Media Spin at its Finest

Attached is a recent study about the problem of back pain in Iraq. Quickly persue the study first:

Download Cohen-AnesthAnalg-2005-InjuriesOIF.pdf

Once you're finished, click here to view an 'article' from the World Chiropractic Alliance about the 'implications' of this study on the need for chiropractic along the front lines. We can have frank and open debate about the optimal mix of health care providers in Iraq to best care for the troops. However, it doesn't take a rocket scientist to figure out that this study has nothing to do with chiropractic or demonstrating the need for it. The Soldiers included in this study were suffering from chronic pain  (all presenting to a chronic pain clinic) and would likely benefit most from multi-disciplinary cognitive behavioral intervention. There is no way this sub-group of Soldiers is getting back into the fight in any substantive numbers. The notion that chiropractic (or traditional PT for that matter) would benefit these patients is ludicrous. The word chiropractic never even appears in a study that has nothing to do the optimal mix of health care providers in the first place. This is an example of media spin at its ‘finest’, or worst depending on perspective.

John

 

Comments

[Herb Silver, PT]

In the table that lists treatments, it says 4.9% received "chiropractic manuipulation". Apparently this was not provided by a chiropractic, and hence should not be referred to as chiropractic manipulation, or maybe there are chiropractors available.

[Jason Silvernail]

The federal (VA and military Tricare) system has chiropractors available to selected beneficiaries (ie active duty military for Tricare)by law. Unfortunately, they aren't providing any service not already available in the military system through PTs and DOs (unless we're talking vertebral subluxation correction), and they merely have become a mandatory additional step in the care of those with spinal complaints. Many active duty personnel who see me stop going to the chiropractor when they realize that they can get manipulative care in my office as well as a host of other exercise and therapy approaches that they can't from the DC.

Reading their notes, it's pretty funny:
S: Tx, Cx
O: adjust C5-7, T4-6, T10-12 to improve motion
A/P: cont care, (list CPT codes for chiro manipulation).

It's always the same note, though sometimes the levels do change.
Overall, I like having them in the military system, because it's so easy to look good and do well when we have these people to "compete" with. I especially like the stories patients tell of the "little clicker thing" (activator) that some of them use. If you look at the spectrum of services provided and the scientific basis for such, they can't hold a candle to us.

And, for this study, the idea that manipulation could help this group of people with chronic pain is just...silly. As he said, multi-disciplinary pain and cognitive-behavioral programs are clearly what's needed, though expecting that particular group (the ICA) to know what evidence is, much less apply it, may just be asking too much.

J

[Steven L. Vanden Hoek, D.C.]

In regards to the ICA - they do not stand for the majority of D.C.'s. Secondly - of course they think chiropractors should be included when the number one problem presented was back pain. What do you think chiropractors are effective at? I have worked with many physical therapist - they think chiropractors are idiots, and we think your idiots - until they work side by side. Then they realize they compliment each other. Look, a D.O. manipulation is nothing like a D.C. manipulation. And when did you become licensed to diagnose?? Or when did you get licensed to MANIPULATE - i thought you were still requried to only mobilize - maybe your board changed the rules?

At any part - is this why a D.C. runs one of the N.Y. Army reserve clinics?

And regarding that clicking gun "activator" - spend an hour doing some research on it - you might actually learn something.

[Rob Wainner]

Steven,

I appreciate your willingness to post on our blog. Certainly PTs and DCs both see a lot of patients with spinal disorders. While the manual interventions and techniques used are certainly different, mounting evidence indicates that with regard to manipulation, technique is probly not as important as once thought.
A good thing about the blog is that it allows open dialogue, which is great for exposing weak arguments and fostering debate of ideas. As someone has said, all progress comes through debate.

One thing that the appointed leaders in your profession will have to deal with in a straight forward manner is the unsubstantiated theory upon which chiropractic was founded. It doesn't mean that the manual methods employed by Chiropractic may not have an effect, but it does invite valid criticism of Chiropractic practice patterns and the underlying philosophical approach of the profession.

Anyway, continued dialogue is a good thing. With regard to manipulation, it is included in the Guide to Physical Therapist Practice, a component of both the Normative Model of Practice and CAPTE (our educational accrediting body), and is permitted by the licensing boards of 47 of 50 state.

I encourage you to keep contributing but just remember, a cogent argument is more effecive than vehemence.

Rob Wainner

[Carina Lowry]

I really don't think there is a place here for petty turf wars.

In the end it is what is benefitting the patient. There is excellent evidence out there that Physical Therapists are just as qualified to treat low back pain as any other practitioner. There really is no question about our ability to diagnose since "diagnosis" falls under such a broad category (ie Low back pain, lumbago, lumbar strain, etc---my secretary could have made that diagnosis.)

What matters is that we have the skills to screen for serious pathology, order the appropriate test or recommend it if you are in the civilian world, classify the patient appropriately, and apply the appropriate treatment, whether it be manipulation, stabilization, traction, or direction specific exercise.

This is what gets the patient better, and the sooner that we can figure out that certain groups of patients need psych help along with these manual skills or "adjustments" then the sooner our patients will be returning to a productive life. And isn't this what it's really about???

Carina

[Jeff Hebert, DC]

Carina,
Well said, I greatly appreciate your sentiment. The patient should be the focus, however when you have professions with overlapping scopes and expertise, conflict is sure to follow. Combine that with the fact that many chiropractors are unaware of the research efforts of physical therapists in the realm of spinal manipulation and the problem escalates. If however, as you stated, we all focus in the needs of the patient, the turf wars should not be an issue.

Thank you.

Jeff

[Al Augustine]

Wasn't one of the main issues the need of chiropractic care on the front lines?

Are there enough chiropractors to set up shops overseas?

Bottom line, this should be a great example of what can be done for people with early intervention. There should be tons of stories of soldiers getting treated and return to duty quickly. I would love to read about that in a newspaper.

[Cameron MacDonald]

Steve,

I would encourage you to post the research you refer to with regards to the activator use in Chiropractic care, if it has a sound methodological base. I would agree that when Physical Therapists and Chiropractors spend time side by side a lot of the turf wars can dissipate, but this will depend on the uniqueness of each individual situation.

Unfortunately, you demonstrated though why there is such vehemence towards PT's by a lot of DC's when you strongly question the right to diagnose of PT's when it is the job of PT's to reach a PT diagnosis, and the role of a DC to reach a Chiropractic diagnosis. Is anyone here trying to make a Physician diagnosis, no. What is the point of this statement, outside of perhaps demeaning a PT's education.

Also, Rob noted to you that PT's are not restricted from manipulation in 47/50 states. The evidence behind manipulation success in the form of RCT's and CCT's trials is heavily based on PT trials.

We all appreciate your posting and taking part in open dialogue, we do not need agression or wehemence though, it does nothing to serve the interests of either profession with regard to patient care.

The other issue from the ICA article is that there is a statement that DC's are needed on the front line to diagnose subluxations. We do not need that. I would say fair enough to having skilled practitioners to regian a loss of mobility or to restore normal joint mechanics based upon the research demonstrating the effectiveness of interventions based on a clinical examination, but I do not believe since the 1880's there has been any evidence put forward to support a diagnosis of subluxation beyond testimonials and theory.

If you believe you there is, then please post the research on this so a fair review can be made.

Cameron

[Steven L. Vanden Hoek]

I appreciate the respectful replys. Pardon my spelling.

I've had the pleasure of working with several physical therapist side by side. And I have a great deal of respect for your services. I however don't feel I'm given the same respect initially. This I gain only after helping them with cases they can't resolve, or reading an MRI, or identifying a kidney problem on their unresolved back patient. I also agree that the majority of studies done to support joint manipulation therapy comes from the P.T.'s and M.D.'s. Thank you - we appreciate it.

Per our organizations - unfortunately we have 3. ACA, WCA, ICA. The major majority of D.C.'s support the ACA - and for the most part anything from the WCA or ICA is going to be subluxation based. The ACA is a little more grounded. The anger from D.C.'s stems from a "Woe Is Me" attitude. We spend 4 years post grad to get our doctorate, and we get paid less than you guys - don't get referrals from the M.D.'s - and have to justify ourselves and our usefullness to just about everyone. Of course we are mad.

Now lets get real, I haven't used the term subluxation in over 3 years in my practice. I agree the founding principles are wacked, but only a small percentage of Chiros even buy into this - unfortunately they are the same group that scream so loud they drown out the voice of reason.

No disrespect on the diagnosis issue either. The issue at hand isn't the level of traing you have regarding NMS conditions and ability to evaluate and treat - as almost all my orders to P.T.'s read "Evaluate and Treat". I wouldn't put this down if I didn't trust your judgement. It is in the area of being a portal of entry with diagnostic ability. I can't honestly say the level of diagnostic training is high enough - as of yet - to meet this criteria. With the PhD programs you guys have - sure - I would love to see you as doctors - you've worked hard.

What I hate is when comments such as in the original post say things like "Overall, I like having them in the military system, because it's so easy to look good and do well when we have these people to "compete" with." Talk about respect?

No, technique doesn't matter - and truthfully mobilization vs manipulation - it doesn't matter. Research shows that the amount of neurologic firing required to facilitate neurologica repatterning doesn't require cavitation of the joint - mobilization is sufficient.

Regarding restriction of using manipulation - forgive me if I'm wrong. The articles I read keep saying how the ACA has once again stopped P.T.'s from manipulation of the spine. I've even seen a couple law suites brought against P.T.'s for this. I looked in my past journals for the references - can't locat them right now.

In regards to safety of cervical manip - could it be any safer? Do you guys even want to do this? Most P.T.'s I meet don't want to manipulate.

Question - how do you feel about the new proposed law to allow sports trainers to evaluate and treat all sports injuries with any means of therapy they desire?

Anyway - activator articles

http://www.activator.com/research_04/page_001.asp

I'm not much a fan of this, except for anterior rib fixations and some cervical fixations with excessive capsular swelling.

Again - thank you. I would like to offer some suggestions for highly effective co-operative treatments. If you would be interest in my observations - let me know. If you want me gone - let me know. My goal, just like yours, is to get the patient better. If working together can do this - then WE should work TOGETHER.

Look around and observe how many D.C. clinics are bringing in P.T.'s. We are going to have to work together, and the better we understand each other - the better our patients will get.

[Jason Silvernail]

Hi Steve-
Glad you decided to stay with us. I for one certainly don't "want you gone" by any stretch. I understand your point, and please don't take my comment about a few practitioners in context of that ridiculous ICA article as an indictment of an entire profession. That's not the case.
Like most sensible practitioners, we all really agree on most things when we get down to it.

I think that while we might want to take the "high road" and avoid issues of turf wars, as long as one group of professional associations is on the offensive, and the other group is on the defensive, then we can't avoid those issues. Not talking about them doesn't make them go away, nor does it make them less important. I think talking about them helps clinicians on both sides to understand how damaging these things are, and that helps steer those organizations toward productive development of quality practitioners- which I think we can agree is everyone's goal.

To fall in with Rob's post above, to consider the ACA a good resource about the manipulation situation among physical therapists is a mistake, in my view. Check out this information, including comments by another DC, to get some background on that issue:
http://blog.evidenceinmotion.com/evidence/2005/08/more_of_the_sam.html

http://blog.evidenceinmotion.com/evidence/2005/11/another_chiro_s.html

Thanks for the good discussion.

Jason.