For Medical Professionals
Welcome to Centre Chiropractic
First, I’d like to thank you for your time and interest. I hope to present concise and accurate information to address any questions you may have about chiropractic, although I likely cannot address them all here. More importantly, I will present basic information about what treatment algorithms I follow as a practitioner.
There is a wealth of information on the science of chiropractic, our methodologies, philosophy and treatment and diagnostic protocols presented in layman’s terms on some of the other pages on this website. What I present on this page is information about the impact of chiropractic history on interdisciplinary relations, research on chiropractic and current theories on the subluxation, and our treatment logarithms. I also outline my focus and interests in practice and appropriate conditions for referral to my office.
Why you may think what you may think about chiropractic
Most people have an opinion on chiropractic, whether it is based on personal experience or that of a friend or relative helped by adjustments, or whether it is one formed by miseducation, the scandal-driven media, or a lack of accurate information.
There are some very simple questions we can pose which facilitate willingness to reevaluate one’s opinion about chiropractic: If chiropractic is nothing but placebo, why do medicare and third-party payors cover chiropractic adjustments? If chiropractors are only concerned with taking unsuspecting peoples’ money, why were chiropractors willing to serve 30,000 jail terms over several decades in every state in this nation for adjusting patients? If chiropractic is so dangerous, why is the average chiropractic malpractice insurance $4,000 a year, versus the medical average of $90,000? Why is chiropractic offered to our men and women in uniform on military bases around the globe and in VA hospitals? Why are so many members of the community so dedicated to chiropractic? Why do doctors of chiropractic have hospital privileges across the country, and why are DCs such mainstream components of integrated health care departments? Why are we primary care practitioners in most states? Why are DCs doctors at all?
The answer is that despite a host of challenges to the profession, including historically difficult relations with allopaths, an antagonistic media, dishonest and unscrupulous members of the chiropractic profession, and a different scope of practice in almost every state in the U.S. - despite all these hurdles, chiropractic is a substantial evidence-based health care protocol.
Why, when, how, or for what chiropractic works is still inconclusive, despite a host of studies and journals and a century of anecdotal success with almost every condition under the sun. If it didn’t work, then physical therapists would not be lobbying for the right to adjust their patients, medical doctors wouldn’t be taking weekend seminars in mobilization and adjusting protocols, and osteopaths would not have been absorbed by the AMA.
So why do most people think what they may think about chiropractic? We are all guided by biases based in our personal experiences and information we evaluate as valid, often times because it resonates with those pre-conceived ideas. Open-mindedness is, for better or worse, a rare quality in most of us. If I am a skeptic about the impact of prayer on healing, for instance, I am going to tend to disregard the 20 double-blind studies that validate the power of prayer in healing; if I am a believer, I will tend to disregard the 20 that invalidate prayer’s impact on recuperation.
In addition to questions about bias and open-mindedness, in any given situation a person only has the information available to them to make evaluations; if you’re like most other people and myself, you find if challenging to make time to do your own investigation in search of the most accurate and neutral sources of information - especially concerning things that don’t bear directly on your life or specialty.
In a Supreme Court case, the AMA finally admitted to being engaged in a decades-long, carefully designed campaign to discredit chiropractors, to deny our licensure, and to orchestrate a public opinion campaign against us, which was named “The Committee on Quackery”. One outcome of this was that generations of fine allopaths in this country were misled, as a part of their education, that chiropractors were snake oil salesmen concerned only with financial gain. So many medical doctors think what they think, at least in part, because they were intentionally mis-educated as an extension of the political agenda of a few people at the AMA.
Unless you are a chiropractic patient yourself (which many allopaths are) you probably have little experience with chiropractic and so have little evidence to relate to except what you were taught during your coursework or residency. I challenge you, as a rational physician committed to your patients’ best care, to ask yourself how much time you have actually taken to read current research on chiropractic interventions… even an abstract? It is sad to say that today most medical students are still not taught what chiropractors do, what our education or credentials are, or when to refer to us.
One of the most exciting parts of my internship at USC was seeing medical interns finally required to do a rotation in chiropractic. One of the most gratifying parts of my internship was having medical interns and residents, and even faculty MDs, refer patients to me as a chiropractic intern. In 1987 a federal judge found the AMA guilty of antitrust practices against chiropractic.
There were numerous positive outcomes of that action. First, the direct challenge stopped, although years of strategic media critiques had lasting effects, effects that remain today. Second, for the first time the AMA was forced to acknowledge its behavior in print and to apologize for the action, which made a contribution toward opening some doctors’ minds to chiropractic. Third, money was made available for research into the chiropractic lesion, its diagnosis, and its treatment - the first time there were significant funds made available for this purpose (and you’d laugh at what I am calling “significant funds”).
Fourth, it gave chiropractors hope for being able to serve more patients with the incredible tools and techniques they had available. Finally, the desire for respect drove a renovation of chiropractic education, which today consists of five years of coursework and internship, taught largely by MDs, using medical textbooks, five national board exams in fifteen subjects, and status as primary care practitioners (a comparison between DC education and MD education is included on the About Chiropractic page).
Unfortunately, there are also lasting negative effects that continue to impede the growth and accessibility of chiropractic. One of these is the deep internal division over our professional goals, evidenced in part by our five national professional associations, which exhibit significant differences in philosophy and practice. This stems, in my mind, from the insecurities that such a long and intense attack from the AMA fostered in our profession. Today there are chiropractors intent upon gaining status and recognition, who lobby for titles and degrees like “Chiropractic Medical Physician,” and who wear white lab coats and stethoscopes because of their insecurity.
Ironically, part of the chiropractic community today is striving to acquire all the status symbols and behaviors that have been driving many people away from the medical system; the level of clinical detachment and the egotistical manner that so many MDs are urging their profession to surrender (most notably Andew Weil, Dean Ornish, Deepak Chopra, Bernie Segiel, Rachel Remen, and Larry Dossey). Another major hurdle for chiropractic is the difference in scope of practice and the differences in algorithms from practitioner to practitioner. This challenge is one reason I pursued the technique I did in school; I know that if a patient of mine on vacation were to visit another Gonstead practitioner in Alaska, Texas, or Vermont, they would get exactly the same chiropractic treatment they get in my office.
You can imagine that a lack of uniformity would not only present as a tremendous challenge to the creation a public opinion, or how to explain to our allopathic peers what we do as chiropractors, but it makes the efficient design of chiropractic research a nightmare. One chiropractor may implement cryotherapy, trigger point treatment, and general long-lever mobilization of the patient, whereas another will focus on diagnostic procedures and one or two highly specific, low-amplitude, high-velocity short-lever adjustments. Even more complex, both practitioners may get significant results with the same patient.
So I believe an important question for you to ask, in service not only to the health of your patients, but to your own health, is how did you develop the opinion you did of chiropractic? In the end (and again, in my opinion) it is my responsibility as a primary care physician, as a doctor, as a chiropractor - as someone who entered this work out of a desire to be of service - to send my patients wherever the research shows there is help for them, whether it is surgery, prayer, chiropractic, or salsa dancing! To shirk this responsibility is in my mind tantamount to malpractice.
Research to date
As of the 2004 publishing of the fourth edition of Robert A. Leach’s The Chiropractic Theories, A Textbook of Scientific Research, a Medline search of chiropractic and randomized controlled trials or hypotheses yielded over 3000 references. That, in comparison to the struggle to find any useful references for his first edition in 1980, is quite a paradigm shift for the profession.
For chiropractors, it is a given that the chiropractic lesion exists and that reducing them is a significant intervention—we have more than a hundred years of clinical anecdotal experiences with this. However if there is to be any vestige of evidence-based justification for what is done in the 60,000 chiropractic treatment rooms in the U.S., this trend in research needs to continue, though the challenges outlined above to design “useful studies” remain.
Even in 1980, there was a substantial body of medical knowledge, specifically in the realms of biomechanics, neurology and soft tissue pathologies, that described and explained the clinical entity being addressed by the chiropractic adjustment. However the chasm between professions and chiropractic’s long history of “faith-based” terminology and perspectives aligned us in peoples’ minds more with magnetic healers and crystal therapists than with rational, focused practitioners or clinical diagnosticians. The fact that the subluxation (the name for the chiropractic lesion) describes different stages of the sprain, the strain, disc degeneration, facet syndrome and, in the end, osteoarthritis is something that has been obscured by interdisciplinary communication problems and the lack of funding for chiropractic research.
Ironically, subluxation is now an 800-series medical ICD-9 code which chiropractic interns are taught not to use due to its history as an ad-hoc, faith-based entity. One travesty resulting from these interdisciplinary problems is that thousands of combined years’ clinical experience is being lost as our chiropractic pioneers age and pass away; wisdom lost not just to those seeking better caregiving, but also to those seeking to develop effective hypotheses on the impact of the adjustment. At this time, there are a number of active chiropractic theories being researched by those interested in evidence over anecdote about the adjustment.
In the realm of soft tissue and biochemical theories, there is the inflammation hypothesis, the instability hypothesis, and the immobilization hypothesis. Several neuropathological hypotheses, including the somatoautonomic reflex hypothesis, the segmental dysfunction/muscle pathology and facilitation hypothesis, the neuropathology hypothesis, the neuroimmune hypothesis, and the myelopathy hypothesis strike closer to the original “pressure on a nerve” concept. Despite the traditional philosophical difference between “allopathic vascular supremacy” and “chiropractic neurological supremacy”, the vascular system plays an important role in many of these, as it does in the veterbrobasilar insufficiency hypothesis.
All of these can be evaluated in great detail in a more appropriate setting. A process to be concerned about at this time is the loss of traditional treatments that are unproven in the laboratory due to the search for scientific validation. An allopathic correlative of this is the highly effective treatment of gout with cherry juice, an “old wives’ remedy” lacking research support and abandoned for decades in favor of pharmaceutical treatments—yet it is now enjoying renewed, widespread use by MDs for gout symptoms. While country doctors, homeopaths and chiropractors continued to “prescribe” cherry juice over the decades until the biochemical mechanisms at work could be identified, there is no group of practitioners transmitting these potentially valuable traditionalchiropractic treatments. We will never know what resources are being lost to health care as a whole as a generation of clinical experience is lost as “old timers” pass on.
It is difficult to summarize, in any way, the research to date. In the Medline results a seeker will find both conclusive and inconclusive, both validating and negating studies; everything from general long-lever manipulation to specific short-lever adjustment studies, from over-generalized studies on lumbar pain management protocols to specific studies on the effect of thoracic adjustments on levels of substance P. Until issues of scope of practice, inter-examiner consistency and research funding are addressed, we are unlikely to see more useful studies. In the meantime, we will have to make decisions based on more demographic analyses (such as the results presented in the About Chiropractic section) on safety, work hours lost, recovery time, and cost of treatment. There are a few links below to more substantive and useful recent studies on chiropractic adjustments and general manipulation.
The general chiropractic approach to a presenting complaint obviously varies from practitioner to practitioner and with the demographics of the patient base. Obviously a country chiropractor who is the only primary care physician for miles around will be far more likely to exhaustively evaluate nontraumatic low back pain for the chance of tumor or visceral referral, or to perform a DRE, than a DC practicing in a work-comp multidisciplinary practice in Chicago.
That said, there are standards of care and common practice that every DC must observe which are common to all physicians. The first step in patient care involves an exhaustive personal and family history followed by a general physical exam and specific investigations relating to the chief complaint. Acute or traumatic pain invites differential diagnosis to rule out fractures, dislocations, gross instabilities, and hemorrhage. Nontraumatic pains require ruling out tumors, infections, arthritides, or visceral referral.
At Centre Chiropractic, I strive to avoid the pitfall experienced by doctors of all disciplines; viewing every complaint as a nail just because I’m holding a hammer. I understand and treat patients with the understanding that not every pathology is an acute chiropractic neurological problem. Case by case treatment protocols vary too widely to reasonably discuss here, with widely varying approaches dictated by type, duration, chronicity, location, and severity of injury and the involved structures, whether ligamentous, tendinous, capsular, muscular, osseous, or visceral.
In an effort to address every complaint as close as possible to its causal level rather than merely at the symptomatic expression, lifestyle factors must be considered and addressed as fundamental. Essentially treatment in my clinic involves first determining the presence of neuromusculoskeletal chiropractic lesions and their state of progression. Clients are educated as thoroughly as possible about the nature of the lesion, how it is related to their chief complaints, what the possible natural progression and sequelae are, and also what treatment options are available and which are recommended.
As a 41-year IDDM patient, I have a great sensitivity to the poor job most physicians do at presenting options and information to empower patients to make informed decisions. This is a major focus of the exam and report of findings process in my clinic. Treatment consists of specific, short lever, low amplitude, high velocity adjustments to vertebrae and/or extremities with attention paid to adjusting within either the sympathetic or parasympathetic systems on any visit.
After sufficient adjustments have been administered that objective findings indicate the anterior muscular and ligamentous structures have had a chance to heal and restore proper alignment, extensive attention is paid to soft tissue rehabilitation in the form of restoring proper functional dynamics between the postural and phasic muscle systems, a primary factor in the occurrence of subluxation, and eliminating scar tissue and other myofascial adhesions via therapeutic ultrasound or cross-friction work.
Eventually patients are supported in addressing ADLs, nutrition, exercise and focus on mental emotional spiritual and physical nurturing and balance. Treatment ranges from one week to four weeks based on acuity/chronicity of the lesions and complexity of the case.
My interest is in developing better relations and communications with all health care practitioners. This is a personal, political and professional intention for me. I left a lucrative career and came to chiropractic out of a desire to be of service; so my concern is that every member of our community who wants help has every resource available to them. This requires that our chiropractors disabuse themselves of prejudices against pharmaceuticals and surgery, and that all health care practitioners take personal responsibility for educating ourselves on the diagnostic procedures, treatment protocols, philosophy and outcomes measures of all our peers.
There was a time in practice where I, for example, could not have begun to tell you what exactly a rolfer does, how it might benefit any of my patients, or if any evidence exists in support of rofling for, say, fibromyalgia. In my opinion, for me to abdicate responsibility to harness what information is availble to me in this regard is tantamount to malpractice.
Referral to a Doctor of Chiropractic
If you have read any of the above material on the history of chiropractic or our research challenges, you can already guess that speaking in general terms about when to refer to a chiropractor is a tricky endeavor. With this in mind, it is reasonable to say that a number of case types that often frustrate medical physicians involve conditions that chiropractic physicians frequently treat; low back pain, leg and buttock pain, neck pain, TMJ disorders, and headaches.
In addition, while treatment of the chiropractic lesion still has its detractors, it is an appropriate and effective alternative to refer a patient who is not responding to your conventional care. Patients appreciate the willingness to consider other options and procedures. A 1998 survey of medical physicians indicated that 40% had referred to a chiropractor, and referrals have increased as research continues to lend importance to the role of neuromusculoskeletal dysfunction as a precipitating factor in disease and debilitation.
One of the things that is different about Centre Chiropractic is our holistic focus on extremity problems, soft tissue disorders and rehabilitation. A vast majority of the DCs in Pennsylvania are what are called “straight” chiropractors; they adjust the spine. In our office, adjusting the spine is a primary focus, however we actively address disorders at all levels possible. For instance, frozen shoulder would be addressed by:
- assessing the cervical spine for related radiculopathies and adjusting where appropriate;
- mobilizing and adjusting the GHJ where appropriate to restore proper joint dynamics, ROM, and restoration of synovial fluid production, stimulation of chondroblasts, etc.;
- applying soft tissue techniques, therapeutic ultrasound and muscle stimulation to the GHJ and adhesions within the muscles of the rotator cuff where appropriate; and
- assessment of postural/phasic muscle system imbalances with focus on supraspinatus, pec minor, teres minor, upper and lower trapezius, and rhomboids with modification of ADLs and prescription of at-home therapeutic exercises to reduce the chances of recurrence.
At Centre Chiropractic, we will only treat patients you refer to us if they are appropriate candidates for chiropractic care, and only for the conditions you refer for, unless other conditions are diagnosed during the physical exam and the patient consents to care. You will be respectfully regarded as a partner in the process, with regular reports of patient progress and consultations on treatment protocols. Most importantly, once the patient has attained the maximum therapeutic benefit, he or she is discharged.
Patients are encouraged to be self-advocating masters of their own health care. In alignment with this, we provide regular updates to our patients on current research, nutrition, diet, and exercise recommendations, advise regular check-ups with a dentist, family doctor and gynecologist, and offer support in living a balanced and positive life. There is significant evidence that the mind-body continuum is a tremendous resource in health care, and we work with patients to help them master their experience of their own bodies.
Copyright 2005-2017 Centre Chiropractic, PC
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