Lies that life is black and white, spoke from my skull I dreamed. - Bob Dylan, My Back Pages
During the past several years, chiropractic has painfully endured a protracted series of gargantuan debates in which the extreme protagonists of allegedly irreconcilable positions have locked horns at a variety of venues, usually research symposia. College presidents, professors, celebrated private practitioners and attorneys have been asked to line up for or against issues like vaccination; the chiropractor as primary care physician; wellness vs. MSK chirodigms (thanks, DH); and so on.
Having been there for much of this, and frankly, having found this series of spectacles quite interesting and always entertaining, I must admit that it has all had little impact on my practice of chiropractic, even if it has generated some interesting classroom discussion at the chiropractic college where I profess.
On the proverbial Monday morning following the conference, or whenever I make my next guest appearance at my very part-time office, little has changed, except that I am more comfortable with the way I already was. I don't know if this is good or bad, but it certainly is a fact. The same patients come in with about the same complaints, and I treat them all about the same way. No matter what the profession builders have declared about this or that, I am still "Dr. Coop," and they are still George, Windy and Suzanne.
Yes, I treat them. No, I don't find them all subluxated. Yes, my practice is mostly limited to musculoskeletal complaints. No, I don't often find nerve interference has much to do with their complaints. Yeah, well, I function more in crisis intervention mode than within a wellness/maintenance care setting. With your permission, I would like to offer up a few explanatory comments.
Diagnosis, Subluxation and Nerve Interference
Over 90% of my patients come in complaining of pain in their back, neck, head or extremities. This is not surprising, since I do not claim to treat systemic diseases when speaking with prospective or existing patients, and do not usually receive referrals on that basis. If a patient presenting with pain has a secondary complaint involving a visceral disorder, I explain that this other complaint may improve under chiropractic care, but I make no claim to directly address it.
On the other hand, as a fairly good diagnostician as as someone quite versed in pathology, I often find myself guiding patients through the medical jungle. I help them interpret what they have been told, offering them counsel or at least a second opinion. I frequently steer them toward the referrals they need, perhaps winding up the hub in the case.
I have no problem with saying I diagnose MSK disorders, and make no distinction between a "chiropractic" and a "medical" examination. I derive listings from the results of standard ortho-neuro tests, and see no basis for preferring the word "analysis" to "diagnosis" to describe what I do. In my office, leg checks and motion palpation are orthopedic tests, while Kemp's testing helps generate listings. The walls of my office are covered with charts of trigger points, muscle and skeletal anatomy, dermatomes and peripheral nerve maps, and "drawings" created by my four and six-year old boys.
Even though I do not usually claim to treat visceral disorders, I often try to diagnose them. I am not reluctant to spread a color atlas of dermatology across the back of a prone patient to identify an ominous looking pigmented lesion on his back, nor do I hesitate to get out Barbara Bate's physical exam book on the spot to refresh my recollection of the appearance of atrophic skin. As everyone knows, mom-and-pop chiropractors (especially if they are part-time, like me) just don't see enough of these darn cases to always make the call, at least not right off the bat.
Sometimes I figure the best explanation of a patient's complaint is "subluxation," but not usually. I most certainly do not use that term as a default option, something of an umbrella term for everything I treat. That's the Subluxation with a capital S. I lose no sleep trying to decide what word or phrase best describes the chiropractic "bad thing" in the spine, since I am already aware of a perfectly good lexicon for that sort of thing: trigger points; muscle hypertonus; joint fixation; sprain; strain; synovitis; facet jamming; disc herniation; thoracic outlet syndrome; anterior weight bearing; lateral curvature; pronation; PI ilium postural distortion syndrome; etc. - and sometimes subluxation, in the sense of segmental misalignment. The chiropractic effort to stuff the huge wealth of disorders from which their patients can suffer into one can of worms really has been something of a nightmare, an enterprise I rejected early during my chiropractic education.
Likewise for "nerve interference." If a patient provides evidence of a neurological disorder such as asymmetric or impaired deep tendon reflexes, muscle weakness or wasting, skin sensory abnormalities, a positive Romberg test, abnormal gait, a tremor, poor two-point discrimination, etc., so be it. If they don't, I do not feel the need to infer asymptomatic or subclinical neuropathy from some other finding, such as functional leg length inequality, uneven weight distribution, therapy localization, thermal asymmetry-you name it.
Pain-spasm-pain cycles, facilitation, complicated reflexes and many other subtle neurologically-mediated mechanisms can figure in the patient's overall symptom picture, but more research in neuroscience is needed for me to simply assume "nerve interference" in the absence of evidence. Just give me a PI ilium, T2 hyperkyphosis, a stiff shoulder or headache, and I know just what to do without the assumption of sub-clinical neuropathy. Give me paresthesia, hyporeflexia or impaired heel walking, and I also know just what to do!
Treatment, Adjustment and Ancillary Procedures
The word "treatment" does not bother me in the slightest. I have this old-fashioned view, which decades of syntactical juggling cannot dispel, that patients have complaints and doctors treat them. I do not get tongue-tied struggling for ways to avoid using the T word by inventing forced constructions like "take care of practice participants" or "correct the vertebral subluxation complex."
What of the Adjustment, capital A? I have grown comfortable with the word out of habit, even though I have had new patients almost die of laughter when I explained to them that I intended to "adjust" their vertebra. This experience always reminds me just how odd an expression it is, as if we could adjust vertebra like the valves of an automobile engine! Although I often use the word, it is not in the sense of the well-worn phrase "The adjustment corrects the subluxation to eliminate nerve interference." It's my way of saying that I provide uniquely chiropractic care by a variety of adjustive methods that the chiropractic profession has developed that have withstood the test of time: HVLA thrusting, blocking, drop table moves, and so on.
What makes this armamentarium uniquely chiropractic is not the practitioner's goal (to remove nerve interference), nor the identity of his avowed enemy (subluxation), but the chiropractor's expertise in providing hands-on care. We are simply the best. We train harder, have the most experience, and fully deserve the product distinction that chiropractic enjoys in the public mind. So long as we remain the best adjusters, chiropractic will thrive and survive any attempted expropriation by non-chiropractors who would provide "chiropractic" care.
I do not use any physical therapy modalities except for a Thumper massage machine that I find helpful at times, and ice or heat very occasionally. Most office visits include a significant amount of soft tissue work, including lots of stretching, ischemic compression, etc. Although I have a Leander table, I have done no drop table moves since the mechanism broke over a year ago. Neither myself or either of the other two chiropractors with whom I share office space (Hickey and Vicky) appear to care enough about what has malfunctioned to even look under the table. I confess to having preferred unassisted HVLA adjusting (without much of an evidentiary basis) ever since my chiropractic college days, although I use padded wedges once in a while and a hand-held percussive instrument once in a blue moon.
I talk to my patients about lifestyle modification, but not very much. Most of them get a fairly standard account of my views on what defines a good diet, and a few get my comments on the general role supplements may play in modern living. Once in a while, I make very pointed recommendations to manage specific health conditions (e.g., multiple sclerosis, hypercholesterolemia, etc.).
I try not to get involved in directly assisting my patients with their psychosocial problems: busted marriages, rotten jobs, evil roommates, sick pets and existential despair. We keep up a constant patter and chatter regarding this and that (you know, the usual stuff like hominid paleoanthropology, the collapse of the French government in 1968, subatomic particles and Jello Biafra) while my hands are gimping around in this or that muscle, pressing into some soft tissue that I located while on autopilot. Patients invariably leave feeling better than when they came in, partially due to the somatic intervention and partly due to all the great conversation. Those who need counseling are advised to seek counseling from someone trained in it. I am very disturbed by chiropractic techniques that explicitly and directly treat the psyche, and look forward to the day when chiropractic psychotherapy will go away.
Crisis Intervention, Preventive Care and Practice Management
As a full-time teacher, I don't have much time to practice. I pretty much stick to crisis intervention and remain rather indifferent to the wellness/maintenance care model. I try hard to not confound what I believe to be the appropriate level of clinical care and my financial self-interest. If I tell a patient, "I need you to come in twice this week," it's not because I need them to come in so I can pay my mortgage, if you know what I mean.
No doubt I err on the side of not seeing my patients frequently enough. Some of them even chastise me for not recalling them for periodic checkups. They are right, but at this time in my life, I am struggling with the concept of checking my office answering machine daily, perhaps even returning most of the phone calls from current and prospective patients. I am not aware of any good evidence on what defines appropriate care of asymptomatic patients, although I do have some opinions on the indications for chiropractic care in such situations. Indeed, while we await outcome studies on the value of preventive care, there are basic science reasons to think there's something in it.
Still, I wish I knew what patient characteristics predicted whether some level of preventive care would delay rather than hasten musculoskeletal degeneration. (How many times can you thrust a joint into its paraphysiological space before you create a problem?) Anyway, my persistent patients still find ways to get a visit with me. Many of them schedule themselves for maintenance care, sympathetic to my hectic and even goofy-hectic time problems.
I accept virtually no insurance these days because the mom and pop part-time chiropractor can not easily become credentialed in managed care plans, nor can they figure out in their spare time how to get paid in this very challenging market. As a result, I have a cash practice. I will not herein discuss my fee structure, but suffice it to say that I sure wish I could have practiced in those days when chiropractors accepted chickens in lieu of cash, or even kept a box on the counter into which patients just tossed money on the way out. How romantic.
My Back Pages
I don't think the era of chiropractic great debates has clarified very much, but I have nothing but respect for the debaters themselves (especially Craig), who have shown great courage and often surgical precision in publicly assuming the extreme positions they are cast to take, sometimes more extremely than they would like. I also understand that our national and state organizations have to argue positions with governments, and chiropractic credentialers have to make decisions about what chiropractors should be doing. All debates notwithstanding, these decisions will be based on evidence, not opinion.
In the meantime, you, the readers of Dynamic Chiropractic, may decide whether I am to be condemned for "treating"; ostracized for "diagnosing"; and pilloried for eschewing the metaphysical usage of terms like Subluxation and Adjustment. You may decide whether I function as a primary care provider, medipractor, wannabe or straight chiropractor. All I know is, I am very happy with the way I practice, and I get good results, thank you very much. At the same time, I understand that my example is not for everyone, or even anyone.
When I was in second grade, the fifth and sixth grade girls used to wear huge buttons to school saying either "I love Elvis" or "I hate Elvis," but never anything in-between, like "Elvis is just all right with me." At about the time I entered high school, society forced me to choose between the Beatles and the Rolling Stones. The shocking first-time experience of hearing the Stones' "Get Off My Cloud" on a six transistor radio while walking down the Grand Concourse in the Bronx to hear some a cappella singing (ya know, street music widdout music) resolved that! But now, I think I'm old enough to just kick back and simultaneously entertain several irreconcilable positions: the Beatles and the Rolling Stones, the Kabalas and Dean Martin (thanks, Elaine). Bob Dylan got it right when he equated "lies that life is black and white" with immaturity. Hegel also seems to have been on the right track.
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
