Dear Editor:
We would like to comment on the "Industrial Consulting" column by Paul D. Hooper, DC in the June 16, 1997 issue of Dynamic Chiropractic.
We believe Dr. Hooper was attempting to be reasoned, but his discussion was confusing at best. At first, he appeared to support the narrow positions of Dr. Nortin Hadler, a rheumatologist and surgeon based in Chapel Hill, N.C., that (1) clinically significant results of nerve conduction studies (NCS) are required for any diagnosis and treatment of CTS, and (2) that with few exceptions, cases of CTD, and especially CTS, are only flare-ups of "arm pain," as common as "back pain," and are neither work-related nor compensable.
Dr. Hadler's position is that the workers' compensation system, in Hooper's words, "creates claimants where none should exist." As an example, Dr. Hadler referred to telephone directory assistance operators who, according to him, had unjustifiably blamed their keyboards for their CTS. Again, Hooper appears to agree with Hadler, commenting that on a number of occasions, he (Hooper) has lectured that "disability is the result of psychosocial issues rather than injury severity" and "disability has much more to do with who we are than how badly we are injured."
Having apparently stated his position, however, Dr. Hooper than appeared to have second thoughts. At Dr. Hadler's lecture, he "looked around ... and (became concerned) ... that ... people who are managing claims at companies across the country may actually believe him." He justifiably worried about a hypothetical worker in an assembly plant in Michigan "who develops early signs of (assumed work-related) CTS when symptoms are present before any evidence of disruption of nerve conduction velocity" whose claim is denied. To integrate his two positions, Dr. Hooper states that "somewhere between the convincing argument of Dr. Hadler and the experience of a large group of seemingly hysterical telephone operators is a realistic middle ground."
We think there are ways to achieve a reasoned middle ground, though not by averaging the narrow criteria of Dr. Hadler with the "hysterical" criteria of the telephone operators or siding with one against the other. We believe the answer lies in reframing the issue and recognizing there can be differential criteria for either primary or secondary interventions: treat-the-symptoms criteria sufficient for primary intervention and higher-threshold criteria for non-conservative, surgical care.
Dr. Hadler's narrow position on diagnosis of CTS may well be appropriate for screening candidates for open or endoscopic carpal tunnel release, but if universally applied, it would effectively deny early intervention, and possibly diversion from surgery, to tens of thousands of people annually who suffer from work-related and non-work-related CTS and CTS-like symptoms.4-6 Criteria relating to surgery are necessarily more definitive, since the intervention is taken with risk of continued or exacerbated discomfort and dysfunction.7-9 The nature of primary care, however, is such that definitive diagnosis is often lacking, and patients' symptoms are treated or managed, usually with inexpensive and low-risk strategies.5 We believe if symptoms are present in the median nerve distribution and occur frequently, it would be the height of folly to deny primary intervention.
Regarding Dr. Hadler's contention that CTS is not work-related, we believe the cause of CTS in the workplace cannot be determined except with site-by-site ergonomic worksite analyses. A growing literature is establishing the connection between some CTD and CTS and several, specific worksite risk factors.10-17
Our advice is, if workers in such settings make reasonable cases for assessment and early intervention, provide and cover the care. If workers in other less well-defined situations make no substantiative cases for their claims, deny coverage. Rather than routinely blame claimants, the most effective strategy, in our view, will be to compensate assessment and treatment of workers exposed to and affected by known worksite risk factors and, while you're at it, address the risk factors themselves.
References
- Putz-Anderson V. Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper Limbs. New York: Taylor and Francis, 1988.
- Gelberman RH, Rydevik BL, Pess GM, Szabo RM, Lundborg G. Carpal tunnel syndrome: a scientific basis for clinical care. Orthop Clin North Am 1988;19(1):115-24.
- Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial. Submitted for publication.
- Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report: Occupational Disease Surveillance -- Carpal Tunnel Syndrome, DHHS, Washington DC, 1989;38(28).
- Miller RS, Iverson DC, Fried RA, Green LA, Nutting PA. Carpal tunnel syndrome in primary care: a report from ASPN. J Fam Pract 1994;38(4):337-44.
- Sucher BM. Myofascial manipulative release of carpal tunnel syndrome: documentation and magnetic resonance imaging. J Am Osteopath Assoc 1993;93(12):173-8.
- Das SK, Brown HG. In search of complications in carpal tunnel decompression. The Hand 1976;8(3):243-9.
- Kuschner Sh, Brien WW, Johnson D, Gellman H. Complications associated with carpal tunnel release. Ortho Review 1991;20(4):346-51.
- Murphy RX, Jennings JF, Wukich DK. Major neurovascular complications of endoscopic carpal tunnel release. J Hand Surg (Am) 1994;19(1):114-8.
- Armstrong TJ, Radwin RG, Hansen DJ, Kennedy KW. Repetitive trauma disorders: job evaluation and design. Hum Factors 1986;28(3):325-36.
- Blanc PD, Faucett J, Kennedy JJ, Cistermas M, Yelin E. Self-reported carpal tunnel syndrome: predictors of work disability rom the National Health Interview Survey Occupational Health Supplement. Am J Ind Med 1996;30(3):362-8.
- Delgrosso I, Boillat MA. Carpal tunnel syndrome: role of occupation. Int Arch Occup Env Health 1991;63(4):267-70.
- Gerr F, Letz R, Landrigan P. Upper extremity musculoskeletal disorders of occupational origin. Ann Rev Public Health 1991;12 543-66.
- Gerr F, Letz R. Risk factors for carpal tunnel syndrome in industry: blaming the victim? J Occup Med 1992;34(11):1117-9.
- Hertz RP, Emmett EA. Risk factors for occupational hand injury. J Occup Med 1986;28(1):36-41.
- Moore JS, Garg A. Upper extremity disorders in a pork processing plant: relationships between job risk factors and morbidity. Am Ind Hygiene Assoc J 1994;55(8):703-15.
- Silverstein BA, Fine LJ, Armstrong TJ. Hand wrist cumulative trauma disorders in industry. Br J Ind Med 1986;43(11):779-84.
P. Thomas Davis, MUP, DC
J.R. Hulbert, PhD
John J. Meyer, DC, MS
Wolfe-Harris Center for Clinical Studies
Northwestern College of Chiropractic
Bloomington, Minnesota
Need to "focus our time and money on our image problem"
Dear Editor:
Thank you for publishing the article on the PR efforts of the physical therapists (DC, July 14, 1997). I believe we have a good opportunity to "catch up," and quickly. Here are my opinions on the subject.
Our problem is not our professional education, competence, or even greed. We have a bad public image and that is simply that. Would anyone seriously disagree with this conclusion? The quickest way out of this situation is "virtue by association." That is to say, the chiropractic image must be seen, heard, and associated with already-respected professional images.
The best way to do this is for each state association (at least, in my opinion, the more progressive and enlightened ones) to underwrite particular segments on National Public Radio. This should be done first on stations which broadcast in state capitols, because surveys of legislators indicate that many of them listen to programs like "All Things Considered" and the state and national news, which comes on at evening drive time.
The objective is to have decision makers, legislators and the social intelligencia hear something like, "This segment of All Things Considered is underwritten by the Michigan Chiropractic Council, guarding and protecting your most precious possession -- your family's health -- with a proactive, hands-on approach for young and old alike," and by Steelcase, where being a good neighbor is just as important as being a good company.
So, dear colleague, we therefore link our profession, which we all recognize has a rather nasty image problem, with mainstream, well-accepted groups and corporations with very good images. Thus, we bestow virtue by association. This is a great, time-tested strategy and it should work well for us.
The costs of underwriting are clearly among the world's best advertising bargains. In Michigan, the last time I checked, it was between $3,000 and $5,000 a year. It also occurs to me that any national associations or chiropractic colleges may be well advised to consider this effective strategy.
I believe we must focus our time and money on our image problem. We must concentrate on educating decision-makers as out target group, not just the one satisfied patient after another, as we have done in the past.
Paul Tuthill, DC
Grand Rapids, Michigan
"With My Heart, My Head and My Hands"
Dear Editor:
I've enjoyed your editorials in Dynamic Chiropractic over the years and always read them even if I don't have time to read anything else. You do a fine job of touching on the most salient aspects pertaining to the chiropractic profession and its relationship to medicine, politics and the future of chiropractic. In your June 30th column ("Our Last Chance?") you asked a few good questions which got my attention and made me think you overlooked something, so I just want to bring it to your attention.
I can understand your feeling that the Alliance for Chiropractic Progress is the best way today to promote chiropractic to all the millions in the world who do not understand what we can do for them. But there is a better way, I think. You ask, "If the ACA/ICA don't do it, who will?" To me, the answer is simply, the individual chiropractor!
You mention the pioneers of chiropractic "peering through the bars of their jail cells past their own personal and financial struggles to see a great and mighty profession in formation. They knew what had to be done and did it." I don't believe our pioneers focused so much attention on building a profession as they did on simply providing their patients with a simple and effective alternative to orthodox medicine. The pioneers of this profession kept chiropractic alive by helping sick people get well and they did it at a time when there were no third-party payors involved. In fact, that was an advantage, for when you get a third party involved in any relationship it leads to disaster (especially when the third party doesn't want one of the parties to survive anyway). Our chiropractic pioneers provided a great service at an affordable price. The word spread, and the profession grew.
You also asked the question, "Are you as successful as you were 10 years ago, or even five years ago?" To me, the answer is an unequivocal "Yes!" Why, you ask? Because I stopped mimicking the medical establishment and went back to practicing basic chiropractic the way our pioneers did. I decided that I didn't want to be an over-priced "paste," but a "real" gem. Also, I didn't want to go down with the "sinking ship" of the medical establishment.
Although I never did feel a "real" chiropractor could effectively treat a hundred patients a day, I did see a lot more than I really had time to do justice to them. Even so, I chose to start over and build a practice based on results and direct referrals with no third-party payors. That was 10 years ago, and I have built a practice based on what I do with my heart, my head and my hands.
Today I am much more successful than I was 10 years ago because, first of all, I really enjoy my work (there's no more burn-out); secondly, I feel I am demonstrating what chiropractic really is to more people than I ever did with all the lectures and advertising I did before; and thirdly, without all the tremendous overhead, I have more money and time to enjoy my family. You see, I have been practicing for 22 years, but for the last ten years I've been making house calls only. Maybe someday I'll want to set up an office again, but I won't ever go back to dealing with a third-party payor.
Although I admit it was a bit slow building a practice this way, it wasn't the ICA or ACA that did it for me; it was my giving 110 percent to my patients, and my patients feeling they got results at a price they could afford. Like our chiropractic pioneers, I don't expect to get rich off of my patients, but I'll always have a good practice and make a good living.
So, my friend, it is not the organizations that make the profession any more than it is the government that makes the society; it is the people within the profession or the society. When chiropractors get their attention back to delivering "chiropractic" and not just making money or stroking egos, then we will take chiropractic to the world. The old adage, "By your work you shall be known" is even more apropos for the future of this profession than it was in the past.
Wayne R. Fiscus, DC
Prescott, Arizona
Giving DCs the Respect They Deserve
Dear Editor:
After rereading Dr. Culbert's letter from your June 30, 1997 issue, a feeling of comfort came over me. Just think, the medical professionals are showing respect and actually rendering honor to a colleague! And that is occurring just 70 miles from where I practice!
How odd, I reason, when patients have entered my doorway and begged for help. It seems their medical professionals have not only denied them access to chiropractic but have actually refused to be their physician any longer! The patients were actually warned of some horrible injury if they do come!
The medical people here have refused to allow two of us to be granted privileges to their precious hospitals even after being given the ACA guidelines. No explanation was relayed and to pursue an answer would cause some of our patients undue hardships when they have to be admitted for tests! One hospital staff member even said that only a lawsuit would do any good to allow us access to their board.
I have been a nurse for many years, Dr. Culbert, so I do possess some medical expertise. I still have fellow nurses turn their noses up and tell horror stories of this chiropractor or that chiropractor that hurt, maimed or killed someone, yet they can not come with a name or an address for that person to be traced! They forget how many patients have died in their hands due to poor medical management.
Wasn't it USA Today that published how many injuries occur in the U.S. due to medical management! I haven't seen anything large like that pertaining to us!
Again, you're right about how they don't deserve the negative attacks. We need to put more information out there about choosing less drastic measures than surgery, be it exploratory ("we don't know what is causing your pain!") or fusions ("Yes, this will stop your back pain!") to "Here, take this prescription and you'll be all right!"
Again, I am delighted that the MDs have given you the respect you deserve. After working the emergency room and intensive care, we do need physicians to aid in the crisis management. We chiropractors need to be included in the care of all patients, before their condition becomes critical or as they are recovering, to use our healing powers for the public good.
Bob Bell, RN, DC
Carl Junction, Missouri