Dr. Fraser recapitulated for us Cyriax's very discogenic and quite controversial concept of low back pain, explaining even more controversially that the pain patterns that result are usually dermatomal, which allows isolation of the segmental lesion to a very narrow region of the spine. One wonders what Cyriax would say to the proponents of nondermatomal pain: trigger points, fibromyalgia, facilitation, and the rest. Chances are he would reject such entities, perhaps as emphatically as did another eminent doctor at the previous ABS meeting: "Dr. Farfan, is myofascial pain syndrome a real clinical entity?" Answer: "No."
Dr. Fraser demonstrated several manipulative procedures directed at undoing the motion restrictions that result from "loose bodies in the joint." His treatments for the elbow, knee, and hip all involve axial traction with the joint flexed, combined with repetitive internal and external rotations, followed by a return to the extended position while traction is maintained. I couldn't help thinking that the same patient presumed by Dr. Fraser to have a loose body in the joint that was preventing full extension, would have found by one of my sports chiropractic buddies to have muscular dysfunction. The patient would then be treated with postisometric stretching or something like that, with probably the same excellent outcome as that achieved by Dr. Fraser.
The next workshop I attended was conducted by Dr. Phil Lander, and authority in the field of provocative discography and related procedures: myelography, facet injections, chemonucleolysis, prolotherapy, and epidural blocks. Provocative discography involves injecting a radiopaque dye into the nucleus pulposus of intervertebral discs suspected to be causing low back pain, especially as a pre-surgical procedure designed to give the surgeon a precise anatomical diagnosis. The dye demonstrates a variety of appearances, ranging from the "cotton ball" appearance of a normal nucleus, to the very diffuse pattern of internal disk disruption, and finally to the escaping dye appearance that confirms HNP.
Apart from the information provided by the radiological image, the injection of the dye should reproduce the patient's pain, and should do so exactly. Although a disk may be so injured that injecting dye cannot increase its internal pressure enough to cause pain, the ability of the disk to take in more than 1-2 cc of fluid already suggests severe disruption. At several points in his talk Dr. Lander had to take on the thorny issue that imaging studies, including low-tech x-ray and high-tech MRI, often fail to distinguish pain patients from normals, suggesting that the imaged lesion may be a red herring more than anything else. He suggested that the image only becomes significant when associated with other clinical findings. Dr. Lander cited an article in JBJS, 1990, by Walsh, Weinstein, and Aprill in support of his central points.
Tell me if you have ever heard this one at a chiropractic seminar: "Doctors: are you tired of chasing symptoms around the body, never really treating the true cause of your patient's dis-ease?" Well, thanks to my patient Alan, the next time I get asked this humiliating question, I'm going to jump up and down and confess, "Yes, yes, I'm that doctor, the one who chases subluxations around the spine, never really treating the true cause of dis-ease! My patient Alan suffers from fibromyalgia syndrome, the subject of a very special evening session conducted by Dr. Thomas Namey, a rheumatologist from Tennessee."
I considered telling him that I had discovered a new law of physics, according to which the amount of pain suffered by the fibromyalgia patient is a constant: it can neither be created nor destroyed, only changed from one form to another. "Yes, my neck is feeling better, but now there's something wrong with my ankle, you know, just like that elbow thing I got right after you put my rib back in place..." It would be well worth attending an ABS meeting just to hear Dr. Namey speak on the fibromyalgia syndrome. After distinguishing it clearly from myofascial pain syndrome, he described its overlap with clinical depression, deep-sleep fragmentation, primary dysmenorrhea, and chronic fatigue syndrome. Dr. Namey discussed both pharmacological treatments directed against the neurophysiological disturbance at the root, and other nonchemical treatment alternatives, such as biofeedback, stress-reduction, and aerobic exercise. All chiropractic doctors should be very knowledgeable about this disorder. Two articles have been published in our own Chiropractic Technique journal on this subject.
Every chiropractor has treated whiplash cases where the patient exhibits a variety of apparent neurological symptoms involving cranial structures, a short list that would include: vertigo, dizziness, diplopia, clouding of the sensorium, stuffiness in the ears, and headache. Dr. Jacques Duranceau, who headed up a task force assigned to evaluate the pathoanatomic basis for such whiplash-related cranial results, told us that at the present time he cannot yet identify the structural basis for the cervicocranial syndrome. He did review several of the suggested models, most that are familiar to chiropractors, involving putative lesions of the cervical ganglia, the upper cervical cord, the suboccipital muscles and nerves, etc.
In the end, Dr. Duranceau's group concluded that both the cranial and caudad signs and symptoms of the whiplash patient accrue from post-traumatic short-term damage to neurological tissues, and that treatment should address the various stages of the inflammatory process and the reparative responses. (This reminds us of similar points made for many years by chiropractor Richard Stonebrink.) During the initial 45 days following an accident, the patient's complaints are to be understood on the basis of this "biomedical" model, but symptom persistence after 45 days would suggest the need for a comprehensive "psychosocial" approach. It was not at all clear to me why, given the slow rate at which neurological injuries tend to heal, symptom persistence was interpreted so differently after 45 days.
Manga: Turf Wars and the Case for Chiropractic
When Dr. Pran Manga took the floor, it became immediately apparent that this was not going to be just another presentation. After all, the Manga Report, were its conclusions to be even partially implemented, would have a drastic impact on the practice, and probably the income, of all the MDs in the room. Dr. Manga straightaway informed us that his report had earned him the immediate love of chiropractors, but something closer to the hatred of physical therapists and the dislike of MDs. He said that he and his group strongly desire to be made aware of information and studies that they had not considered, but unfortunately most of the criticism has come in the form of irresponsible and ill-considered attacks. There is no need for me to summarize what Dr. Manga said of the clinical effectiveness, cost-effectiveness, and safety of the manipulative treatment, especially chiropractic, of the low back.
Dr. Manga stood his ground and even reversed the questions that were posed to him during the panel discussion that followed. No doubt the questions raised by his report will continue to be very controversial over the years. Witness for example the remark attributed to Dr. Paul Shekelle, who authored the RAND reports, in the very negative article about chiropractic in Consumer Reports: "We all looked at the same information as did Dr. Manga, but failed to come to the same conclusions."
Later that same day, I caught the last half of a workshop conducted by some of the Canadian chiropractors. Dr. Manga was once again present. In the context of a very unpleasant exchange between Dr. Manga and a Canadian pediatrician/orthopractic advocate (who was featured on the "20/20" broadcast and also figured prominently in the recent Consumer Reports article, Dr. Manga clarified his position a little further. He spoke of the attempt by medicine to maintain its market dominance, and said that as an economist he is against such attempted monopolization of an industry, which always comes at the consumers' expense. From an economic point of view, the fervor of the current orchestrated attack on chiropractic (and derivatively on Dr. Manga) is purely a question of "turf wars." This was particularly thought-provoking for me, since I had quite accidentally earned a master's degree in economics in what surely must have been a previous lifetime.
The "orthopractors" were there, manning a table in the exhibiting area. This was the first I had seen or heard of them, but certainly not my first exposure to their professed ideas, many of which had always seemed quite attractive to me. An agreeable enough orthopractor with whom I spoke extensively described an avalanche of interest (mostly among American chiropractors) in the orthopractic movement, which he said is restricting membership to "no more than 1,000 new DCs per year." He told me that things are really steamrolling and attracting interest on the part of politicians, insurance companies, and governments everywhere. Apart from the ideas nominally expressed by the orthopractors, this group must be understood sociologically for what it is: a pure dupe organization, embodying the tactical response of a few medical monopolists and hateful physical therapists who would contain chiropractic by co-opting some of its most frustrated, ethical, and intelligent practitioners. I wish I had the space to go into this insidious development further.
Next ABS Meeting
The next meeting of the American Back Society will take place December 1994 in Beverly Hills, California. It is my understanding that very affordable hotel accommodations have been arranged. For further information, please contact the American Back Society at 2647 E. 14th St., Suite 401, Oakland CA 94601. Tele: (510) 536-9929; fax: (510) 536-1812.
Robert Cooperstein, DC
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