Archive for chiropractic care
Over time, surgeons have moved to more and more complex procedures. But whether these lumbar spine surgeries are better is still in question.
Initially, spinal surgeries were less complicated with procedures like laminotomies and laminectomy, but surgeons (at least under Medicare) have been moving towards more complex procedures that are more expensive with a higher rate of complications. The problem with the vast majority of studies on the outcomes of surgery look at very short-term, usually no longer than 1 or 3 years. The re-surgery rate is known to be as high as 23% after 10 years.
So, if you didn’t have a repeat surgery, what can you expect after 10 years, and will you outcomes be any better than under the care of a competent physician who truly understands low back pain (like maybe a chiropractor….)? This is the question that was asked in this particular study. Researchers followed 473 patients with chronic low back pain of at least 1 year’s duration who were all considered candidates for spinal fusion. The average follow-up was 11 years. The patients were put into one of two groups:
- Lumbar spine fusion with either instrumented or noninstrumented fusion.
- Nonoperative treatment that included multidisciplinary cognitive-behavioral and exercise rehabilitation.
Keep in mind that true management in the #2 scenario above is not done by the average practitioner. Rather, this is a comprehensive approach encompassing both your mental state, the way you related (or don’t relate) to your pain as well as the physical treatments that can go a long way towards reducing the level of pain.
So what did the researchers find out after 11 years about the differences between spinal fusion and the comprehensive approach?
Yup. No difference in the long run. And this does not take into account the fact that a lumbar fusion will lead to further degeneration of the levels above and below as well as the chance that the surgery will not relieve the original symptoms it was attempting to address.
The bottom line is that surgery really should absolutely, positively be your last resort. And THEN you still try something else before surgery. You need to make sure that you can look yourself in the eye 6 months after surgery and tell yourself that you tried everything else before surgery. And yes, this DOES include chiropractic.
Maybe “required” is a strong word, but is it possible that negative changes occur with neck pain that can only be fixed by chiropractic adjusting?
As always, this is the time for my disclaimer: As a chiropractor, my viewpoint on this topic is clearly biased, but very well informed.
It seems like most of medicine jumps on a short course of anti-inflammatories and muscle relaxers for non-specific neck or back pain. Give it a few days of medications and see what happens. If the patient doesn’t get better, than consider referring out for (most likely) PT or chiropractic care. If they do get better, everything’s great. Or is it?
Are there changes that occur either from neck pain, or that lead to neck pain that are at a much deeper level than just symptoms?
I know that, for far too long my profession has promoted the “bone out of place” theory about chiropractic adjusting. However, this is just not how things work and I think many of my colleagues just found it easier to described what we do in overly simplistic terms. Closer to reality is what is called the “disafferentation” model. Joints like to move and are surrounded by a massive amount of receptors that fire off to the brain when we move.
That’s why we can close our eyes and still touch our noses with our fingertips. When we have an injury, or spend too much time in a single position at the computer for hours each day or we wake up with severe neck pain, the input from these receptors surrounding the affected joints will slow down. This means less input into your brain from these receptors. The brain doesn’t like this and sends a signal out to your pain centers that something is wrong.
At this point, what do you think that any type of medication, regardless of the class it is in, will do to fix this loss of input to the brain? The correct answer is a big fat nothing.
So what does all this have to do with this particular study? While a small study, it raises some very interesting questions about neck pain and how what kind of an impact chiropractic care has. Here’s a summary:
- Patients had subclinical neck pain, or minor neck pain for which they had not yet sought treatment (specifically, intermittent neck pain such as mild neck pain, ache, and/or stiffness experienced over at least 3 months’ duration)
- Patients demonstrated a 19% decrease in reaction time as well as a decrease in cerebellar inhibition (CBI–the brain was no longer reacting the way it was supposed to be).
- Follwoing a keypad based exercise to increase moto sequence learning, there was a decrease in CBI following chiropractic manipulation.
- The control group also had a 25% improvement in task performance, but no changes to CBI.
While the article itself gets a little technical, the bottom line is that, in these patients with mild, occasional neck pain, the neurological system is no longer functioning the way it is supposed to. Additionally, chiropractic adjusting has a positive impact on the nervous system in these patients.
While no hard conclusions can be drawn from this, I would suggest, in my very biased opinion, that NO cases of neck pain can be properly addressed without the use of chiropractic adjusting. Medications alone, which is a common route of treatment, does nothing to fix the negative changes in the nervous system that are present in neck pain patients.
Understanding the burden of musculoskeletal conditions
I find it very interesting that, despite the fact that musculoskeletal conditions are so prevalent in the population, relatively few medical journals touch on the topic. That may be because the medical profession has typically handled musculoskeletal problems poorly with little effect. I am biased in this regard, but I really feel that if everyone received chiropractic care for injuries and on a regular basis that the incidence of musculoskeletal conditions could be dramatically reduced.
bmj.com Woolf and Åkesson 322 (7294): 1079
Sounds like kind of a mixed up question, doesn’t it? “Anti” generally means opposed to, as in stopping. But what if anti-inflammatories are so damaging to your system that they initiate inflammation?
You know, of course, that I wouldn’t be asking such a rhetorical question if it didn’t have something to do with this particular article.
In it, researchers take a good, hard look at what NSAIDs do to us from a physiological standpoint. And it’s not a pretty picture.
You are probably aware that mainstream medicine hands NSAIDs out with Butterfingers to Halloween trick or treaters (at our house, we usually liberally hand out cruciferous veggies and hummus). Unfortunately, beyond the risk of a bleeding ulcer, I don’t think most of these providers are aware of the growing list of problems caused by this class of drugs. (If you’re interested in learning more, you can check out my eBook on the dangers of the NSAIDs by clicking here).
Back to the article…
As mentioned, there is a very clear and well known association between NSAID use and the development of bleeding ulcers. Depending on the year, this side effect kills anywhere from 16,000-21,000 unsuspecting users per year. The deaths from the cardiac side effects likely dwarfs these numbers.
Since the GI side effects are the most legendary, these researchers looked at what happens to the cells of the stomach under the influence of one of the more notorious anti-inflammatories, indomethacin.
The use of indomethacin in rats leads to the damaging of the mitochondria. I won’t go into how much I LOVE this organelle and how important they are to life and health, but just suffice it to say that this is a very, very bad thing to happen. This mitochondrial damage, which is not good for a cell, kicks off inflammation, leading to the production of chemical messengers in the cell with exotic names like intercellular adhesion molecule 1(ICAM-1), vascular cell adhesion molecule 1(VCAM-1), interleukin1β (IL-1β), and monocyte chemotactic protein-1 (MCP-1).
This inflammation acts as a beacon for more inflammatory chemicals to come to the aid of the NSAID-damaged tissue, wreaking havoc. Then here’s where the story gets complicated (just in case it wasn’t already).
When the cells recognize the mitochondrial damage and resulting oxidative stress, the cells produce a protective enzyme known as heme oxygenase-1 (aka HO-1), Sounds good, right?
It turns out that, if antioxidants like zinc containing compounds are present, the release of HO-1 may be blocked.
Great. It’s safer to take NSAIDs if you avoid healthy foods like fruits, vegetables and spices just so you don’t run the risk of massive inflammation in the lining of your stomach.
Personally, I’d opt for finding a good chiropractor instead. Sounds a whole lot less complicated. But then again, my opinion is pretty biased.
Irish children may have been given animal vaccine for whooping cough
Just remember…many have said that chiropractic care is unsafe and unproven by scientific methods. Go figure…
bmj.com Payne 323 (7305): 128a
Pondering Vioxx: Easier on Stomach, Harder on Heart?
Remember one thing in medicine–there is no miracle cure and anything that is advertised as the best thing since slice whole grain bread-you can bet there’s some major side effects. So, when it comes to joint pain relievers, you can take one of the new COX-2 inhibitors and maybe have less chance of death from bleeding ulcers, but you may die of a fatal MI instead. Some choice, huh? How about exercise, chiropractic care, glucosamine, chondroitin, MSM instead?
Joint Letter 7(4):37,44-46, 2001 Pharmaceutical giants Pharmacia and Merck recently petitioned the U.S. Food and Drug Administration (FDA) to relax gastrointestinal (GI) safety warnings on the labels of their respective COX-2 inhibitors. Last month, we reported on Pharmacia’s submission for celecoxib (Celebrex). This month, we examine Merck’s request for rofecoxib (Vioxx). As of press time, the FDA had not issued a final decision.Vioxx is easier on the stomach than generic naproxen. But it may be harder on the heart, according to recent briefings presented to the U.S. Food and Drug Administration’s Arthritis Advisory Committee.On February 8, representatives from Merck presented data to the advisory committee from Merck’s huge randomized VIGOR trial, which compared Vioxx to the nonsteroidal anti-inflammatory drug (NSAID) naproxen in 8076 patients with rheumatoid arthritis (RA). The advisory committee also heard from the FDA’s own in-house analysts, who offered interpretations of the VIGOR data that sometimes conflicted with Merck’s. After factoring in all the safety data on GI benefits and cardiovascular risks, the FDA’s medical officers concluded that the highly touted COX-2 inhibitor was no safer than naproxen. They recommended the Vioxx label be modified to include more cautions, rather than fewer. “To a patient it, doesn’t matter whether you end up in an intensive care unit with a big GI bleed or whether you end up in an intensive care unit with a myocardial infarction,” noted advisory committee member Steven Nissen, MD, reflecting this concern. “They are both pretty bad things to have happen.”
Here in Arizona, chiropractic care is not included in the Medicaid system (termed AZ Health Care Cost Containment System, or AHCCCS). As an active member of my state association, I have been in the front lines trying to get chiropractic care included in this system. Here is how it usually goes:
- Arizona Chiropractic Association: We would like you to add chiropractic care to AHCCCS member who need chiropractic care.
- Insurance companies: Chiropractic care is expensive and the state budget will have to absorb the costs.
- Legislator: We’d love to, but the insurance company says it will drive up costs to small business.
- Chambers of Commerce: We’d love this as well, but the insurance companies say small businesses will pay much more.
Sounds like a wrap, huh? After all, some insurance companies actually sell chiropractic as a rider, meaning your employer will pay extra to offer it (if this fits you, stick around–you’ll be burning up in anger in just a little bit…).
Now that the emotional side has had it’s say, let’s look at the common sense side of things.
First, it is very clear that chiropractors are conservative providers who do not use drugs or surgery. Here in AZ, we can order all the imaging and labs we’d like, but I think you’ll find that chiropractors, as a group, are very conservative with ordering advanced imaging like MRI or CT scans (you can read more about the exact statistics in a previous blog article by clicking here).
Next, it has been clear from several studies that those patients undergoing treatment from a chiropractor have lower medication, imaging, hospitalization and surgical costs (you can read about how much money insurance companies blog on expensive and ineffective procedures in a previous blog post here) . It just makes sense.
So, overall, chiropractic care is safer with better outcomes and costs less.
If chiropractic care saves money for your own care, how much less will it cost for the health plan? I’m glad you asked, because this particular article was designed to address just this question. Researchers looked at a group of 12,036 insured individuals with self reported neck or low back pain who did or did not use complementary and alternative medicine (CAM). Here is what they found:
- Average annual spending for CAM users (based on propensity matching) was $526 lower for spine-related costs.
- Annual costs for CAM users was $298 lower for total health costs.
- Cost differences were primarily due to lower hospital inpatient costs for CAM users.
While CAM does not related specifically to chiropractic care, this is the largest chunk within this group–large enough to be considered equivalent.
Back to my comment earlier about charging to add a rider for chiropractic care on a health plan. They are charging your employer MORE to provide chiropractic care, but the reality is, that by adding this service, they are likely saving money per life insured. How’s that for making money at both ends of a deal??
Musculoskeletal pain in Europe
As a chiropractic physician, I am not surprised that the authors were basically beating up on the medical profession in their handling of musculoskeletal complaints. I see many patients in my office who’s cases were not handled properly. I do not fault allopathic medicine for their lack of training and knowledge in musculoskeletal medicine–there is so much to learn it really is its own curriculum There just is not enough time in medical school to learn all of it. What I do have a problem with is physicians handling musculoskeletal complaints when they are not familiar or trained in them.
Ann Rheum Dis — Abstracts: Woolf et al. 63 (4): 342 -
Effectiveness of Multidisciplinary Intervention in Treatment of Migraine
Wow!! A multidisciplinary trial that would use the best of all worlds!! It was great to see chiropractic added in here… Oops…they didn’t add chiropractic. Am I missing something? Does the term “pink elephant in the room” ring any bells here? How is it that I get wonderful results with headaches in my office and yet never seen trials or comments including chiropractic care in mainstream medical journals? Can the rest of the medical profession truly be that ignorant of what chiropractic does??? I feel much better now…Synergy Abstract
Pattern of declining blood pressure across replicate population surveys of the WHO MONICA project, mid-1980s to mid-1990s, and the role of medication
Okay. Let me get this straight. Study after study (with millions being spent) to determine which blood pressure lowering medication is best (and it turns out to be the cheapest–the brand new “fancy dancy” BP meds are less effective and much more expensive) and, when all the cards are laid out on the table, BP meds have had very little effect on the overall drop in BP over a decade. So, insurance companies want to limit chiropractic care to 6.7 visits per year, but they’ll pay indefinitely for meds to lower BP when they’re not shown to be effective over the long run. Sign me up for the lifestyle changes.