Imagine this conversation:
Dr Joe: You have presented with neck pain, headaches, back pain, depression and anxiety. When I examined you, there is extreme pain when I touch around your mid to lower back. It has me concerned.
Patient: Yes, me too. Its been there for years. I am now 30 but I remember it being there since I was a child.
J: Lets get some plain x rays, come back this afternoon for a full report
Patient comes back and I read the x rays. Looking at the shot above, I see a portion of the inferior-lateral margin of a middle thoracic vertebra missing. As it happens, her cervical spine shows signs of whiplash injury.
J: Mrs P this area here looks as if you have suffered an injury that has crushed the front part of your vertebra. Have you ever broken your spine, traits of being hard-working and concentrated help them gain success in virtually any endeavor, but the close the top is the more people want to do something new and unknown. or suffered a fracture? Its like you have folded your body in half?
P: what? (mild panic)
J: it certainly looks like you have fractured your spine.
(patient thinks, eyes welling up with tears, and then remembers)
P: Oh, God, years ago when I was about 10 I rolled and tumbled over in a go-kart. I have had pain in my back ever since. The worst thing is was that nobody believed me at the time. I begged to be taken to the doctor and ever since I have lived in pain.
J: Let me tell you one thing: you have been justified in your suffering and I am sorry that nobody believed you. This could have created ongoing anxiety and self doubt issues. Now you know why.
The moral? Plain film x rays when properly used to confirm a diagnosis can not only ascertain prognosis, but can also be used to explain some yellow flags considered barriers to progress.
In addition, human beings are complex, and, often anxiety is not just an disorder without purpose.
Most importantly: children are to be believed, until reasonable doubt is gone.
Dr Craig Moore and I collaborated on this case with AO and CBP to great affect, IMHO.
On Evidence Based Medicine and Science.
Lately, say the past 20 years, there has been a lot of fuss in the health literature about EBM – Evidence Based Medicine. Evidence documented is, of course, the key to universally beneficial and reproducible ordered knowledge. We cannot function religiously on faith, nor hearsay, but how else can novel new discoveries be made if nobody can do anything outside the “evidence base”? Some ideas are “time worn” and others the result of new research. A blend of this shouldsuffice...
We all know of the cultural authority that medical practitioners RIGHTLY have gained through over a century of saving lives. In emergency care, in disease care and prevention and especially sanitation and hygiene. Let just not forget NURSES too. The oldest profession, as I see it. But the pendulum has swung.
Perhaps not, in this new dark age of professional jealousy where many point to financial conspiracies, such as “Big Pharma” but I will stay away from this one for now, even though much is real and some is just our own paranoid/self protective way of thinking in conspiracies.
The rise of EBM is like a Born Again Christian explaining Jesus to the Pope. Better still; a cave man who has time travelled with a stone disc explaining to the Michelin brothers what a wheel is. “Evidence” has been resurrected because medicine was largely devoid of it. Does not mean chiropractors, naturopaths and so-called “alternative” practitioners weren’t living a few lies themselves, but medicine was supposed to be the gatekeeper of health. To me, as far back as the 1980s, this status was long gone. I’d seen too much authority granted to a largely drug pushing cult. I was heavily influenced by the late paediatrician Robert Mendelsohn MD, who called his own the “priests” of paternalistic cult that dishonestly covered up its own messy iatrogenesis.
I became a chiropractor because I saw the evidence for making the spine work right beyond drugging it with chemistry and screwing it up with, well, screws.
A procedure could be totally without therapeutic active ingredients, but very safe in terms of side effects (e.g. A “placebo” sugar pill). I may believe that the chiropractic adjustment cured my pain, even my common cold, but without adequate protocols and sheer numbers in appropriately blinded studies, the truth is far from being universal, as opposed to “your own”. We aim to exclude the placebo, from the active effect. So how is medicine doing? Superbly – in treating heart disease, saving children with birth defects and disorders, etc. It boggles the mind when we see the daily effects of life saving procedures.
Pretty badly though - when it comes to spinal pain and musculoskeletal health. Very badly with things like ‘flu vaccines that don’t work and surgery for shoulders, knees and spine that do more harm (iatrogenesis) than good. Enter EBM... People started pointing the finger at the antics of medical doctors prescribing untested things such as antibiotics on colds (I did) and said that they’d rather choose a herb or – Buddha forbid - a chiropractic adjustment. Or dog saliva... anything - including snake oil. Then “medicine” struck back: “Hark, you have NO EVIDENCE!” (They’re still telling methat... after 122 years since the birth of chiropractic).
In my years of study of health since my youth informally, and, formally under two university degree programs, and many years in practical application as a chiropractor I was under the impression that we were always using EBM: The gaining of scientific knowledge to assist the human to be well. I was aware of its limits and the bane of using it as the “search for truth”. Science was a soft tool, not a hard master.
Use of aspirin was evidence based, as it seemed to work, and then its modes and mechanisms of action were discovered. An apple fell on Newton’s head and gravity suddenly existed. Let me posit to you this:
There is no evidence that an apple landed on Newton’s head to cause him to ponder the theory of gravity.
See what I did there? Did it sound authoritative? Is it true? I just made it up. Fact is, gravity is true and it doesn’t matter how Newton formulated it. But you can call “no evidence” on almost anything. Do it. Try it. People will suddenly question it. It’s almost a natural phenomenon. But sadly, you can destroy someone and/or something entirely – if you have a little bit of con man conviction, or a few letters after your name (or you have maybe, as the old joke goes: “grey hair, are slightly impoverished and suffer haemorrhoids” to give you that concerned doctor look).
Chiropractic worked on people miraculously in some cases, to which I will also testify unapologetically. My own feeling of wellbeing, my pain, my own aches and my witnessing of others restored function. It was never easy to explain how, but we know so much now that it is unquestionably scientific.
Trawling through pieces of evidence, from research papers to books written by doctors, from personal communication with practitioners to compulsory text books for university: I made my choices based upon my decisions untainted by parents or family in the health care industry or by what I was compelled to believe in. My parents were almost illiterate, only completing a third-grade post-WWII education in Italy. They never spoke English upon arrival and never understood any of my school reports. I was always SELF DIRECTED. Neither DD nor BJ Palmer was my messiah. They were flawed humans as I imagine were also Vesalius, Hippocrates, James Cook, Columbus, Edison, Ford, Pasteur or Marilyn Monroe. Paradoxically, flawed and gifted.
For me, the treatment discipline that focused on the interface between bio-structure of the human skeleton and the functional electrical nerve centre of the body, via manual application, was the most basic, conservative and beneficial to the human spirit and body.
The Palmers called it Chiropractic. Meaning “practiced by hand” in Greek.
At a time when Medicine was gaining the reputation of being “hi-tech” – advancing in miracle drugs and marvellous technological processes and instruments. Chiropractic was “hi-touch” - Traditional, personal and affronting to medical practices that circumnavigated seemingly barbaric interventions and yet rediscovering a lost art of ‘hands-on’ healing.
Removing the flawed judgment of the human hand from healing was seemingly medicine’s mode of operation. Diagnostic tests advanced as the judgement of “quacks” could be curbed.
Chiropractic had faith in the meeting of these two modes of action blended in the ancient and the modern, holding the key to our healing salvation. It blended manual technique with radiography as the primary technical tool. Medicine was set to use mainly chemicals that could be scientifically blinded and blended on the human. Chiropractic proved a more difficult interaction to map scientifically. Though not impossible, it is hard to create chiropractic ‘sugar pill’ that removes the placebo effect, or can measure what is actually happening. Chiropractic is mostly placebo, some said, due to the power of human touch. Problematically, it has become elusive to even measure what a subluxation does; let alone when it is absent? Admittedly this can easily spawn the medical mantra of “no evidence for chiropractic!”
Perhaps chiropractic’s arrogance of matching medicine’s boldness of pushing drugs with little evidence overtook our good sense in getting some research done for our own procedures? Yes it was true, but not to the point of condemning an entireprofession. This is what power lobby groups like the AMA do, throwing out the baby with the bathwater on so many occasions. They still do it with nurses, chiropractors from day one, acupuncture, Traditional Chinese Medicine and now Homeopathy.
EBM states that the placebo effect works to ‘cure’ in 30% of patients, so you have to create something that people think is treatment, but is not, in order to see what is at work. So if a treatment is no better than 30% it is as effective as a sugar pill, or mere convincing suggestion.
Too bad that in the coming years as I learned more, the truth did not quite meet the actuality. Health care politics had other plans, but lets not let that get in the way of a good uplifting story.
There’s a dark side to all things worth knowing, it seems. Evidence was mounting for chiropractic being superior at treating neck and back pain, at the very least, so then the bar was raised to the double-blind placebo controlled study(the gold standard for research) and we were suddenly at the beginning again. Turns out that although medicine was doing pretty badly at treating the neck and back, chiropractors had virtually no gold standard evidence. Suffer us.
Perhaps our arrogance of matching the boldness of medicine pushing drugs with little evidence overtook our good sense in getting some research done ourselves?
So gradually as of the 1990s, medicine, knowingly under threat, just pointed and said, “They have no evidence” so its quackery and deception. You see, it’s very hard to defend yourself from an allegation that is true, as the new kid on the block, because the majority rules the day, and the status quo remains.
That is until a tipping point.
This represented a MAJOR threat to the AMA: it may have to forgo its policy of “non-communication” with chiropractors. No way, it pushed into false media a la 2013: “chiropractor breaks baby’s neck”. It was everywhere but alas it never happened. Damage done. Reputations sunk.
Over the decades, chiropractic pushed medicine to put its money where its mouth was. So many medical procedures were as shoddily based on “evidence” resembling faith, if not ever more dangerous, than chiropractic. Not that I would rely on a chiropractor to remove or heal a swollen tonsil obstructing breathing, but in the light of so many tonsillectomies for useless (or monetary) gain, as a young student of the healing arts and sciences I could see more evidence of removing obstruction of physical stress in the human spinal-neural system than merely outing an offending organ for flaunting its natural defences to inflammation?
Over the years then, we saw the demise of “routine” tonsillectomies and appendectomies, and rightly so, the elevation of the chiropractor beyond “witch doctor” status by shedding a lot of the zealotry, such as “subluxation is the cause of all dis-ease” - which it clearly is not. My friends Drs Michael McKibben and Peter Rome have all too often raised the alarm bell to IATROGENESIS. The word means “doctor caused illness”.
If medicine was to be EBM then it created its own “failed back surgery syndrome” hinting responsibility, despite it still refusing to work with those who actually reduce surgery: the chiropractors. People like distinguished orthopaedic surgeon Hon. Professor Gordon Waddell had eyes wide open when talking about options to back problems:
What matters is the balance of the effectiveness versus risk, and that is strongly in favour of manipulation
Why do quotes like this seemingly fall on deaf ears of your medical doctors? Well, by and large, the market determines the flow and people keep showing up to OUR offices for spinal pain increasingly despite large chunks of discouragement and ignorance in the medical community. Secondly, you can basically find an article to counter any advice on the Internet.
Thirdly, not all doctors are on par with the AMA. Many, many medical doctors earn an honest living working for the patient, reducing suffering and occasionally, I am sure, saving lives.
For every article of EBM, it seems, there is an equal and opposite entity of advice. Perhaps this speaks of a new age of information? That individual treatment is more important than a mass effect of opinion that just doesn’t fit all people anyway? And that a hospital, to treat disease, should be a totally separate building to the one we might call “The Department of Physical Morality”? (OK, more on this later... Its what Dr Virgil Strang posited could be the apt name for a place where we go to get well, instead of what hospitals do, which is emergency care: totally different, it could be argued).
In my opinion, the emergence of evidence-based practice as a recent phenomenon in medicine has been not so much for rationalising of so-called un-researched alternative medicine and quackery, but curbing the medical crisis escalating it to a leading cause of death in itself. Antibiotics are being used without intelligent diagnosis and best practice guidelines. People still believe that antibiotics protect against progression of the rhinovirus into some kind of respiratory disease. Some doctors will even prescribe for stomach ache, claiming an infective agent at work. Addiction to pain drugs is epidemic. Drug companies are even being sued now for pushing them and hiding side effects from some major studies. The list goes on, for Doctors (of all kinds) ignoring the evidence of best practice. So much for EBM, even though we are all for it, right?
The flip side is the zealots of “natural” medicine claiming cure because it is somehow an antithesis to medicine’s harm factor, therefore safer. Flip it again and you see the hard-core EBM pushers that say virtually nothing works for anything.
This leaves doctors powerlessly despondent and hopelessly reconsidering their craft. Here is where the individual has the power of choice - albeit very confusing at times. Shall we remain as natural as possible, then? Is that what vitalism is? Or “natural medicine”? This is also difficult. I have always maintained that there is very little that is “natural” about chiropractic despite BJ Palmer having written that it is. Well it is easy to argue that putting hands on the sore areas of the body is a somewhat natural thing to do, but the practice as I perform it took me seven years of quite “unnatural” student life to master it. I’d compare it to “natural justice”. Pure, yes, but not so simple to define. In particular when you have terminology like “subluxation v chiropractic subluxation” or “disease v dis-ease [hyphenated]”.
Health care of any forms is a skilled, learned craft with professional boundaries, and mental application. Just because it is allegedly “natural” gains it no extra kudos anyway. Hemlock poisoned Socrates ever so naturally. Additionally, medicine is as natural as the practitioner wants to make it. What is nonetheless the key to it all is that it is the product of human thought: man-made. By definition, natureis that which is beyond the construct of man. The confusion is perhaps that the philosophy of ‘natural’ cure seeks to remove obstruction to “vital” bodily intelligence. Medical “allopathy” seeks primarily to curb and suppress symptoms. Hence, that chiropractic does not address symptoms directly, it may be more “natural”. Whilst one could criticise the practice of allopathy as being incongruent with chiropractic’s “vital” natural approach, it would make complete sense to me that in order to adjust someone’s spine to functional perfection would only be worth it if that kidney transplant were done first so that they may stay alive! We need both approaches – so what if one is more natural or vital than the other? If there’s a need you probably should fill it!
Iatrogenesiswill become a more familiar term in future: it means illness caused unintentionally by the treatment or doctor. For example antibiotics used indiscriminately for colds, or viruses are causing the rise of super-bugs.
Careful study states that the risk of being hurt by a so-called “alternative” practitioner like a naturopath or massage therapist, dims in comparison to hospital injuries and deaths peaking at a reported one in ten procedures. My experience is that the public has always tried to follow the evidence.
As a student I always tried to unearth evidence, dug deep into the literature during my anatomy years, science years andchiropractic years, as did all my colleagues and fellow science students that we studied alongside in the buildings of the Wallace Wurth School of Medicine at the University of New South Wales.
EBM has been there since Lister looked at germs and Harvey studied blood circulation. Nothing new under the sun, it seems, except now we have the ability to control information more.
The next step - already taken - will be to control what you think with authoritarian personal opinion. Has that step be taken, already? Why didn’t the media run that story that showed spinal manipulation was more effective than drugs, before the same drugs killed those people from heart attacks, instead of going with that one about a drug that will be ready to cure this, that and the other in ten years time?
But enough about conspiracies lets look at what happens to the world when YOU change you- from within. Who needs the media then? Watch what happens when we all change our attitude, what happens to the media then? Can you imagine one of these stories - in the next chapter - leading the next radio bulletin and not one about religious hatred and war… or some politician yelling at another? Hang on, in this country we have banned testimonials...
The government thinks it is more important to protect you from an open forum in health care. That may be a good move away from quackery. But is it quackery that’s killing us more than mainstream medicine?
I denounce my colleagues who make promises to patients they cannot keep. Touting cures for diseases or straighten all scolioses or whatever, and rightly this should be marshalled accordingly.
All fine until you read that in a recent study heartburn drugs raise your risk of dementia by 44%. Then another study refuting the one above!
So, I can be prosecuted for saying anything eventuated from a neck adjustment beyond pain relief. But since when is less actually more, in the information game?
Shekelle, P.G., Adams, A.H., et al. (1991) The appropriateness of spinal manipulation for low back pain: project overview and literature review. Santa Monica, California: RAND; Monograph No. R-4025/1 – CCR/FCER.
The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain, Pran Manga, Ph.D., Douglas Angus, M.A., Costa Papadopoulos, M.H.A., William Swan, B.A., Funded by the Ontario Ministry of Health. August 1993.
When is a Neck Normal?
Maybe it happens in all professions?
The late Leonard Coen sang "There is a crack in every thing. Thats how the light gets in."
Perhaps surgeons overwhelmingly see chiropractors' failures? Of course they do. Does this warrant statement that much of chiropractic is dangerous? And I have seen medically injured patients too. Just because I spoke about it once or twice I got crucified as 'anti this and that' on the internet by groups with typing skills surpassing their ability to observe variation in perceptions. I am not "anti anything", just apt to question. But you can read all the lies about me on the nearest google search some day, because "skeptics" don't like it when you oppose their skepticism with scepticism (sic). Its frightfully convenient that only they're allowed to be questioning... Back to the point:
I am not anti-neurologist, either. I refer to them several times a year. And they're stellar physicians, the ones I choose because they have knowledge, are minimally invasive and treat respectfully.
I have come across some certainties in life. Not many, but some are. Like the flavour of my mum's home made tagliatelle. Its the benchmark for all cuts of dough to this day. But what gets into neurologists who take your well earned dough and tell you that your neck is normal when it isn't?
[caption id="attachment_1316" align="alignnone" width="300"] Same old arguments, disagreements, scepticism... based upon research, ignorance, or just arrogance?[/caption]
Its getting to me. It's hurting patients. And it deserves a blog...
Your damaged disc is just normal ageing?
Degenerative cervical disc disease is not always natural ageing. The truth is, sometimes it is, sometime it isn't. And certainly not when its traumatically induced.
Once a neurologist said to a patient and I quote: "there is no way the neck is related to any type of headache". But of course, the patient was probably deaf or stupid, it is presumed. He could not possibly have said that.
Most people can have degenerative cervical discs, decreased disc spaces, minor bulges and loss of lordosis and lead perfectly sane, painless, and happy lives. I know it.
Alas, When the disc is either:
- desiccated (yep like dried coconut)
- protruding into sequestration (not much comfort there as it pokes into central nerves)
- encroaching on nerve roots unrelentingly (ouch)
- cause vasovagal responses (yucky feelings)
- weakening a dominant-hand shake (I look like Arnold S, shake like a Phyllis Diller)
- causing a weak muscle reflex (clumsy)
- causing insomnia through constant nociceptive (pain signals) firing (baaah 1, baaah 2, ...)
- disrupting autonomic nerve function (I can't even eat this bland tofu)
- chronically actuating a sympathetic cascade stress response through spinal pathway stimulation... (smart words)
- contributing to cognitive decline/changes...etc. (brain fog is a good one I heard first about 10 years ago, now its in the parlance)
You CANNOT TELL THE PATIENT ITS NORMAL, or "go home and live with it" or merely "take these antidepressants" !
This is precisely the point where I rely on intelligent and diligently educated neurosurgeons.
Recently, a patient came in bearing gifts, his wife beside him in tears. I knew I was good, right, but, it turns out it wasn't even about the treatment.
They continued by stating that if they had not met me they'd be lost and hopeless thinking nothing happened to his neck when he was suddenly kicked in the head during martial arts. This caused an obvious damage of at least two discs clearly shown on MRI. See image below.
An irresponsible neurologist ignored it as a cause of any of the myriad symptoms and syndromes he had developed.
I see these cases time after time... after time.
Doing the right thing isn't always popular
Being a graduate of the oldest chiropractic college in the world means I was exposed to a "cervico-centric" education. That is, the neck was where the commotion and motion was at. The action. The vibe. The Lux! Yes we got microbiology, medical pathology and radiographic diagnosis... thank goodness.
A patient of mine, so utterly disgusted at his lack of neurological vindication that his recumbent BP of 70/40 (among other poor health nightmares) was not psychosomatic, went and started his own A-Neck-Dotes blog!
Twenty or so years later it means that I study a lot of necks and whats co-NECK-ted to them - Pain, sorrow, fear, stiffness, vertigo, brain fog, headache, umbilicus (a while ago anyway, wrapped around it), whiplash, suffering, more suffering and more fear of the future. Will I get better? What is the cause? Will my spouse stick around while I go mad?
Basically what we need to get across is that the most important thing your neck is connected to is ... a person! The neck area carries through it:
- every nerve from the body to the brain to tell it whats going on
- blood pipes from heart, also gauges managing pressure
- muscles that carry information that is like a million computers (I made that up) to affect balance, movement and motion
Commonly I get images like these:
[caption id="attachment_1280" align="alignnone" width="207"] I am 30 but my C3/4 and 5/6 are unrelated mutations concomitant to being smashed in the head by well-meaning combatant?[/caption]
This unfortunate male in his 3rd decade was kicked in the head in a sporting match.
The scan delineates extensive disc damage and his symptoms were clearly associated with all sorts of debilitating sympathetic effects and neurological symptoms which were starting to extend deeply into behavioural patterns. His life had become almost unliveable.
One of the doctors he saw was a specialist neurologist who advised that it was normal ageing.
This stuff infuriates me. For one, degenerative discs at the high level are rare, and the traumatic history described the site of injury satisfactorily. Also, athletic, healthy men in their 20s do not suddenly think suicidal thoughts the month after being knocked unconscious and having to deal with constant pain.
Please, neurologists and neurosurgeons, doctors, and yes some chiropractors too: listen to the patient. And do not dismiss necks like this as insignificant. You damage people, disempower them and make them feel like fools (with light wallets) for no benefit at all. Except perhaps that one day, one of these 6 foot giant kick boxers (not on antidepressants) might take it a bit hard and find a crack to let the light in.