- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Hey stud....waiting for a link to your website still. What's up? You are a big, bad chiro now right? Whatcha got to loose?
North American Spine
- Thread starter SleepIsGood
- Start date
Hey stud....waiting for a link to your website still. What's up? You are a big, bad chiro now right? Whatcha got to loose?
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
See post #186.
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
I know there has been more movement in recent years regarding chiro and military care. I don't have the details though.
Let's take these first. When to refer to a chiro: I would suggest that you start by referring musculoskeletal pain cases, more than likely spine cases. As mentioned earlier, chiros seem to do well with facet-mediated pain, so start there if you wish. Send cases that haven't done well with the treatments attempted to date.
I see patients everyday that have peripheral symptoms.
We do use modalities of all sorts. Most chiros utilize some form of rehab exercises, even if it's prescribing home exercises. Many chiros have some type of low-tech rehab in their offices.
I do treat extremity conditions, depending on the situation. I will often get an ortho or physiatry opinion if the extremity condition seems complicated, and I will always refer if the condition fails to improve with my conservative care. I tend not to get many referrals from MDs for these though; they refer mostly spine cases.
I do lots of myofascial work on my patients and find this is often a missing link in their care. Good myofascial treatment is more than just massage (not to put massage therapists down, of course) and takes a good understanding of anatomy and biomechanics.
I order xrays, MRIs (mostly spine, sometimes shoulders), and refer for electrodiagnostic testing.
To impress chicks. Just kidding. I don't think too many chiros go around wearing stethoscopes, although I do take blood pressures on some patients.
Depends on how you define "primary care". If that means having direct access to patients without a referral, then yes, and that's how it is now. If you mean a replacement for a family physician or internist, then no. Truthfully, I don't know that many DCs would have any desire to replace family med physicians.
During chiro school, we do learn about all of that stuff, even EKGs, at least the basics. But we never get a chance to really use it and develop the proficiency as you guys do. We learn it for Boards, pass, and unfortunately forget much of it. Chiro school, however, does include the entire body, not just the spine, which I think is a common misconception. Believe me, chiro students do a lot more than learn to "crack backs".
I usually don't order labs myself. In many cases, this comes down to insurance reimbursement issues. I will recommend lab studies to a patient from time to time and have him/her see their PCP for them. There are times, however, when it would be easier to do it myself and skip the extra step. I think many DCs do order labs, and doing so may be more a function of state scope of practice and insurance issues.
As to vitamin D specifically, I do usually encourage patients to get their serum vitamin D levels checked so we can be more exacting in dosage recommendations. (Getting the PCP to order it is another story, although this is slowly changing.) It's pretty tough to go toxic from vitamin D though, so any reasonable dose is almost always well tolerated.
No prob.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Firstly, why dont you just but out and stop coming to this quack's rescue. I agree, this is a medical forum, not a chiropractic one....
Secondly, why dont you just mind your own business?
If you dont like the posts, just dont respond to them. You can handle that I'm sure. Thanks.
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
what a thread
Sleep is good-- the more you post the more you embarass yourself. You are being showed up by a chiro. Does that hurt your bloated ego?
Facet-- I do refer a select group of patients to chiro and they seem to do well. I appreciate your contribution
Sleep is good-- the more you post the more you embarass yourself. You are being showed up by a chiro. Does that hurt your bloated ego?
Facet-- I do refer a select group of patients to chiro and they seem to do well. I appreciate your contribution
- Joined
- Mar 22, 2008
- Messages
- 3,543
- Reaction score
- 2,165
what a thread
Sleep is good-- the more you post the more you embarass yourself. You are being showed up by a chiro. Does that hurt your bloated ego?
Facet-- I do refer a select group of patients to chiro and they seem to do well. I appreciate your contribution
he needs to see it a peer-reviewed physician journal before he realizes that he is portraying himself as an undeniable idiot.
facetguy i also appreciate your input on this thread.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
what a thread
Sleep is good-- the more you post the more you embarass yourself. You are being showed up by a chiro. Does that hurt your bloated ego?
Facet-- I do refer a select group of patients to chiro and they seem to do well. I appreciate your contribution
clearly a touchy subject...
I'm voicing my opinion. You can have yours. If you are ok with selling out you profession and embracing quacks that come in and market equivalency. That's great!
I know I'm not in the minority as evidenced by PMs I've received stating the contrary.
Again, this is why docs get run out. You guys just 'give in' and 'buy in' to this outside voodoo magic stuff. Again, that's fine. But most of us new guys arent necessarily going to be that way.
PS if this was such a ridiculous thread, I ask you why it's had the MOST amount of posts in a while. And no, most are NOT from just me. I think I've asked people a few times to resort to the ORIGINAL theme of the thread, however, it always comes back to the chiro subject. So you tell me if this isnt an important issue, why does that happen. Actually, I dont really need to know your reason.
Last edited:
- Joined
- Apr 25, 2009
- Messages
- 53
- Reaction score
- 0
Facetguy,
Thank you for your informative responses. Please don't forget to send me a link where I can read more on chiropractics.
I try to not form opinions on things I know little about, especially when emotions or vested interests may be involved. I also always keep the story of Ignaz Semmelweis in mind.
There are many ways to voice an opinion but a little diplomacy goes a lot further than purposefully being hurtful and cruel, which are words that should never be used to describe a physician in any circumstance.
Thank you for your informative responses. Please don't forget to send me a link where I can read more on chiropractics.
I try to not form opinions on things I know little about, especially when emotions or vested interests may be involved. I also always keep the story of Ignaz Semmelweis in mind.
There are many ways to voice an opinion but a little diplomacy goes a lot further than purposefully being hurtful and cruel, which are words that should never be used to describe a physician in any circumstance.
Last edited:
- Joined
- Apr 25, 2009
- Messages
- 53
- Reaction score
- 0
Just out of curiosity and because I am very interested in learning more, can you please let me know why you are so vehemently opposed to chiropractors? Surely you can't blame an entire profession on a few immoral outliers. Also, since evidence is very important to you, as it is me, can you please direct me to documented literature that shows that chiropractics does not work? Please do not take any disrespect from this post, I am truly just trying to educate myself on both sides of this issue.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Here's where a chiro caused paralysis essentially:
Spine (Phila Pa 1976). 2010 Mar 1;35(5):E149-51.
Cervical intradural disc herniation after spinal manipulation therapy in a patient with ossification of posterior longitudinal ligament: a case report and review of the literature.
Hsieh JH, Wu CT, Lee ST.
Department of Neurosurgery, Chang Gung Memorial Hospital, Change Gung University, Taoyuan, Taiwan, Republic of China.
STUDY DESIGN: Case report and review of the literature. OBJECTIVE: To report a patient presenting with Brown-Sequard syndrome due to cervical intradural disc herniation after spinal manipulation therapy. SUMMARY OF BACKGROUND DATA: Spinal manipulation therapy (SMT) is often used by people with neck pain or discomfort as an alternative therapy due to its claimed less invasiveness and comparable efficacy. However, excessive manipulations are reported to cause rare but serious complications such as tetraplegia, vertebral artery dissection, epidural hematoma, and phrenic nerve injury. METHODS: Clinical history, physical examination, and radiographic findings of the patient were described. Anterior cervical discectomy at the C3/C4 level and interbody fusion with a Caspar plate-screw system for fixation, were performed. RESULTS: A favorable surgical outcome was obtained. The Brown-Sequard syndrome improved and the patient regained full muscle power at a 3-months follow-up. CONCLUSION: Cervical intradural disc herniation after SMT is rare and most often cause Brown-Sequard syndrome. Definite diagnosis and prompt surgery usually achieves a satisfactory outcome. Anterior discectomy with interbody fusion is recommended. The OPLL associated with degenerative disc reminds us of the increased risk of intradural disc herniation. Those high-risk groups should be more cautious with spinal manipulation therapy due to its serious sequelae.
----------------------------------------
Can cause strokes!!
J Pain Symptom Manage. 2008 May;35(5):544-62. Epub 2008 Feb 14.
Chiropractic: a critical evaluation.
Ernst E.
Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, United Kingdom. [email protected]
Comment in:
J Pain Symptom Manage. 2008 Sep;36(3):e4; author reply e6-7.
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.
-------------------------------
Again...quackery...
J Pain Symptom Manage. 2008 May;35(5):544-62. Epub 2008 Feb 14.
Chiropractic: a critical evaluation.
Ernst E.
Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, United Kingdom. [email protected]
Comment in:
J Pain Symptom Manage. 2008 Sep;36(3):e4; author reply e6-7.
Chiropractic was defined by D.D. Palmer as "a science of healing without drugs." About 60,000 chiropractors currently practice in North America, and, worldwide, billions are spent each year for their services. This article attempts to critically evaluate chiropractic. The specific topics include the history of chiropractic; the internal conflicts within the profession; the concepts of chiropractic, particularly those of subluxation and spinal manipulation; chiropractic practice and research; and the efficacy, safety, and cost of chiropractic. A narrative review of selected articles from the published chiropractic literature was performed. For the assessment of efficacy, safety, and cost, the evaluation relied on previously published systematic reviews. Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today. Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. The core concepts of chiropractic, subluxation and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.
--------------
- Joined
- Apr 25, 2009
- Messages
- 53
- Reaction score
- 0
Sleep,
Those are good points and do worry me. Thank you for posting them. However, do you think similar arguments can be made against us? A quick PubMed search revealed the following:
Efficacy:
J Bone Joint Surg Am. 1985 Jan;67(1):63-6.
The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study.
****ler JM, Bernini PA, Wiesel SW, Booth RE Jr, Rothman RH, Pickens GT.
No statistically significant difference was observed between the control and experimental patients with either acute disc herniation or spinal stenosis. Long-term follow-up, averaging twenty months, failed to demonstrate the efficacy of a second injection of epidural steroids administered to the patients whose pain did not respond within twenty-four hours to an injection of either eighty milligrams of methylprednisolone acetate combined with five milliliters of 1 per cent procaine or two milliliters of sterile saline combined with five milliliters of 1 per cent procaine.
____________
N Engl J Med. 2009 Aug 6;361(6):569-79.
A randomized trial of vertebroplasty for osteoporotic spinal fractures.
Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingworth W, Ghdoke B, Annesley-Williams DJ, Ralston SH, Jarvik JG.
Improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group
________
N Engl J Med. 1991 Oct 3;325(14):1002-7.
A controlled trial of corticosteroid injections into facet joints for chronic low back pain.
Carette S, Marcoux S, Truchon R, Grondin C, Gagnon J, Allard Y, Latulippe M.
We conclude that injecting methylprednisolone acetate into the facet joints is of little value in the treatment of patients with chronic low back pain.
Complications:
Pain Med. 2009 Nov;10(8):1389-94. Epub 2009 Oct 26.
Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports.
Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N.
It seems like you can find studies to support almost anything. I tend to think that the best marketing is word of mouth. If patients aren't happy with the care they're receiving, then they don't return to that practicioner and don't recommend that particular treatment option to their peers. I can't tell you how many times per day I hear that a patient won't go back to this doctor or that doctor because that particular physician is not doing anything effective to control or treat their pain. Why would patients continue to return to chiropractors if they weren't offering something beneficial?
Those are good points and do worry me. Thank you for posting them. However, do you think similar arguments can be made against us? A quick PubMed search revealed the following:
Efficacy:
J Bone Joint Surg Am. 1985 Jan;67(1):63-6.
The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study.
****ler JM, Bernini PA, Wiesel SW, Booth RE Jr, Rothman RH, Pickens GT.
No statistically significant difference was observed between the control and experimental patients with either acute disc herniation or spinal stenosis. Long-term follow-up, averaging twenty months, failed to demonstrate the efficacy of a second injection of epidural steroids administered to the patients whose pain did not respond within twenty-four hours to an injection of either eighty milligrams of methylprednisolone acetate combined with five milliliters of 1 per cent procaine or two milliliters of sterile saline combined with five milliliters of 1 per cent procaine.
____________
N Engl J Med. 2009 Aug 6;361(6):569-79.
A randomized trial of vertebroplasty for osteoporotic spinal fractures.
Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingworth W, Ghdoke B, Annesley-Williams DJ, Ralston SH, Jarvik JG.
Improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group
________
N Engl J Med. 1991 Oct 3;325(14):1002-7.
A controlled trial of corticosteroid injections into facet joints for chronic low back pain.
Carette S, Marcoux S, Truchon R, Grondin C, Gagnon J, Allard Y, Latulippe M.
We conclude that injecting methylprednisolone acetate into the facet joints is of little value in the treatment of patients with chronic low back pain.
Complications:
Pain Med. 2009 Nov;10(8):1389-94. Epub 2009 Oct 26.
Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports.
Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N.
It seems like you can find studies to support almost anything. I tend to think that the best marketing is word of mouth. If patients aren't happy with the care they're receiving, then they don't return to that practicioner and don't recommend that particular treatment option to their peers. I can't tell you how many times per day I hear that a patient won't go back to this doctor or that doctor because that particular physician is not doing anything effective to control or treat their pain. Why would patients continue to return to chiropractors if they weren't offering something beneficial?
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
When it comes to reporting complications of spinal manipulation in the literature, bear in mind that not all of these cases involve a chiropractor, even if it's implied that they do:
http://www.ncbi.nlm.nih.gov/pubmed/7636409 . Sleep provided a study from China describing a cord injury after manipulation; I'm not even sure they have chiropractors in China.
Yes, complications do rarely occur following chiropractic care. But I think expertise does count for something. These events are indeed rare however.
As to negative chiro studies, Prof. Ernst almost always shows up, as in Sleep's other examples. Bear in mind, however, that Prof. Ernst has been criticized by colleagues and fellow co-authors for having a definite bias and cherry-picking the literature to make his case. http://www.chiroandosteo.com/content/14/1/14
That's not to say that chiropractic is beyond criticism. But the literature continues to evolve and we as a profession are improving everyday.
http://www.ncbi.nlm.nih.gov/pubmed/7636409 . Sleep provided a study from China describing a cord injury after manipulation; I'm not even sure they have chiropractors in China.
Yes, complications do rarely occur following chiropractic care. But I think expertise does count for something. These events are indeed rare however.
As to negative chiro studies, Prof. Ernst almost always shows up, as in Sleep's other examples. Bear in mind, however, that Prof. Ernst has been criticized by colleagues and fellow co-authors for having a definite bias and cherry-picking the literature to make his case. http://www.chiroandosteo.com/content/14/1/14
That's not to say that chiropractic is beyond criticism. But the literature continues to evolve and we as a profession are improving everyday.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Friend-
of course you would say that. I didn't think you wouldnt, but hey those are the facts.
As for Tenesma- Let me ask you something. Last time you've done an ESI did you use Fluro? Although not necessarily the 'standard of care'. I'd venture to say that MOST (>90%) of Pain Physicians utilize fluro to do most of their injections. Yes, indeed you can't 'see' the spinal cord, but you can definitely appreciate landmarks which clue you into where the cord,etc lies. Furthermore, one can use DSA and contrast to determine when arterial/venous uptake occurs. These technologies and methods allow one to practice safely. Of course things happen. However, as I recall, usually it's those 'weekend' warriors without fellowships that do not have A CLUE as to what to look for (ie vascular uptake) that have those severe complications. I've met people that go to those cadaver courses that are NOT fellowship trained and have done TFESI's etc in the real world. They come to these courses to 'hone' their skills, yet have no idea what types of things to look out for. Ridiculous! Not saying it's IMPOSSIBLE to have complications, but if you do the right thing and dont cut corners, it's less likely.
Now, let's flip to chiros. Do they use fluro or any imaging CONCURRENTLY while performing their manipulations? ABSOLUTELY NOT. Can they destabilize structures,etc absolutely yes! Look at the studies above.
Facetguy's denounciation of the studies that I quoted is trivial. It's common sense. Again as some have implied already on here. Chiropractics and massage therapy/physical therapy can be clumped into one category, they all may be used as adjuvant therapy to temporarily make someone feel 'good'. However, I still firmly believe MEDICAL therapy by a qualified MEDICAL DOCTOR should be the PRIMARY therapy.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Refer to my last post.
- Joined
- Jun 12, 2002
- Messages
- 5,332
- Reaction score
- 138
sleep... i am personally aware of cervical sticks by well-trained pain guys while done under fluoro - i was asked to do chart review for those cases...
in training, there is this concept of a perfect world and that, duh, it is safe/easy when done right... well, once you do enough of anything, complications start creeping in...
i think the bottom line, if i were to summarize the efficacy of my practice and the success of my practice - it has LITTLE to do with interventions, or my technical expertise at performing interventions.... it has a LOT to do with LISTENING to patients, explaining things in layman terms and holding hands and being compassionate and truly caring...
and that is why i see chiros doing well in my community because (besides being judicious in their approach), they also really care and patients love that
we sometimes forget that medicine is NOT just outcome based but also is an art of healing...
in training, there is this concept of a perfect world and that, duh, it is safe/easy when done right... well, once you do enough of anything, complications start creeping in...
i think the bottom line, if i were to summarize the efficacy of my practice and the success of my practice - it has LITTLE to do with interventions, or my technical expertise at performing interventions.... it has a LOT to do with LISTENING to patients, explaining things in layman terms and holding hands and being compassionate and truly caring...
and that is why i see chiros doing well in my community because (besides being judicious in their approach), they also really care and patients love that
we sometimes forget that medicine is NOT just outcome based but also is an art of healing...
- Joined
- Apr 25, 2009
- Messages
- 53
- Reaction score
- 0
I want to understand your point better because ultimately I want to understand what's in the best interest of my patients. However, I don't think you really addressed my post.
My point is that pain procedures have been shown to cause complications in the literature just as chiropractics has. It has also been shown to be no more effective than placebo just as chiropractics has. Also, please answer why patients continue to return to chiropractors if they are so ineffective?
You make a lot of assumptions for someone who always asks others to provide evidence. Do you have evidence that it's mainly the "weekend warriors" who cause most of the complications?
It seems that we hold others to a different standard than we hold ourselves. We ask others to provide evidence for what they do but when asked of us we say things along the lines of "lack of evidence is not evidence of lack of effectiveness."
Anyhow, I think at this point this thread may begin to go in circles. If that happens it's time for me to bail. Happy posting to the rest of you guys/gals.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
I like how you are trying to silently patronize. Sorry man, I can see right through your 'inquisitive' approach and see what you are really trying to do...
If you believe chiropractics is just as effective and you indeed are a "pain applicant' I invite you to not apply to Pain Medicine Fellowships, as they would be a waste of your time with that sort of attitude.
To Tenesma. Look, of course patient contact and your bedside manners mean a lot. That's COMMON SENSE ! However, you can do all the hand holding you want (like the chiropractors as you implied, which will get your patients coming back) but that's almost as effective as placebo then.
On the otherhand I've seen 'jerk' Pain Physicians. However bad their bedside manner is, they do REALLY good work that's effective. OBVIOUSLY, I'm not suggesting anyone should do that. Again, physicians use fluro and imaging to 'guide' their needles,etc. I stated earlier that bad things can happen, but atleast we take REASONABLE precautions. When chiros 'crack' backs, do they have any live imaging to verify what they did actually? Or that it actually stabilized something or that it DESTABILIZED something? No.
Again, just because chiropractors are slick with their tongue and are able to give lip service, MEDICAL SCIENCE produces results. I don't understand why people like you pursue medicine then. Why dont we all become naturopaths and prescribe Vitamin D to everyone as we are all apparently deficient per the Chiropractor.
The answer is obvious. Physicians do research and figure out the pathophys behind why things go wrong. They then SCIENTIFICALLY (not mystically) try to address these issues. Do they get it wrong sometimes, yes. But the bottom line is, if you are compassionate and scientific, patients will have good outcomes. People go back to Chiros for "15" or so treatments because they get transient relief, but at the cost of the chiropractor charging them $$$$ each time, essentially milking them. If patients get that much of good relief, but only transients, why not refer them to something cheaper like massage or PT?
Let me ask you this. Would a physician give 15 LESI in one month? HECK no. They are atleast somewhat spaced out. Wouldnt having to do 15 of the same thing in one month imply that 'it isnt working'? Why do patients go back that frequently? Well because chiros are good con men and can persuade patients. Common sense again should lead you to believe, that it's irresponsible to do the SAME EXACT thing 15 or so times in one month--clearly suggesting they don't work.
So is your max oxycodone 14 per month?
What about ibuprofen?
14 Lyrica per month?
Some treatments aren't long lasting... that doesn't mean they are not useful in certain circumstances.
Sleep you haven't yet had the privilege of doing all the right things, taking all of the necessary precautions and still getting a complication... but you will...
I bet that your attitude will change once you're in practice...
Most of us were cocky in training... but be realistic... needles and scripts don't cure all pain problems.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Why is this being 'cocky' ?
Did I say that I have the answers to everything? No..
Do I want to preserve the Pain Medicine profession from being corrupted and skewed by non-physicians, yes. It would seem that you would want the same thing.
I dont know if this is how all of you guys are in real life towards residents and fellows. You used to be one. I think there are attendings on here that feel like they overnight became one.
Cocky is berating people for complications. All of us who do procedures get them. We probably get a lot more than we know about... I wish someone talked me down a bit as a resident or a fellow... I probably would have learned even more during my training... and on some level Sleep -- you do become an attending overnight... one day you become instantly and fully responsible for what you are doing. It's not even close to being in training. I was given some advice in training and I didn't understand it then: being a good doctor has everything to do with how you handle your complications.
I agree with many of you that HVLA in the c-spine is very scary. I warn my patients with real cervical pathology who see chiros that it can be catastrophic... To be honest I also think that transforaminal cervical ESIs are very scary. It's high priced real estate...
If a chiro can get a patient's pain better, then neither you nor I have any business violating their skin with a needle or a knife. Just to be clear... I'm talking about good, ethical, self-aware chiro's... not the charlatans.
So I really don't see how they are going to interfere with your profession.
The truth is spine pain is poorly treated across the board. I think that we need to learn from each other. "Cross-pollination" makes sense and makes us all better.
This has been a great thread...
I agree with many of you that HVLA in the c-spine is very scary. I warn my patients with real cervical pathology who see chiros that it can be catastrophic... To be honest I also think that transforaminal cervical ESIs are very scary. It's high priced real estate...
If a chiro can get a patient's pain better, then neither you nor I have any business violating their skin with a needle or a knife. Just to be clear... I'm talking about good, ethical, self-aware chiro's... not the charlatans.
So I really don't see how they are going to interfere with your profession.
The truth is spine pain is poorly treated across the board. I think that we need to learn from each other. "Cross-pollination" makes sense and makes us all better.
This has been a great thread...
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Agreed with a lot. Now quote me where I stated that we DONT make mistakes or have complications. NO where.
Again, relax. I think you and others are perhaps overreading or reading into what I've written on here. What I stated is that atleast physicians take reasonable steps to prevent complications. Docs are the biggest critics of docs as evidenced by this thead even. Chiros dont have that.
If you went into medicine to help people and get them to feel better, I think its incumbent on you to protect patients from quacks.
- Joined
- Apr 25, 2009
- Messages
- 53
- Reaction score
- 0
Thanks for the advice but I think I'll pass on your help. I've already got a spot at an ACGME program at a top university, was offered a position in another ACGME pain program as early as June of my PGY 3 year, and have published several articles on issues related to interventional pain, including one in Pain Medicine. I guess you'll have to deal with me being your colleague. I wonder how you have contributed to the field.
I did and still do really just want to learn more but it's funny how you still manage to not address my post. Anyhow, we'll just have to agree to disagree on this one.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Awesome. Let's just say I've got very similar credentials and have probably published just like you have
I'm sure we'll definitely cross paths. I can definitely agree to disagree since you have put your money where your mouth is: attending a ACGME accredited pain fellowship.
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
This is why you are a clown. I linked to several studies in mainstream medical journals, and could have provided a dozen more, which showed that vitamin D insufficiency/deficiency is epidemic (pandemic, in fact). Nobody even debates that anymore. Yet, you still make a statement like the above. You are so closed-minded that all you saw was that a chiropractor had provided the links. You were blind to the actual information itself. That, to me, is what's dangerous. You are a pain physician yet have no idea that vitamin D deficiency has been associated with chronic pain. Keep studying my friend.
PT is almost always more expensive than chiro, and depending where you are getting the massage, it too is typically more costly than chiro.
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
Vitamin D for the treatment of chronic painful conditions in adults.
Straube S, Derry S, Moore RA, McQuay HJ.
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007771.
BACKGROUND: Vitamin D is produced in the skin after sun-light exposure and can also be obtained through food. Vitamin D deficiency has recently been linked with a range of diseases including chronic pain. Observational and circumstantial evidence suggests that there may be a role for vitamin D deficiency in the aetiology of chronic pain conditions.
OBJECTIVES: To assess the efficacy and adverse events of vitamin D supplementation in chronic painful conditions.
SEARCH STRATEGY: We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to September 2009. This was supplemented by searching the reference lists of retrieved articles, textbooks and reviews.
SELECTION CRITERIA: Studies were included if they were randomised double blind trials of vitamin D supplementation compared with placebo or with active comparators for the treatment of chronic pain conditions in adults.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected the studies for inclusion, assessed methodological quality, and extracted data. Pooled analysis was not undertaken due to paucity and heterogeneity of data.
MAIN RESULTS: Four studies, with a total of 294 participants, were included. The studies were heterogeneous with regard to study quality, the chronic painful conditions that were investigated, and the outcome measures reported. Only one study reported a beneficial effect, the others found no benefit of vitamin D over placebo in treating chronic pain.
AUTHORS' CONCLUSIONS: The evidence base for the use of vitamin D for chronic pain in adults is poor at present. This is due to low quality and insufficient randomised controlled trials in this area of research.
- Joined
- May 30, 2005
- Messages
- 21,272
- Reaction score
- 12,403
But it is very fashionable to treat with Drisdol. There is a lone voice crying out against uniform and national Vit D replacement. Some doc from Boston (or New England) was on CNN spouting off on how we just don't know...
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
Probably Trevor Marshall. He and some colleagues are about the only ones who call for restricted vitamin D in some cases. With the deluge of vitamin D research opposing them, they are swimming upstream for now.
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
"Deluge of vitamin D research"?
4 double blind studies is hardly a deluge, and 3/4 found no benefit of vitamin D over placebo in treating chronic pain.
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
This Cochrane Review included 4 studies, 1 of which showed benefit. I'd like to see what the dosages used were, as it's not uncommon (and certainly was quite common even just a few years ago) to use small doses that we now know aren't going to get it done.
There has been a lot of interest in vitamin D in all facets of health and disease, including pain. If you do pain for a living, you have to at least be aware that these lines of investigation are going on (Sleep, that means you). Here are a number of studies and case reports just from within the past year that at least strongly suggest there is something going on with vitamin D and pain:
http://www.ncbi.nlm.nih.gov/pubmed/20051755
http://www.ncbi.nlm.nih.gov/pubmed/20016681
http://www.ncbi.nlm.nih.gov/pubmed/19835345
http://www.ncbi.nlm.nih.gov/pubmed/19699370
http://www.ncbi.nlm.nih.gov/pubmed/19655244
http://www.ncbi.nlm.nih.gov/pubmed/19534335
http://www.ncbi.nlm.nih.gov/pubmed/19489344
http://www.ncbi.nlm.nih.gov/pubmed/19373764
http://www.ncbi.nlm.nih.gov/pubmed/19365168
http://www.ncbi.nlm.nih.gov/pubmed/19277814
http://www.ncbi.nlm.nih.gov/pubmed/19124636
Even if you aren't comfortable with trying to get patients into a still-debated optimal range for vitamin D, at least get them into the low-normal range. Vitamin D is cheap, safe, easy to test for, and may confer a whole host of health benefits. Why ignore it?
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
Go to Pubmed, search 'vitamin D', and see what comes up. Vitamin D studies come out every week. It's a very active area of research.
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
You seem to not understand the difference between a meta-analysis of high quality studies and your list of case reports, cohort studies, and retrospective chart reviews. The reason to not address the issue is that the majority of high quality studies DO NOT find benefit over placebo (Cochrane study was from Jan 2010). The literature isn't questionable - the evidence demonstrates a lack of efficacy
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
btw, if you are going to bother posting studies, it would be nice if they actually stood for the proposition you claim they do. 3 out of the 11 studies you posted have anything to do with vitamin d and pain
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
If you noticed, I was careful about how I worded my post. The very limited double blind trials for pain are 3 negative, 1 positive. And I realize that correlation does not equal causation blah blah. But we know clearly that millions of people in the US alone, including newborns, adolescents, teens, adults, and elderly are all at risk for at least D insufficiency if not frank deficiency. So, we have the choice now of either ignoring that, or we can work to bring everyone up to 32 or so ng/mL, the low-normal. Considering the fact that there is a deluge, yes a deluge, of new information regarding vitamin D and it's association with all manner of health/disease issues, we should ask ourselves the repletion question again. Remember, we're not talking about whether or not to administer a potentially toxic or deadly drug that may end up killing patients. We're talking about a substance with low toxicity potential, especially if a patient is being monitored. And it's cheap. If for no other reason, address the problem for bone density reasons. But vitamin D goes well beyond just bone these days.
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
You might have to read a line or two into the abstract. They all relate to pain.
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
read every one of them, but thanks for trying to slip that by us
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
And once again, we have a chiropractor who claims to address only neck and back issues, but then can't resist trying to play doctor. You are not an endocrinologist. Your role is limited, by your own prior admission, to addressing neck and back pain. Yet now you want to address "all manner of health/disease issues" And thus we head down the slippery slope. In doing so, you are practicing medicine without a license. This is clearly outside the chiropractic scope of practice.
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
C'mon. Don't try to twist things here. My interest in these patients is primarily pain. But it's not a bad deal that repleting their D may well help them in many ways. If there were a drug that did that, it'd be a blockbuster and even SleepIsGood would know about it.
And by the way, I said it's associated with all manner of health/disease. I didn't say I'm an expert in every manner of health/disease. And yes, an endocrinologist would be interested in aspects of vitamin D. But so would cardiologists, pediatricians, obstetricians, orthos, etc., as vitamin D cuts across many specialties.
Last edited:
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
Exactly. You are not a specialist in nutrition - that is why you should send patients to dietitians. You are not a specialist in any of the areas you mentioned, and suggesting that your care might impact paediatric, cardiologic, or orthopaedic health again takes you outside your area of expertise, which, just to reiterate, by your own prior statement, is neck and back pain. Implying that your care might have impact on other areas is inappropriate, and outside your scope of practice.
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
I guess this is your story and you're sticking to it. With that in mind, I suppose I'll stop telling patients relax more to help control stress, because then I'm being a psychiatrist. And I certainly won't tell them to go for a walk, because then I'm stepping on the exercise physiologist's toes. Cut out overconsumption of sugars? Better not, or else I'll come off as an endocrinologist. Drink clean water? Nope, toxicology. Deep breathing exercises? Nope, pulmonology. Get plenty of fiber in their diet? Uh-oh, gastroenterology. (Do you see how silly your argument is yet?)
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
Actually no. You are not an FP. You are not a PCP. Your chiropractic brethren tell patients they improve immunity, address allergies, and can improve the health of children with asthma. You clearly don't see the slippery slope you embark upon when you venture outside your area of specialization. There are experts who address these issues every day. I, as a physician, may dabble, because I recognize my limitations, and know when to send patients to other specialists. The point has been made in this thread before, and you have taken umbrage at it, but as a chiropractor, you don't know what you don't know. I know you will disagree, but I speak from having dealt with a large number of chiropractors. Yes, i know you are the best. Yes, i know you are smarter, and better versed, than all the others. Wanna bet they would say the same?
When a pain patient of mine has elevated blood pressure, I make certain they go back to their PCP, or their cardiologist. I then follow-up a week later to make sure they have acted on my recommendation. What I don't do is start them on an anti-hypertensive. Could I? Sure. But I would be dabbling. I send the patient to someone who addresses those issues daily. You should do the same.
- Joined
- May 31, 2001
- Messages
- 1,059
- Reaction score
- 2
you shouldn't be telling patients to do ANYTHING. you are billing for services in which you do not have an accepted level of competency. clearly, you do not know what you don't know - trivializing what other PROFESSIONALS do is a hallmark of this.
- Joined
- Apr 16, 2006
- Messages
- 1,965
- Reaction score
- 2
Hey bud it looks like there are some 'older and more wise' guys on here that agree with the fact that you are just a charlatan.
How do you bill for these things you chiropractors do/say? Seems like medicare/medicaid fraud.
No offense, but there's always been a rep you guys have as being shady, undermining physician wanna-bes. I believe your VitaminD panacea plan just brings it home.
Again, if you want to do doctoring....go to MEDICAL SCHOOL.
- Joined
- Jan 10, 2008
- Messages
- 3,581
- Reaction score
- 11
I could of course sit here and argue with my biggest fans about these various points and their distorted views. But what's the use. Truth is, some folks just won't be happy until I and my fellow DCs all go somewhere and die, no matter what anyone presents to them. Call it dogma, or obstinance, or whatever. But, at the very least, the next time the issue of vitamin D comes up, you 3 will think of me...and that's gonna sting a little.
- Joined
- May 13, 2007
- Messages
- 4,352
- Reaction score
- 738
My distorted view remains that you have yet to illucidate specific treatment algorithms for disc, facet, and based low back pain, leaving me to conclude that all low back pain is evaluated radiographically (if the patient's insurance will pay for it), random line-drawing on said x-rays (www.ncbi.nlm.nih.gov/pubmed/14970809), discussion about the terrible findings on said x-rays, and then treated indefinitely with the same adjustments, discussion of good posture, and conversation regarding nutrition.
No, I want to you prove to me that what YOU DO (chiropractic care, not spinal manipulation, which includes what D.O.s do) works better that a placebo (not PT, or massage, just a placebo) in a prospective, double-blind, placebo-controlled trial for specific indications (not non-specific chronic low back pain). Until your field can measure up to the same demands we in medicine hold ourselves to, then yes, I will indeed consider it voodoo. Not because of any medicine vs chiropractic dialectic, but rather because that is the standard all of medicine is held to.
Yup, I will wonder what disease entities you might have missed, and look forward to the day a judge in a malpractice suit holds you to the standard of an ordinary and reasonable physician when your attempts to practice medicine go awry.But, at the very least, the next time the issue of vitamin D comes up, you 3 will think of me...and that's gonna sting a little.
