"Maximum chiropractic improvement." Just words. What the claims review doctor meant by this term is still unclear to me.
That claims reviewer was referring only to recovery from an automobile accident. That is Symptom resolution, perhaps a little more.
Symptom resolution is not maximum chiropractic improvement. Just words? Politics, regulations and propaganda are just words. If we allow misleading terminology to become established by antagonistic insurance carriers, we will become slaves to that terminology. Soon we will be subjected to laws and regulations that relegate us to being mere providers of symptomatic relief. Based on these words, I did not become a doctor of chiropractic to mimic the medical model of symptomatic relief. Neither did you.
With this in mind, I correct insurance adjusters and claims reviewers when they use the term "maximum chiropractic improvement."
I say, "The patient will not reach 'maximum chiropractic improvement' in six weeks, but probably will return to pre-injury status, or at least a medically stationary status. I was not aware that your accident policy is responsible to bring the patient to radiant health -- is it?"
I do not object to the term "maximum medical improvement." That usually is merely symptomatic relief, perhaps a little more.
In any debate, if you accept the premises, you must accept the conclusions. I suggest that we should nip this premise in the bud. As we strive for precision in our clinical techniques, we can insist on precision in the words and terms that describe the results of appropriate, medically necessary chiropractic care.
Jonathan B. Sevy, D.C.
Vancouver, Washington
Central DuPage Hospital: Why Let Medicine Set the Standards?
Dear Editor:
After reading the article on the front page of the January 17, 1990 issue of Dynamic Chiropractic, entitled, "Central DuPage Hospital Policy Regarding Doctors of Chiropractic Revealed," I would like to share some ideas with you. This article reminds me of B.J. Palmer's prediction in the 1930's about chiropractic, that is, chiropractic is attempting to gain recognition into the scientific community by the medical standard of acceptance. I agree with the hospital policy in that chiropractic theory is incompatible with medicine, and doctors of chiropractic do not administer medicine or practice surgery. Confusion definitely would result in the minds of patients who understand chiropractic and know the difference between the two health practices. I feel there is a definite place for the medical profession and for the chiropractor, but a medical doctor is not a chiropractor, nor a chiropractor a medical doctor.
We should have learned something from the osteopathy profession. There is basically no difference today between the medical doctor and the osteopath. Chiropractic, without the philosophy, is a mere modality or therapy. It seems that in order to be accepted into a hospital, we would have to give up the principle upon which this great profession was founded. Chiropractic is a distinct philosophy, science, and healing art, whether the medical doctor accepts it or not. Why is it so hard to stand up for what we are and what we do? If we would, we would gain the respect we deserve. If chiropractic gets this acceptance, that I feel the minority want, chiropractic will be nothing more than a therapy and the chiropractor a third-rate MD -- osteopathy being second. It seems like the only way that the principle of chiropractic will be totally recognized as a scientific art is when the medical profession discovers it. We need to be more concerned about acceptance from our patients and not from the medical community. I think the majority of chiropractors who feel as I do, have not joined either national association because of their feelings of not wanting to "rock the boat."
L. H. Elsner, D.C.
Crete, Nebraska
Prevention Magazine Controversy
Dear Editor:
I've just been reading your article Prevention Magazine in the Feb. 14 issue. I have been reading this magazine off and on for years, and it has always taken a very anti-chiropractic stand. In articles on arthritis pain, headache, back injuries, and overall health, they have either never made reference to chiropractic care or, worse, said something denigrating and discouraging for anyone who might be considering chiropractic. I never bothered to write to them on this because I figured, what good would it do? I'm sure the editors are biased -- not just in the books promoted through their magazine, but in articles submitted and printed. It is insidious and damaging to the field.
Instead of a "strong message" to the publisher of the book, Future Youth, etc., why not send a very strongly, legally flavored letter to the editors of the magazine and suggest that groups within the chiropractic field or without, are discussing contacting all chiropractors on a national scope and putting a ban on their magazine? i.e., not ordering them for our waiting rooms, as well as discouraging patients from reading it as it is strongly biased and uninformed.
I will send letters to both the magazine and the Rodale Books people. It is so infuriating reading these slurs when anyone in the field sees the "victims" of medical malpractice, and the damage and suffering caused by the practitioners who are guilty of negligence in that they do not refer to DCs.
Rebecca Caplan, D.C.
Maynard, Massachusetts
Cryotherapy Temperature Range Disputed
Dear Editor:
I'm writing in reference to R. Vincent Davis' article, "A Review of the Biophysics and Clinical Application of Cold Infrared Therapy (cryotherapy), in Dynamic Chiropractic, March 14, 1990. My comments are based on research programmes I am associated with in the School of Chiropractic and Osteopathy, Phillip Institute of Technology, and relate to a recently published paper based on one phase of that research.1
The Hunting Response does not seem to be present in all human tissue, rather it seems to be a phenomenon of particularly highly vascular extremity tissue, such as the ear or digit.2,3 We do not find it in our studies of the extensor digitorum brevis.
The ideal therapeutic temperature range for cryotherapy can be argued as being 10oC +/- 5o, a range from 5oC to 15o, on the basis of analgesic effects appearing around 15o and cellular damage below 5o.4,5,6
Contrary to common belief, cryotherapy actually promotes edema formation in subcutaneous tissue.7,8,9 It is the elevation of the injured body part which seems to play the greater role in reducing edema.
Finally, the most appropriate duration for the application of a wet ice pack was found to be ten minutes.1 Anytime beyond ten minutes did not produce greater cooling and did not alter the recovery curve. A shorter period did not achieve the desired level of cold, nor did it result in an appropriate recovery curve.
Our current research is answering the questions concerning repeated application of a cold pack, and a paper from phase two of our studies will be submitted, shortly, to the J. Chiropractic Sports Medicine.
I trust the above clarifies the current concepts regarding the application of cold infrared therapy.
References
- Ebrall, P.S.; Moore, N.; Poole, R.T. "An Investigation of the Suitability of Infrared Telethermographjy to Determine Skin Temperature Changes in the Human Ankle During Cryotherapy." J. Chiro. Sports Med. 1989; 3(4):111-9.
- Knight, B.L.; Londeree, B.R. "Comparison of Blood Flow in the Ankle of Uninjured Subjects During Therapeutic Applications of Heat, Cold, and Exercise." Med. Sci. Sports Exer. 1980; 12(1): 76-80.
- Lovallo, W.; Zeiner, R.A. "Some Factors Influencing the Vasomotor Response to Cold Pressor Stimulation." Phychophysiol. September 1975; 12(5):499-505.
- Sapega, A.A.; Heppenstall, R.B.; Sokolow, D.P., et at. "The Bioenergetics of Preservation of Limbs Before Replantation: the Rationale for Intermediate Hypothermia." J. Bone Joint Surgery 1988; 70A(10):1500-13.
- Shepherd, J.T.; Rusch, N.J.; Vanhoutte, P.M. "Effect of Cold on the Blood Vessel Wall. Gen. Pharmacol. 1983; 14:61-4.
- Meeusen, R.; Lievens, P. "The Use of Cryotherapy in Sports Injuries." Sports Med. 1986; 3(6):398-414.
- Lievens P.; Leduc, A. "Cryotherapy and Sports." Int. J. Sports Med. 1984; 5(suppl):37-9.
- Farry, P.I.; Prentice, N.G.; Hunter, A.C.; Wakelin, C.A. "Ice Treatment of Injured Ligaments: An experimental Model. NZ Med. J. 1980; 91:12-4.
- Matsen, F.A.; Questad, K.; Matsen, A.L. "The Effect of Local Cooling on Post-Fracture Swelling." Clin. Orthop. Relat. Res. 1975; 109:201-6.
Phillip S. Ebrall, D.C.
Phillip Institute of Technology
Melbourne, Australia
Friction Massage Helps Cure Suffering
Yesterday, I examined a 20-year-old female weighing approximately 138 and being 5'4" in height. She complained of chronic soreness of the right ankle and left knee pain while standing at work. The left knee pain started with a knee injury at 11-years-old, which caused chronic patellar slippage. The right ankle problem started nine months ago with a severely sprained ankle. The patient is employed at The Price Club and says that she works on concrete floors, standing all day, and towards the end of the day the discomfort becomes unbearable.
The patient was treated by a DO, first for the knee problem and then she saw a DC for her ankle. The patient stated that the chiropractor would adjust her spine monthly and "yank" her ankle. I asked her if this gave her any relief and she said it felt good, only temporarily, and then started hurting again. The doctor also used muscle stimulation on the other knee which helped with the patellar slippage; however, she still had knee pain toward the end of the day.
Examination revealed a left weak psoas, a low (pronated foot) left arch, and upon stressing the left knee joint into internal rotation, there was no joint play due to the pronation problem. The right foot displayed only a slight pronation problem as compared to the other side. Active examination of the patient's right foot had shown tendinitis in the region of the medial calcaneal-talar ligaments. The symptoms were reduplicated by having the patient flex her foot against the resistance of my hands, showing the exact area of irritation.
My recommendations were for orthotics to correct the pronation problems with heel cups. The orthotics will also correct the sheering created by the pronation on the cartilage in the back of the kneecap. On pronation, the kneecap rotates and the groove doesn't glide smoothly over the knee joint. The patient was also given exercises to balance her left quadriceps and right ankle muscles. These are important to help restore normal proprioceptive responses to regular joint motion. For the residual tendinitis, transverse friction massage was applied to the involved tendon and the involved ligament. After the massage, the patient walked out of the office with her ankle being asymptomatic and was told to return for followup in one week where she will again receive the friction massage and receive her orthotics
The other doctor who treated this patient's ankle relied on a talus break in order to give this patient relief, although this case demonstrates the importance of a proper history. Most of my diagnosis was made during the initial consultation and the examination only confirmed what the history told me. Incidentally, friction massage is an invaluable tool of which every chiropractor should have some working knowledge.
William D. Charschan, D.C.
North Brunswick, New Jersey