|J. Michael Menke,MA,DC, is involved with the integrative medicine programs at the National University of Health Sciences in Chicago (postgraduate faculty), and the University of Arizona School of Medicine (associate fellowship).
On April 23, 2002, I presented a half-day workshop on chiropractic at Dr. Andrew Weil's "Integrative Medicine and Pediatric Fellows" program at the University of Arizona in Tucson. Attending were about eight MDs; one medical student; one osteopathic student; and one DO. The program began with my two-hour Power Point presentation on history, models, techniques and research of chiropractic care. "Hierarchies of evidence" were reviewed, and the current status of chiropractic research findings presented. Also covered was the degree of chiropractic utilization: 30 percent of all alternative medicine users are chiropractic patients; one in three back pain patients sees a chiropractor for their condition; and so on.
For over 10 years, I have presented to MDs for CE credit at hospitals, public programs at hospitals, and other medical groups. The program is always custom-tailored to the needs and interests of the audience. For the program in integrative medicine, less lecture and more observational and touch experience would be the approach. In addition, I presented the ancient spiritual metaphors and yogic roots of the "perfect spine." My objective was for participants to appreciate the skills required for chiropractic assessment and management. A discussion and question period followed:
"What about the New England Journal of Medicine study1 finding that chiropractic was no more effective than a one-dollar exercise booklet?"
As a researcher and statistician, I commented on flaws of the study: for one, taking the square root of back pain to tame variance is not a good sign). And, yes, everyone with uncomplicated back pain seems equally better at six weeks, no matter the treatment. But meta-analyses of chiropractic manipulation trials indicate improvement at three weeks by 34 percent,2 and this was hinted at by a nonsignificant trend at three weeks in the NEJM study.
- "What is the story on the use of chiropractors as primary care providers at Alternative Medicine Inc., in Illinois?"
- "Are chiropractors really trained to provide primary care, given that chiropractors do not have a hospital-based training program? Yes, a cold may just be a cold 99 times out of 100, but one time in 100 it is leukemia - and only clinical experience can elicit suspicions of a more serious condition."
- "Do you diagnose skin cancers?"
- "In a room of 500 people, how many have subluxations?"
- "Why the antivaccination stance?"
After the questions and discussion, the balance of the four hours was spent in demonstrating the standard examination for new patients with upper-extremity/spinal complaints and lower-extremity/spinal complaints. After covering standard orthopedic/neurological evaluation of patients; discussing standard patient history; and interview about chief complaints, we practiced observing posture and discussed its relationship to pain and dysfunction.
Then we moved to the chiropractic examination. Leg-length tests, as an indicator of pelvic obliquity, were demonstrated. After observing active range of motion, we paired up for static and dynamic palpation of joints and muscles. Before addressing the subtler-nature chiropractic palpation, the general response was, "Yeah, that feels like a neck, alright." Later, chiropractic palpation revealed points of tenderness and pain; fixation; swelling; referred pain patterns; deeper paraspinal muscles and fascial planes; and so on. After a short time, they were performing impromptu "reliability" tests. They felt fixations and tender points, and traded off to confirm each other's findings. They were quite enthusiastic in trying to understand and feel joint fixations, pain and dysfunctions in each other, and in corroborating each other's findings. It seemed as though they were gaining an appreciation for the world of chiropractic distinctions of chiropractic assessment.
With trust and comfort established, some of them began recalling stories of their own problems helped by chiropractors, and chiropractic success stories among their patients, spouses, and in-laws. We discussed approaches to back pain in the primary care setting, with some simple orthopedic and postural tests to sort serious pathologies with long healing times from simpler mechanical problems with the better prognoses.
My perspective has always been this: Chiropractors should get first "crack" at back pain and perhaps most, if not all, musculoskeletal disorders. As most of them were primary care physicians, I asked them what they did with back pain patients. Standard medical conservative care is tried first (medication + rest + home exercise), followed by referral to physical therapy. My next question was always: "How is that working for you?" The answer was usually less than enthusiastic.
When teaching other health professions about chiropractic, I present the chiropractor as the expert in the "spinal approach to health," and the best first approach to spinal health. With an emphasis on skills in differential diagnosis, we state that we do work from a common operating premise and speak the same language. I encouraged them to identify chiropractors they could work with in their communities, and what results to expect.
In response, the participants thanked me for presenting the chiropractic information in a way that included medicine, and did not demean allopathy; did not state that the chiropractic approach was the only one; and that chiropractic was not a substitute for medical care (was not an "alternative" medicine).
With back pain in the top five reasons for primary care visits, and an imminent physician shortage, primary care physicians need our help, not as cheap labor, but as a source of expertise to help with this $100 million epidemic3 called back pain. Back pain should be the domain of the chiropractor (but not the only one). Avoiding contact with the enemy - MDs - is an unethical position, when the public's health is best served through integrated service delivery.
- Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998; 339(15):1021-9.
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med 1992; 117:590-598.
- Grossman RJ. Back with a vengeance. HR Magazine, August 2001; 46(8): 36-46.
J. Michael Menke,MA,DC
Palo Alto, California
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