A colouring book for young patients of chiropractors says “A is for alligator and adjustment. B is for bells and for back. C is for caterpillar and for chiropractor. D is for dog and for doctor.” The latter two may have more in common than is apparent at first glance.
It is as much of a surprise to the medical profession to find that their standards of back care are under attack as it would be to a high-rise executive to be attacked through his office window by fighter planes.
The orthopaedic surgeon, secure in his strength and apparently limited in his intellect, seems ill-equipped to withstand the challenges mounted against him from a variey of paramedical platforms. The face of the enemy may be unfamiliar, but the threat to the doctor’s authority is absolutely clear. The battleground is the low back. The opposing forces clash at the point of pain.
The public has little confidence in the medical profession’s ability to diagnose or manage back pain. Recently, on my way to conduct a seminar, I took a taxi from my hotel. The driver, seeing my carousel full of slides, observed I was going to give a lecture. When I responded to his questions that my topic was back pain, he observed I must be a chiropractor.
The medical profession is justifiably under attack because the conventional medical management for back pain is often wrong.
Prolonged bedrest beyond five days is of no proven value, and admitting a patient to hospital merely to sit on him is boring for the physician and makes it difficult for the patient to breathe. Getting high on drugs seems somehow more appropriate on the street than in the clinic. The prescription of modalities, such as traction, to treat a structural spinal abnormality leads to lengthy treatment producing temporary alteration but which ends precisely where it began, with a structural spinal abnormality.
Medicine’s fascination with excessive and even unnecessary investigations proceeds towards one of two unfortunate conclusions.
The patient is told, “The results of your tests were negative. Get lost.”
Or, the surgeon is seduced into operating on an x-ray. When the radiograph, rather than the patient, demands treatment, I recommend that the surgeon content himself with the film, a view box and a pair of scissors.
Faced with this apparent lack of medical success, there is little wonder that many patients seek out alternative treatment, searching for “a backache remedy that works”.
Therapeutic touch is one such alternative. It is a non-invasive therapy utilising “the body’s own electromagnetic field” which assists the client (no longer the patient) to return to “a more balanced state of body, mind and creative spirit”. I suspect the client/patient is not the only one who is being creative.
Polarised Haemoglobin
The Magnetic Four Season Band is typical of the commercially available remedies to relieve backaches. Naturally, since over 80% of backache subsides spontaneously within three months, the Four Season Band comes with a money-back guarantee.
The advertisement also explains the Band’s mode of action to relieve back pain, namely the polarisation of haemoglobin by small magnets. I have no idea what that means, but I feel better already just knowing my haemoglobin has been polarised.
The lack of proof or scientific validity seems no deterrent to the method, and the picture is confused, as it is with so many spurious treatments, by the coincidental subsidence of pain or some unrelated additional benefit.
In the case of the Magnetic Four Season Band, for example, you might use the magnets to attach yourself to the outside of a bus and be allowed to travel for half-fare.
Skull Manipulations
Perhaps striking closer to home is the practice of craniosacral therapy. Instruction in this art form throughout North America generates an annual revenue of more than three million dollars.
The therapy is based on a philosophy expounded in 1908 by an osteopathic student, who felt that since suture lines were visible on the human skull, God had intended there to be movement. The fact that no movement can be demonstrated and that the suture lines commonly fuse over the age of 50 was, and is, considered irrelevant.
Having spent considerable time and money, and having been required to memorise, for example, the over 20 articulations at the base of the skull (none of which move) as potential sources of pathology, it is little wonder that the initiated are reluctant to dismiss the technique as a waste of time.
Furthermore, patients find it comforting to lie in a darkened room, listening to soft music and having their heads massaged. But transient relaxation does not justify a belief in the repetitive expansion and contraction of the skull every five to ten seconds, nor does it establish cranioscaral’s link, as described in one of their texts, with Phillipine psychic surgery.
And I have great difficulty in accepting craniosacral’s “Laws of the Lines of Gravity”, which state:
Man deals with himself in such a manner that his brain becomes more perfect because he arranges his lines of gravity in a different manner from any other creature. Also, the gravity lines pass through his diaphragm, and no animal has this diaphragm-gravity relationship.
I advise patients who wish to have the bones of their skull rearranged to choose their therapist carefully.
Whiplash Worries
Clearly we are on the road to confusion, and it is the patient who may become the accident victim. And what motor vehicle injury is more classic than whiplash?
Every one of us who has ever worked in an Emergency Room has treated this problem, and yet whiplash is not a diagnosis. It describes only a particular mechanism, commonly seen in rear-end collisions, which may lead to a variety of neck injuries.
The pathology after an acceleration-deceleration injury may be as simple as a minor muscle haematoma or as devastating as a cervical fracture with cord damage.
Each is a distinct entity requiring specific treatment, and the diagnosis should reflect the individual conditions — not the common physical cause.
Whiplash to the chiropractor offers a different vista. Gone is the range of diagnoses, to be replaced by the ubiquitous vertebral subluxations. Anatomical reality is replaced with a line drawing where the neck bows like a willow in the wind.
In case of accident, medical attention is not recommended, but the admonition to see a chiropractor follows immediately after advice to remain at the scene of the accident until all information has been collected, and before being instructed to notify your insurance company.
Thorough examination by a chiropractor is presented as a wise precaution to determine the presence or absence of injuries.
As an example, headaches are a current complaint after a whiplash-type injury, and according to matrial supplied by the chiropractor:
Most headaches result from spinal subluxations, in other words, malfunctioning vertebrae. These subluxations cause irritation of the delicate nerves and arteries that supply the head and face area, causing pain. Subluxed neck vertebrae can also interfere with the blood circulation to the brain.
The chiropractor’s adjustment keeps the body free of nerve interference and allows normal blood flow. This allows the body to use its own inherent healing ability to maintain a state of health.
A Blow to the Head
For minor cervicel adjustments, a chiropractor may employ the activator gun. This instrument closely resembles a dental implement which used to be used to pound an artificial crown on a tooth. A spring-loaded plunger is propelled a centimetre or so beyond the end of the barrel.
Patients are told that contact with the skin and subcutaneous tissues creates a subtle pressure wave, sufficient to restore minor subluxations without the discomfort or potential risk of a full adjustment. In Ontario, each trigger pull is worth $10.
Market Forces
In health care, as in any retail business, effective marketing means listening to consumer demands. Giving the client/patient what he or she wants is the name of the game.
When the validity of treatment is not an issue, everything from electric pain management to dietary regulation can have a place in the control of back pain. When you treat a self-limiting condition, easy access, lucid explanations, emotional support and physical contact are powerful weapons.
It should come as little surprise that most sociological studies rank the chiropractor well above the doctor in the ability to control back pain.
And where is the doctor? Has the battle been lost by default? Medical training provides little knowledge or skill to justify the restoration of public confidence.
The modern medical attitude says, “Well, Bob, it looks like a paper cut, but just to be sure, let’s do lots of tests.”
Even the doctor confronted by a patient on whose back clings a large, green monster may be reluctant to make a definite diagnosis.
Although the doctor thinks he has found the trouble, he may refuse to make a commitment until all the investigations are complete, all the while muttering under his breath about the complexity of back pain and the possibility of arthritis or cancer.
D is certainly for Dog, and seems an appropriate mark for the doctor’s attempt at back care.
The fundamentals of patient back education are too often left to junior colleagues without the depth of knowledge necessary to answer questions or the depth of experience necessary to command respect.
A concerned patient requires a clear understanding of the problem, but the lesson in consumer satisfaction so clearly demonstrated by the chiropractor is lost on the physician.
Doctors Gullible Too
Equally quick to criticise the chiropractor for non-scientific methodology, the doctor is equally vulnerable to promotions based on scant medical research — an appeal through showmanship rather than science.
Consider the cold laser. Lasers are high energy light beams which travel in perfectly straight lines. They can be used to signal satellites or to burn holes in bricks. When the energy of the beam is reduced below the combustion point there is no known effect.
Laser surgery relies on the laser’s ability to vapourise tissue. Laser therapy relies on the laser’s unseen ability to increase the energy-containing capacity of the mitochondria within the cell. There is no way to measure this!
Lasers are said to normalise Brownian movement, the random particle movement typified by dust motes in a beam of light. Since random motion is an element of quantum mechanics, and cannot be measured in the living body, there is no way this theory can be tested.
Furthermore, I find it difficult, even in a large scale model, to differentiate between normal random movement and abnormal random movement.
Finally, the laser is heralded as being able to increase the nervous system’s light-carrying capacity, or bioluminascence. This capacity, unknown to the neurophysiologists and anatomists, is well recognised by those who sell medical lasers for $10,000 apiece. Still, lighting up the nervous system has a great deal of appeal.
Having purchased my own expensive equipment, in order to keep up with the clinic across the street, I intend to treat all my joggers so that they can run safely in the dark.
Mind-Body Interaction
The back is an emotional target, and is subject to storng mind-body interaction. Dreaming he is falling, Jerry forgets the well known “always wake up before you land” rule and is flattened like a pancake in his own bed. Here is mind-body interaction in the home.
Six months of inactivity with a bad back, too much beer and too much televisio, and we have the perfect male specimen poised to return to the job. Here is mind-body interaction in the workplace.
Lack of physical stamina limits performance. Strength requires exercise. The willingness to actively participate in the recovery process is a positive mind-body interaction.
Using exercise to control back pain is not a new idea. One manual published in the 1920s pictures the author, complete with bow tie, demonstrating his own routines.
But modern medicine’s love of technology threatens to make even this simple idea unmanageably complex. A bride in her wedding gown standing next to a computerised exercise machine smiles out from a glossy advertisement and exclaims, “Superb! I passed my dorsal stress test. Have you?” I haven’t the faintest idea what she is talking about. I think I prefer the man in the bow tie.
Active, Healthy Machines
Given the choice, of course, many of the doctor’s patients also prefer technology to exercise. One case in point is the passive exercise studio, where you can assure yourself of a healthy, attractive body, painlessly, without perspiration, without the discomfort of strained muscle and bruised joints, and never be out of breath.
The answer, of course, is the machines do all the work. An electric table folds in the middle, helping you with your sit-ups. After a busy day at the clinic, the machines are in great shape.
The same appeal possessed by passive exercise motivates many patients to visit the chiropractor. It is far easier to let something or someone else do the work and take the responsibility than to take charge of your own problems. But chiropractic is not unique in its emphasis on passive techniques. Nor is it alone in its apparent disregard for anatomical considerations.
Manual therapy, performed by a broad spectrum of experts, remains shrouded in folklore and mystery. Thoracic manipulation, as a means of moving the thoracic vertebrae independently, disregards the intervening skin, fat and muscle present in the average living patient.
This same disregard for proven functional anatomy appears in the descriptions of the neurolymphatic reflexes. For example, symptoms of conjunctivitis (an eye complaint) may be treated with pressure on the appropriate reflex location, the upper humerus at the deltoid insertion (arm-shoulder connection).
As surprising as this sounds at first, it is in fact one of the better recognised non-anatomical connections. The next time you meet someone whose eyes are red and bleary from a previous evening’s party, punch her or him sharply over the outer shoulder and watch the eyes fly open. You have just demonstrated a neurolymphatic reflex.
Fallacious anatomy can be used to justify massage or manipulation which brings only temporary pain relief, and yet the patient’s comfort may be enhanced through the erroneous belief that some structural malalignment has been correxted. But when applied in a more sinister fashion, anatomical misinformation can create unwarranted fear and justify the continuation of unnecessary treatment.
Anatomical Misinformation
Dozens of medical conditions are purported to arise because of minor vertebral malalignments. The anatomy seems reasonable, the terms sound familiar, and the medical problems are easily recognised, and yet something is amiss. To accept the diagnosis you must believe. But there are several conflicting belief systems at work in the realm of back pain.
Where better to indoctrinate the true believer than in childhood. Convincing new parents that their infant’s spine requires manipulation to ensure normal growth not only increases current practice, but fosters the child’s lifelong adherence to the principle. “Bring your children for an adjustment. Teach them the benefits of chiropractic.”
Without the knowledge that most back attacks subside spontaneously within 12 weeks, that back pain is a self-limiting condition, and that most back disorders can be controlled through simple measures of self- help, a chiropractic schedule of adjustments outlining intensive care for 13 weeks, reconstructive care for two to two and a half years, and maintenance care for a lifetime seems almost reasonable.
Dependency a Problem
Dependency can be a serious problem, but patients readily accept the idea that their back can somehow be straightened, pressed and cleaned in time for them to pick it up before the shop closes. Passive acquiescence and dependency are the antithesis of active participation and self control.
For those who allow back pain to dominate their lives, the statistics paint an ominous picture. Anyone remaining off work with a bad back for more than six months has only a 50% chance of returning to work on a regular, full-time basis.
Remain off the job for a year, and the chance falls to 25%.
Remain unemployed because of a bad back for two years, and there is virtually no statistical probability that you will ever return to your previous employment in a regular productive capacity.
It is the doctors, far more than the chiropractors, who have been guilty of creating dependency. It is little wonder that many patients will use more than the “apple a day” to keep the doctor away from their backs. The medical profession possesses the potential to eliminate back pain as a major socio-economic problem, but we have yet to demonstrate our understanding of the solution.
Too many meetings, too many publications, and too much time and effort are addressed to the perfect surgical solution while neglecting the simple fundamentals of intelligent and effective back care.
Patients need a simple answer to what can be a simple problem. Most need support, not surgery. They need a platform from which they can achieve their own success.
Joint Responsibility
This is not a popular message. There are too many vested interests and too many strongly held differences of opinion to gain consensus. But whether we like it or not, the battle has been joined and will continue. Both the doctor and the chiropractor have a responsibility to promote better back care.
No longer can the physician place unwarranted emphasis on investigative procedures and invasive therapies.
No longer can the chiropractor hide behind non-diagnoses like “concomitant intervertabral subluxation complexes,” nor report that “the form of treatment given is chiropractic care”.
No longer can the physical therapist be allowed to treat patients solely with modalities possessing no proven therapeutic value, providing temporary pain relief at the risk of long-term dependency.
Dr Hill presented this at a conference of the NZ Society of Physiotherapists.