Chiropractic vs. Primary Medical Care Who is Best & Safer for Primary Spine Care?
FEATURE
William J. Owens
Mark Studin
WHEN WE DISSECT THE BENEFITS OF THE “TYPE” OF PROVIDER THAT A SPINE PAIN PATIENT SEES FIRST, WE MUST CONSIDER CLINICAL OUTCOMES AND THE COST OF CARE AND SIDE-EFFECTS OF THAT PARTICULAR PROVIDER’S TREATMENT. THE MYTH THAT CHIROPRACTIC IS SOMEHOW UNSAFE OR CREATES A NEGATIVE CLINICAL ENVIRONMENT IS NOT ONLY ARCHAIC, BUT IN DIRECT CONTRAST TO THE CURRENT SCIENTIFIC EVIDENCE THAT ILLUMINATES THE TRUTH OF WHAT CHIROPRACTIC PATIENTS HAVE BEEN REPORTING SINCE 1895.
CONVERSELY, UNLIKE THOSE PROVIDERS SINCE 1895, THE LITERATURE IS ALSO QUITE CLEAR THAT THE DOCTOR OF CHIROPRACTIC IS REQUIRED TO BE A COMPETENT DIAGNOSTICIAN TO ENSURE GOOD CLINICAL OUTCOMES, LOWERED COSTS OF CARE AND LIMITED POTENTIAL SIDE EFFECTS FROM A CHIROPRACTIC SPINAL ADJUSTMENT.
It has been well documented in the literature that chiropractic is an effective modality for treating spinal and related issues, inclusive of headaches, scoliosis and other related maladies and the sources are so diverse that we will not add citations. However, the question of who should initially assess and manage the patient and what risks and cost factors are involved with that decision has been a barrier for utilization in both the healthcare establishment and the public at large who have to navigate through rhetoric and unsubstantiated opinions. In addition, there are the insurance carriers who often yield the ultimate decision by controlling the finances of the insured thr ough utilization coverage and political leverage.
Currently, chiropractic is attempting to drive utilization and access thr ough politics and that is a paradigm which has and continues to fail, as we see utilization numbers “flat” at best, spine care outcomes worsen across professions and addiction to pain medicines reach epidemic proportions. Wiegel et al. reported in 2014 that chiropractic utilization in the United States of adults over 18 years of age ranged between 5.6 and 8.6% and Medicare-aged utilization is approximately 4.1 and 5.4% and possibly higher if you include other spinal related issues. Barnes, Bloom, and Nah in (2008), reported that a 2002 finding reveals that chiropractic had a 7.5% utilization rate among Americans 18 years of age and over, further supporting that our current focus on expanding utilization through politics is “upside down” as we have stagnated for over a decade while drug addiction is on a steep incline.
Recent changes in the chiropractic political landscape include organizations that are dedicated to the inclusion of drags in chiropractic and political conglomerates who pool ideas yet
expend resources on duplicable services because we aren’t wise enough, as a profession, to exist under one national umbrella. Although the former divides us as a profession, the latter is perhaps an indictment of the times, helping us to realize we need to be united. Academia needs to drive politics and currently, the State University of New York at Buffalo, School of Medicine Department of Family Medicine has chosen chiropractic as a possible means to help stem the opioid epidemic. Adding the right to prescribe drugs to our profession is a nonissue as it could possibly lead us to increase the pain medication problem in our society, not help reduce it. Medicine is poised to embrace chiropractic at the academic level as a first-line portal for spinalrelated diagnosis by offering something unique they cannot do because we view, assess and treat the patient differently than any other profession.
There has been much “chatter” on the Internet and in some print media about the “dangers of chiropractic” such as stroke and herniated discs. In much of these politically charged negative arguments, they aie centered on single case studies or anecdotal evidence. One only needs to Google “chiropractic and stroke” for anti-chiropractic rhetoric based purely on individual case reporting and not true science. Please understand that this does not minimize those individual cases or the people who have suffered from a stroke in close proximity to a chiropractic adjustment or manipulation by a non-chiropractor. However, one must look at the global picture for a true analysis of the risk-reward ratio from a chiropractic adjustment with accurate and scientific comparison to all healthcare risks associated with spinal disability.
** There was no association between manipulation (chiropractic adjustments) and ischemic stroke or TIA's (transient ischemic attacks). J Ï
In 2008, Cassidy, Boyle, Côté, He, Hogg-Johnson, Silver, and Bondy studied the occurrence of this problem in the province of Ontario over a nine year period with a database representing almost 110 million person-years (12.2 million people, studied over 9 years equals 110 million person-years). The purpose of this study was to investigate if an association between chiropractic care and vertebral basilar artery stroke exceeded the association between medical primary care providers and vertebral basilar
artery stroke. The premise was that if there was a greater association between chiropractic care and this stroke then one could logically say there was a cause and effect relationship between chiropractic care and this problem. There was no greater likelihood of a patient experiencing a stroke following a visit to his/her chiropractor than there was after a visit to his/her primary care physician. The results were conclusive; there was no association between manipulation (chiropractic adjustments) and ischemic stroke or TIA's (transient ischemic attacks).
The research did conclude that overall, 4% of stroke victims had visited a chiropractor within 30 days of their strokes, while 53% of the stroke cases had visited their medical primary care providers within the same time frame. The authors offer the perspective that because neck pain is associated with some stroke, patients visit their doctors prior to the development of a fullblown stroke scenario. Cassidy et aí. (2008) noted, "Because the association between chiropractic visits and [vertebral basilar artery] stroke is not greater than the association between PCP [medical primary care providers] visits and [vertebral basilar] stroke, there is no excess risk of [vertebral basilar] stroke from chiropractic care" (p. S180).
In 2010, Murphy considered the argument that chiropractic manipulation could cause stroke and concluded, "...if this is a possibility, it would have to be considered so raie that a casecontrol and case crossover study covering over 109,000,000 person-years failed to detect it." (http://www.chiroandosteo.com/ content/18/1/22). He also reports that "... in 20% of cases of [vertebral artery dissection and stroke] the individual does not have neck pain or headache and in a very small percentage of vertebral artery dissections can occur in a person who has no symptoms of any kind. Thus, in cases in which an asymptomatic individual experiences [vertebral artery dissection and stroke] after [chiropractic manipulation] it is not clear whether manipulation was a cause or contributing factor to the dissection or whether the patient had an asymptomatic arterial dissection prior to the chiropractic visit" (Murphy, 2010, http://www.chiroandosteo.com/ content/18/1/22). He concluded his report with the following, "...current evidence indicates that [vertebral artery dissection and stroke] is not a 'complication to [chiropractic manipulation]' per se. That is, the weight of the evidence suggests that [chiropractic manipulation] is not a cause of [vertebral artery dissection and stroke]..." (Murphy,
2010, http://www.chiroandosteo. com/content/18/1/22).
In December, 2014, a paper by Whedon, Mackenzie, Phillips, and Lurie, titled, “Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Paît B Beneficiaries Aged 66-99” was accepted for publication in one of the premier spine journals in science. The authors related the objective of the paper, “In older adults with a neuromusculoskeletal complaint, to evaluate risk of injury to the head, neck or trunk following an office visit for chiropractic spinal manipulation, as compared to office visit for evaluation by primary care physician” (Whedon et aí., 2014, p. 2). The main focus of the paper was to see if there is a great risk of a patient seeing a primary care physician for a spine complaint versus a chiropractor and who carries any increased risk of harming the patient. The authors went on to state, “This is the first nationwide population-based study in the US on risk of injury following SM (spinal manipulation or spinal adjusting), and the first study of the risks of chiropractic to focus specifically on older adults” (Whedon et aí., 2014, p. 6).
The authors reported, “No mechanism by which SM (spinal manipulation) induces injury into normal healthy tissues has been identified, but the likelihood of injury due to manipulation may be elevated in pathologically weakened tissues” (Whedon et aí., 2014, p. 5). The point is that the clinician who is evaluating the spine patient has to be the most qualified to diagnose and manage that patient. It is the assessment of the spine that is critical in all cases and this paper adds an additional layer of validation that chiropractic care is best utilized as the first line of treatment in spine care. The authors wrote, “The risk of injury in patients with intervertebral disc disorder with myelopathy was actually reduced, suggesting that this condition is not a risk factor for injury due to SM (spinal manipulation)” (Whedon et aí., 2014, p. 12). “The primary outcome measure was diagnosis of injury
to head, neck or trunk within 7 days of office visit, diagnosed in an emergency department or as the primary diagnosis associated with hospital admission” (Whedon et aí., 2014, p. 8).
The co-morbidities which raised the specter of potential risk, which the clinically excellent chiropractor must be expert in diagnosing PRIOR to manipulating or adjusting the spine, are coagulation defects, inflammatory spondylopathy, osteoporosis, aortic aneurysm and dissection and certain disc injuries. Each of these pathologies ai e within the scope of every doctor of chiropractic in the United States to diagnose and it is the responsibility of each doctor to ensure through graduate level training (post-doctoral continuing education) that they are proficient in ensuring an accurate diagnosis prior to initiating a treatment plan. Remember, our expertise is in the assessment of the spine patient as well as the treatment. Having the latter without the former reduces us from “doctor” to “technician”
or “therapist”.
No mechanism by which SM (spinal manipulation) induces injury into normal healthy tissues has been identified”
The results of Whedon et aí. (2014) study showed, “Among Medicare beneficiaries aged 66-99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within seven days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician” (Whedon et aí., 2014, p. 13). “It is unlikely that chiropractic care is a significant cause of injury in older adults. The lower risk in the chiropractic cohort may suggest to some that chiropractic care is protective against injury in older adults.” (Whedon et aí., 2014, p. 11) Looking at how to best care for patients with spinal complaints, a properly positioned and trained chiropractor is the best entry point for spinal healthcare in the United States.
For those simply shouting the “sky is falling” based upon individual negative case studies, it should be noted that Whedon et aí. (2014) based their study on 6,669,603 subjects after the unqualified subjects had been removed from the study. Those subjects accounted for 24,068,808 office visits with medical primary care office treating 29% more patients than chiropractic. Again, they concluded, “No mechanism by which SM (spinal manipulation) induces injury into normal healthy tissues has been identified." (Whedon et aí., 2014, p. 5)
For the population of the medical profession, who for years have been “holding a hard line,” that the evidence doesn’t exist to consider a chiropractic referral, let alone the first option for biomechanical spine conditions, it is no longer possible to justify that position, as the evidence is clear, supported by medical academia and is becoming the trend. For the chiropractor today, the necessity also exists to become a better clinician and rise to the level required to recognize the most complex and ominous spinal conditions. It requires continued graduate level training in intervertebral disc pathology, spinal cord and nerve root co-morbidities with an attention to patient history, medications and any previous lab reports to ascertain any coagulation issues.
The doctor of chiropractic that understands spinal MRI interpretation, spinal biomechanical engineering and the published chiropractic evidence will lead the profession to significantly higher utilizations based upon necessity. Politics and rhetoric can no longer rule the day as research in paving the way and doors aie opening for those that are meeting that need through clinical excellence. These positive changes have nothing to do with your philosophy or practice paradigm as we need every type of practitioner to care for a nation. If you are willing to be the best of the best clinically and academically the opportunities aie limitless and... it is coming with or without you.
Reference:
1. Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Reports, 12, 1-23.
2. Weigel P., Hockenberry J., Wolinsky R, (2014) Chiropractic Use in the Medicare Population: Prevalence, Patterns and Associations with 1-Year Changes in Health and Satisfaction With Care, Spine (37) 8, pgs. 542-551
3. Cassidy, J. D., Boyle, E., Côté, R, He, Y, Hogg-Johnson, S., Silver, F. L., & Bondy, S. J. (2008). Risk of vertebrobasilar stroke and chiropractic care: Residís of a population-based casecontrol and case-crossover study. Spine, 33(45), S176-S183.
4. Murphy, D.R. (2010). Current understanding of the relationship between cervical manipulation and stroke: What does it mean for the chiropractic profession? Chiropractic & Osteopathy, 18(22), http ://www. chiroandosteo. com/content/18/1/22
5. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2014). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 6669. Spine, [Epub ahead of print] 1-33.
Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic, University Of Bridgeport College Of Chiropractic and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the legal community (www.DoctorsPIProgram.com). He can be reached at DrMark@, AcademyofChiropractic.com or at 631-786-4253.
Dr. Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community. He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences as well as the University of Bridgeport, College of Chiropractic. He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at [email protected] or www.mdreferralprogram.com or 716-228-3847
