however, humility? Please drill it into the Chiropractor on here. Perhaps there's a disparity in the generations. You claim that chiropractics is essentially of no benefit, yet welcome Facet's arrogant comments about his chiropractics.

My generation doesnt like to put up with nonsense that these quacks like to perpetuate. Pain Medicine got a bad rep in the past because we have non fellowship trained docs and chiropractors claiming to be "pain docs' and essentially providing voodoo, magic medicine. Those people need to get weeded out.

This is a medical forum for medical docs. Feel free to have these quacks run all over you, I'm just not ok with that.

---------

Going back to the original thread. I didnt realize how big these North American Spine guys are. If you've flown recently on practically any airline, you will see their ads on the airline magazines. They must be doing well, ads arent cheap to place on those magazines.
1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

The 6 points above are quite useless when you are trying to learn what you are supposed to be doing when you grow up, but become extremely helpful in the last few months in training and first few years in practice. Sleep- read them now, take a deep breath- and enjoy them later. You knw what they say about arguing on the internet....

Chiropractic is no different than phrenology, just a century later. If you don't like it, tell your patients to avoid it. I have a 16 page handout on why to avoid Vax-D (besides the $4k in cash). Chiro is symptom management- and I warn patients not to try HVLA, but the rest is up to them.
 
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i went out and started my own practice in a saturated market from day one. i have been successful treating the failures of others alot of times simply because there was no decent exam by the fellowship-trained guy before. in fact, sometimes i think it makes my double-board look bad. i am in the process of hiring another physician now. all i can say is you wouldn't make the end of my list.
Biting my tongue..or shall I say attempting not to type....

Probably wouldnt work for you either way. Fortunately, I'm not in need to self my soul to make a quick buck. Congrats on your success in a saturated market. BTW..you know what they say about Pain docs like yourself that say he "fixes other pain docs mistakes'. It's typically because someone else is likely fixing yours.

You are missing my point completely....

Steve- Thanks.
 

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Hey PMR

I welcome your criticism, however, humility? Please drill it into the Chiropractor on here. Perhaps there's a disparity in the generations. You claim that chiropractics is essentially of no benefit, yet welcome Facet's arrogant comments about his chiropractics.
First, I have done my best to remain as professional and respectful as possible here. If you hadn't noticed, you and Jeff are the only two for whom I've let that slip; perhaps you can figure out why.

Second, how have I been arrogant? Because in my mind there have been some points with which I disagree and I've tried to explain a bit about where I'm coming from? We're having a grown-up discussion. Everyone in here can handle that.

My generation doesnt like to put up with nonsense that these quacks like to perpetuate. Pain Medicine got a bad rep in the past because we have non fellowship trained docs and chiropractors claiming to be "pain docs' and essentially providing voodoo, magic medicine. Those people need to get weeded out.

This is a medical forum for medical docs. Feel free to have these quacks run all over you, I'm just not ok with that.
This speaks for itself.
 

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Biting my tongue..or shall I say attempting not to type....

Probably wouldnt work for you either way. Fortunately, I'm not in need to self my soul to make a quick buck. Congrats on your success in a saturated market. BTW..you know what they say about Pain docs like yourself that say he "fixes other pain docs mistakes'. It's typically because someone else is likely fixing yours.

You are missing my point completely....

Steve- Thanks.
write what you want to write smart guy. i didn't write anything about selling my soul or anything else. i get your point in my first paragraph. my second point is you have a bloated sense of yourself. my main point, since you missed it, is that a fellowship training at at whatever institute you name doesn't mean you will bat 1,000 or be better than the guy down the road. so grab some humility.
 

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Chiropractic is no different than phrenology, just a century later. If you don't like it, tell your patients to avoid it. I have a 16 page handout on why to avoid Vax-D (besides the $4k in cash). Chiro is symptom management- and I warn patients not to try HVLA, but the rest is up to them.
Even if the patient has failed to respond to other forms of treatment, assuming there are no contraindications? Why are you willing to selectively overlook the data that shows manipulation is at least as effective as other forms of treatment?
 
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write what you want to write smart guy. i didn't write anything about selling my soul or anything else. i get your point in my first paragraph. my second point is you have a bloated sense of yourself. my main point, since you missed it, is that a fellowship training at at whatever institute you name doesn't mean you will bat 1,000 or be better than the guy down the road. so grab some humility.
Your sarcastic remarks are greatly not appreciated.

Bloated sense of myself? Interesting. Well that just sounds like a way for you to minimize what I'm saying. As I recall you are the one bragging about how you busted into a competitive market.

If you think stating that fellowship trained Pain docs are the way to go is considered 'bloating'. All I have to say is that I'm a patient advocate and believe patients (the consumer) should know the facts. They should know if a fellowship trained vs non fellowship trained vs MD vs DO vs Chiropractor vs RN vs CRNA vs LPN vs APN is taking care of them. They should know what the differences are. I'm all for a patient knowing this information and then making a semi-informed decision. Let the cards fall where they should. I am however against any doc hiding behind the "Pain Doctor" title and essentially sheltering their true credentials.

See..realistically we'd probably get along since your thinking toward Chiropractics and mine are similar. Dont have to admit it..I understand.

I dont like antagonizing other physicians (not intentionally), especially not on the internet. Chiropractors, totally different story. As such, I'm disengaging myself from the pissing contest with you.
 

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Your sarcastic remarks are greatly not appreciated.

Bloated sense of myself? Interesting. Well that just sounds like a way for you to minimize what I'm saying. As I recall you are the one bragging about how you busted into a competitive market.

If you think stating that fellowship trained Pain docs are the way to go is considered 'bloating'. All I have to say is that I'm a patient advocate and believe patients (the consumer) should know the facts. They should know if a fellowship trained vs non fellowship trained vs MD vs DO vs Chiropractor vs RN vs CRNA vs LPN vs APN is taking care of them. They should know what the differences are. I'm all for a patient knowing this information and then making a semi-informed decision. Let the cards fall where they should. I am however against any doc hiding behind the "Pain Doctor" title and essentially sheltering their true credentials.

See..realistically we'd probably get along since your thinking toward Chiropractics and mine are similar. Dont have to admit it..I understand.

I dont like antagonizing other physicians (not intentionally), especially not on the internet. Chiropractors, totally different story. As such, I'm disengaging myself from the pissing contest with you.

geez man, take a step back.
i am not writing that i have no failures. i am not bragging about opening my own practice. it was a seque to the point that no matter where you train you will not help everyone. sometime, someone somewhere will swear by their D.C. treatments and not what you did for them. its crazy, but people are crazy. so you can attack the chiro, but there are fellowship-trained pain docs with chiros as part of their practice. no ethics? confused? nah, probably them just knowing that they aren't going to cure everyone.

what is going to irritate you all night is that facetguy can say that he has had some successful outcomes, while at this point in your career you can't.

its simply my thought nowadays. not long ago i was you. :D
 
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geez man, take a step back.
i am not writing that i have no failures. i am not bragging about opening my own practice. it was a seque to the point that no matter where you train you will not help everyone. sometime, someone somewhere will swear by their D.C. treatments and not what you did for them. its crazy, but people are crazy. so you can attack the chiro, but there are fellowship-trained pain docs with chiros as part of their practice. no ethics? confused? nah, probably them just knowing that they aren't going to cure everyone.

what is going to irritate you all night is that facetguy can say that he has had some successful outcomes, while at this point in your career you can't.

its simply my thought nowadays. not long ago i was you. :D
:thumbup:

facet guy can say what he wants...I hope he'll be in my future market. Can't wait....

:laugh:
 

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Even if the patient has failed to respond to other forms of treatment, assuming there are no contraindications? Why are you willing to selectively overlook the data that shows manipulation is at least as effective as other forms of treatment?
I'll stick with the 4 fold risk of vertebral artery CVA in patients 45 and under. If they are older- I let them know that it is no more effective than anything else and they can try it if they want- but there is no anatomic-pathologic correlate that makes HVLA make sense. Then they look at me funny from all the jargon I spewed, and I tell them I think it is bullsh*t.
 

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geez man, take a step back.
i am not writing that i have no failures. i am not bragging about opening my own practice. it was a seque to the point that no matter where you train you will not help everyone. sometime, someone somewhere will swear by their D.C. treatments and not what you did for them. its crazy, but people are crazy. so you can attack the chiro, but there are fellowship-trained pain docs with chiros as part of their practice. no ethics? confused? nah, probably them just knowing that they aren't going to cure everyone.

what is going to irritate you all night is that facetguy can say that he has had some successful outcomes, while at this point in your career you can't.

its simply my thought nowadays. not long ago i was you. :D
We're framing this as some sort of competition now? I hadn't looked at things that way. I always thought it was more a collaborative effort for the benefit of our patients.
 

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We're framing this as some sort of competition now? I hadn't looked at things that way. I always thought it was more a collaborative effort for the benefit of our patients.
More government control. Make providers fight for healthcare dollars to drive down reimbursement.
 

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:thumbup:

facet guy can say what he wants...I hope he'll be in my future market. Can't wait....

:laugh:
I have 3 pain management practices that refer me patients. Some of the docs are from anesthesiology, some are from PM&R, all are experienced physicians. Now why would they do that, particularly when sometimes it takes money right out of their pockets to do so. In my "market", you would be the odd man out.
 

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I'll stick with the 4 fold risk of vertebral artery CVA in patients 45 and under. If they are older- I let them know that it is no more effective than anything else and they can try it if they want- but there is no anatomic-pathologic correlate that makes HVLA make sense. Then they look at me funny from all the jargon I spewed, and I tell them I think it is bullsh*t.
I can appreciate your desire to protect your patients. But a stroke from lumbar manipulation? Even you would have to say that is crazy.

As to the lack of anatomic-pathologic correlate, why don't you explain to them that a chiro just might be able to improve their mobility and reduce their pain? Patients seem to understand that pretty easily. It conveys the point, spares them the confusion, and spares you from having to spew jargon.
 

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I can appreciate your desire to protect your patients. But a stroke from lumbar manipulation? Even you would have to say that is crazy.

As to the lack of anatomic-pathologic correlate, why don't you explain to them that a chiro just might be able to improve their mobility and reduce their pain? Patients seem to understand that pretty easily. It conveys the point, spares them the confusion, and spares you from having to spew jargon.
L-spine is fine to do, but I think it to be ineffective. No significant risk from L-spine HVLA.

Just not OK to do C-spine HVLA or MUA.
 
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I have 3 pain management practices that refer me patients. Some of the docs are from anesthesiology, some are from PM&R, all are experienced physicians. Now why would they do that, particularly when sometimes it takes money right out of their pockets to do so. In my "market", you would be the odd man out.
Tell me what market you're in Slim. I'll let you know if I'm interested. Although I dislike Obamacare. I think Quackcare (synonymous with Chiroprctic Care) will be called out and eaten alive for its use of voodoo magic and manipulation (pun intended).
 

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We're framing this as some sort of competition now? I hadn't looked at things that way. I always thought it was more a collaborative effort for the benefit of our patients.
it is a collaborative effort. i get referrals from chiros and i have at times referred people to them. generally i refer people who i think have clear facet-mediated pain. these people do fine.
 

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i refer to chiropractors.... not often, but i do make referrals... i consider them part of my multi-disciplinary armamentarium...

on the flip-side, i love the referrals i get from chiros.... usually patients with good insurance, who are interested in their health, usually compliant...
 

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For those who do refer to chiropractors, what are the clinical criteria you use to decide which patients would be most likely to benefit?
 

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Chiropractic profession began in 1895.

Physiatry began when again? I'm pretty sure we beat you to the punch.:D
And the practice of osteopathy began in the United States in 1874 by Andrew Taylor Still. Think your patient would benefit from manual medicine? Why not refer to an osteopathic PHYSICIAN.
 

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most likely to benefit from chiropractic are the same patients who will likely benefit from 1) gentle home stretches 2) acupuncture 3) going to the gym and exercising

most of the patients have little pathology on imaging, have an underwhelming exam...

they seem to thrive under the care of a chiropractor primarily because of the concept that they are being seen regularly by a "dr"...
 
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most likely to benefit from chiropractic are the same patients who will likely benefit from 1) gentle home stretches 2) acupuncture 3) going to the gym and exercising

most of the patients have little pathology on imaging, have an underwhelming exam...

they seem to thrive under the care of a chiropractor primarily because of the concept that they are being seen regularly by a "dr"...
problem solved then especially if PT=chiropractics.

Youknow now PTs are becoming "Doctorate of PT", refer to them then. lol

Another form of quackery. everyone's a 'dr' nowadays.
 

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it is a collaborative effort. i get referrals from chiros and i have at times referred people to them. generally i refer people who i think have clear facet-mediated pain. these people do fine.
Facet pain patients do tend to be our best cases. I do pretty well with SIJ pain as well.
 
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http://www.backstrong.net/

check this Chiropractor out. He's even got "physician testimonials". Just make sure you dont suffer from epilepsy, watching the initial page will initiate those epileptic foci.

all you have to do is jump on and get strapped onto that "spine med" device. I cant believe these chiropractors con patients into get 17 treatments on this archaic looking device! You would think that 17 tx's or so in a month would definitely allude to the fact that his is just a 'transient' and homeopathic measure....
 
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http://www.backstrong.net/

check this Chiropractor out. He's even got "physician testimonials". Just make sure you dont get an epileptic seizure from watching the initial page.

all you have to do is jump on and get strapped onto that "spine med" device. I cant believe these chiropractors con patients into get 17 treatments on this archaic looking device! You would think that 17 tx's or so in a month would definitely allude to the fact that his is just a 'transient' and homeopathic measure....
LOL

I noticed I have the same set of 4 vertebral models to demonstrate the stages of DDD in the greeting video.

"Spinal Decompression" is the 2000's new term for traction. They advertise heavily on TV in my town. Always Chiropractic office with MD figurehead and PT's. Pt's get "free initial exam" and then daily 3-5 units of manipulation follwed by 3-5 units PT, come back tomorrow for rinse and repeat. (Except Saturdays and Sundays. I could never figure out why a treatment is needed 5 days ina row, but not on weekends...) I've asked their former pts who come to see me to bring me a copy of their bills, just for laughs. $20 - $30 K/month for months on end.

I work with a select few chiros in town who operate on more of a medical model than a financial one. One sent me a pt today, just to make sure he wasn't missing anything. He wasn't.

I'd bet that if you took 100 pain MD's and DO's and compared them to 100 Chiropractors, each with 100 patients with back or neck pain, you'd fail to find significant differences in outcomes. Why? Selection bias and heterogenicity of diagnoses. People choose to go to chiropractors because they believe in that system. Others choose MD's and DOs becuase they believe more in that system. Some do both. Hey, whatever floats your boat. Plus, most patients get better just by treating them, no matter what you treat them with.
 

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Please elaborate - I know I for one am interested in leaning more about this [pro-inflammatory state]
A pro-inflammatory state is one that promotes inflammation and associated sequelae. I was referring in particular to several aspects of diet that puts people into such a state, which is unfortunately very common today. The first thing coming to mind is the typical over-consumption of omega-6 fatty acids, coupled with an under-consumption of omega-3s. The omega-3s, particularly EPA and DHA, promote production of anti-inflammatory eicosanoids, which is good. Since we tend to consume too many omega-6s in our Western diet, the result is the production of pro-inflammatory eicosanoids from arachidonic acid. It's estimated that the typical American has an n6:n3 of 20:1, where the ideal ratio is probably around 4:1. This all drives inflammation. EPA and DHA are also known to directly inhibit NFkB, which is in effect anti-inflammatory.

Another diet-driven promoter of inflammation is the over-consumption of carbs, particularly junk carbs that cause hyperinsulinemia. Insulin drives the omega-6 pathway into a pro-inflammatory direction by favoring the production of arachidonic acid over DGLA (an anti-inflammatory omega-6).

In addition, whatever diet and lifestyle factors lead to increased adipose tissue will also promote inflammation. Adipose tissue synthesizes any number of pro-inflammatory cytokines.

An anti-inflammatory diet, if you will, will include plenty of veggies and fruits, which among other things contain lots of antioxidants, whose actions are anti-inflammatory.

(There's also interesting albeit early research involving probiotics, which appear to not only reduce GI inflammation but systemic inflammation as well. I think we'll see more and more about this avenue of approach in the future.)

For our purposes here, all of this inflammation stuff obviously causes pain. We should keep in mind that chronic, smoldering inflammation is silent (i.e., not painful) but is now thought to contribute to everything from cardiovascular disease to neurodegenerative disease to cancer. Perhaps this has something to do with why Americans are so unhealthy.:rolleyes: