These Findings Reinforce an Important Point

Dear Editor:

At first glance, reports about the July 1, 2005 Spine study, "Frequency and Clinical Predictors of Adverse Reactions to Chiropractic Care in the UCLA Neck Pain Study," by Hurwitz, et al., seem to suggest that all chiropractic manipulations or adjustments of the cervical spine may produce undesirable reactions.¹

However, the study compares post-manipulative/post-adjustive responses of those who received high-velocity, low-amplitude (HVLA) chiropractic thrusting techniques, with those who received non-HVLA joint mobilization techniques. According to the authors, of 280 subjects studied, 30.4% experienced post-adjustive reactions; increased neck pain or stiffness was the most common symptom, reported by 25% of the participants.¹

A reasonable conclusion, based on the study's findings, is simply that HVLA techniques may not always be the most appropriate chiropractic intervention for all classifications of patients.

In a 1998 issue of The Chiropractic Report, Chapman-Smith stated:

"Much is written about the classic chiropractic adjustment, the precise and fast manipulative techniques that gap the targeted joint and, with spinal joints, produce potent reflex effects in the central, peripheral and autonomic branches of the nervous system. This is the most researched form of chiropractic treatment. However ... chiropractic education and practice encompass a wide range of low-force and soft-tissue techniques. ... Use of soft-tissue manipulation/joint mobilization in combination with joint adjustment/manipulation often means that the latter can be performed with greater ease and effectiveness."²

Chapman-Smith further notes: "There are various classes of patient who will not tolerate, or are at added risk with joint manipulation. For some patients the primary problem, or key link, is in the soft-tissue rather than the joint."²

Similarly, in his text, Principles of Manual Myofascial Therapy," Schneider states: "There are many occasions when clinicians may choose not to manipulate a joint, and soft tissue techniques may become the treatment of choice."³ He cites the examples of frail or elderly patients with osteoporosis; acute, swollen, or inflamed joints; joint or ligament instability from acute whiplash injuries, unstable shoulders or knees; severe or acute disc herniations; prior surgery or joint replacement; those with a history of cerebrovascular disease or transient ischemic attacks; and patients who fear neck manipulation or more forceful techniques.³

Moreover, as Schneider states, "Many potential patients would prefer a soft tissue or low force technique it if were offered to them," and he notes that by blending muscular techniques with osseous techniques, the force required to perform a manipulative thrust is dramatically reduced.³

Unwelcome as Hurwitz, et al.'s findings might be in some areas of the chiropractic profession, their findings seem to reinforce a point argued by Chapman-Smith several years ago: "Perhaps the ultimate goal for some patients is no external force at all."²

This was precisely the concept that Raymond Nimmo, pioneer of chiropractic trigger-point therapy, advocated almost 50 years ago when he urged the chiropractic profession to consider the following: "The trouble is not bones but the things that control them. Muscles and ligaments control bones, but the nervous system controls these. And that control is not lost through nerve pressure. It is a nerve condition, and its correction is our rightful field."⁴

Almost a half-century later, a significant portion of the chiropractic profession still seems to have missed Nimmo's point.

References

1. Hurwitz E, Morgenstern H, Vassilaki M, et al. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study. Spine, July 1, 2005;30(13):1477-1484
2. Chapman-Smith D. Low-force and soft-tissue techniques. Chiropractic Report 1998;12(4)
3. Schneider M. Principles of Manual Myofascial Therapy. Pittsburgh, PA;1999:62.
4. Nimmo R. Receptors, Effectors, and Tonus: A New Approach. The Receptor, Vol.1, No. 1, November 1957. In: Schneider M, Cohen J, Laws S. The Collected Writings of Nimmo and Vannerson: Pioneers of Chiropractic Trigger Point Therapy. Pittsburgh, PA;2001:3.

Gerald A. Anzalone, DC
Peekskill, New York

Let's Not Throw the Baby Out With the Bath Water

Dear Editor:

I am a chiropractor, having practiced for the past 12 years." In that time, I have had many cases where neck adjustments worked fantastically for patients, both with presentation of symptomatic and asymptomatic cases." Many patients truly enjoy the feeling and the "release" they get after a cervical adjustment - particularly the standard supine or seated rotary type." I'm sure that I'm not the only chiropractor who has this happen each and every day." Watching patients get better is so enjoyable.

Admittedly, over the years of practice, there have been times where a new patient receiving their neck adjustment(s) felt a headache afterward or felt somewhat dizzy for a few moments, then felt better." It is in these "clues" that I found a more comfortable way to keep cervical spines under chiropractic care, while also doing no harm." It works for me; whether it works for other chiropractors is another matter.

I believe that screening questions, history, examination, ortho/neuro tests and imaging do a terrific job beforehand - but they are not always 100% effective, and as a doctor, you have to know that." You have to know that there will be times when it seems OK to adjust a patient's neck with rotary motion, but afterward, you will have a patient with more pain, dizziness or light-headedness." Although few in number, it simply happens in the course of seeing thousands and thousands of patients over a chiropractic career. "Talk to most chiropractors privately and they will tell you the same.

I believe that one of the keys is not only in early detection before adjustment, but also in listening to the patient when it does happen." Ignoring it could be bad, not just for the patient, but for your sense of patience with the patient." The days of chiropractors deflecting "I heard that chiropractic adjustments could hurt people" questions from their patients with their defensive, "Well, did you know that anti-inflammatory drugs kill so many thousands of people a year," is not only outdated, but also inconsistent in answering the question." Pointing out one wrong doesn't cancel out another, it just makes two wrongs." Patients deserve better answers and chiropractors shouldn't be so afraid to address shortcomings. "Frankly, I believe that's a large reason we haven't grown.

Over the past few years, I have seen more patients over age 65 and I do see quite a few patients with headaches, neck pain and arm neuropathy." About seven years ago, I switched to light toggling, and Activator if the toggling still seems too much for the patient's neck to properly handle." For my practice, it works beautifully. In fact, with my new and existing patients, if they are benefiting from the cervical rotary adjustments, I continue, but once in a while, if they show a side-effect such as tingling down the arm, headache or dizziness, I switch them to light toggle adjustments or Activator and it seems to do fantastic for them."

Finally and most importantly, I strongly believe that after the first four weeks of care, the patient's neck should show demonstrable improvement with pain scores and range of motion - even if they don't have post-adjustment side-effects." I don't expect that most will be 100% cured, but I do believe that if you don't see results of any kind after 10-12 adjustments to the neck, then referring out is best." I have had patients with neck pain coming from Arnold Chiari malformation, multiple sclerosis, lymphoma, subclavicular lipoma, etc., who were referred out and treated as such." In all cases that I remember, I have never had an angry patient, but rather an appreciative human being.

My real point here is that the question from this study doesn't have to be whether to adjust a neck or not; rather, it should be that if the neck needs care, how can we best deliver it for maximum benefit and the least risk of side-effect?" Also, I would add that there is much variance between an adjustment's force, line of drive and the patient's muscles tightening, not only between different chiropractors, but even with the same chiropractor on different patients."

It was a great study, and it brings out a terrific point that many chiropractors want to sweep under the rug." Most importantly, let's not take it to the point where we are throwing out the baby with the bath water.

Stephen D. Ambrose, DC
Richmond, Virginia

It's About Following the Correct Treatment Approach

Dear Editor:

I have been in practice since 1979 and have learned many things, as I'm sure other DCs have. One is that you can overadjust a patient and be too aggressive, which can cause soreness and sometimes recurrence of pain and stiffness.

I've found that it is necessary to practice a mostly hands-off approach (perhaps light pressure, non-force) if the patient has responded well. The majority of patients will respond negatively if an inappropriate adjustment for the specific condition is performed or at a time when the patient is already responding well to treatment and does not need to be adjusted. Rarely, if ever, have I seen a patient experience a negative response if the correct approach to treatment is followed.

I would welcome the thoughts of other practitioners regarding this subject and their experiences in practice.

Steve Prupas, DC
Blacksburg, Virginia

Another Perspective on Chiropractic Credentials

Dear Editor:

In response to the doctor who questioned the motives of DCs who become board certified in chiropractic specialties (e.g., DACBN, DACBO, DABCR), I wanted to send this reply.

Although one is always "just a chiropractor," even after 20 or 30 years in practice, one's focus may change. One doctor may become interested in nutrition, another in orthopedics, while still another might become interested in radiology. The fact that a DC is willing to enroll in a 300-400-hour accredited, postgraduate program; spend considerable time and money to attend; and then sit for a rigorous examination, is commendable and should be viewed as such.

The above-referenced letter implied that DCs who become diplomates think they are "better" than other chiropractors and somehow seek board certification for ego gratification. My explanation is that the practice of chiropractic has changed in the 22 years since I graduated from college. Though the essential principles have not changed, the applications have. It's pretty common knowledge, for example, that rotary cervical manipulation has come under strong negative scrutiny over the past five to 10 years. Every newsletter from my malpractice carrier includes a section on the avoidance of vertebrobasilar compromise in treating the cervical spine.

If a veteran doctor chooses to ignore these articles, or worse yet, doesn't even know what the word "vertebrobasilar" means, that's not because the publishers are getting uppity or because a board-certified individual is a snob. If a DC chooses to become a board-certified chiropractic internist (DABCI), for example, he or she is in pursuit of a level of diagnostic excellence that should be admired. It's specifically this kind of excellence that will keep him or her from harming a patient and creating even more negative press for the already-tarnished chiropractic profession.

The above-referenced letter also implied that diplomate status and the titles it confers (e.g., DABCO, DABCI, DACBN, etc.) are somehow bogus. All such specialty programs are sponsored by CCE-approved colleges and are similarly accredited - just like the DC degree.

When I was attempting to become a chiropractic provider for a large HMO in New Mexico, back in the late '90s, applications from non-board-certified DCs were routinely rejected. This was a medical HMO that required all of its MDs to have board certification; since we were seeking parity with them, we were expected to be similarly qualified.

In short, there are individuals who just don't like change or growth. When they see these attributes displayed in others, they ridicule the individuals pursuing them. This is an unfortunate practice - one that speaks poorly for our profession and one that speaks poorly for humanity. If there are readers out there who are still not aware of the various diplomate programs available or the meaning of board certification within our chiropractic profession, that information is readily available. Is it possible that the board-certified chiropractic diplomate knows something the "regular DC" doesn't? I guarantee it. While this does not make the board-certified DC "better," it does mean he or she has more education and more credentials.

Seth Allen, MA, DC, DACBN, Dipl. Ac.
Monument, Colorado