Healthcare Professionals - FAQ's
- What can we expect if we refer a patient to Spurlock Spine Centre?
- What about curing cancer?
- What is the major difference between chiropractic and physical therapy? Why should I send a patient to see a chiropractor instead of a physical therapist?
- What are some of the benefits of chiropractic adjustments or manipulations to the spine?
- Are there any risks or contraindications to seeing a chiropractor? What about stroke?
- What happens if we send a patient who is not a good candidate for chiropractic treatment?
- What does the research say about chiropractic care?
- What is the education and training like for a chiropractor?
- Does insurance cover chiropractic treatment?
- Once a patient is seen, do they need to keep coming back forever?
What can we expect if we refer a patient to Spurlock Spine Centre?
One thing which has been common in the past is that there has been poor communication between the two professions. A timely report will be furnished and sent to the referring doctor. This report will outline the history, pertinent exam findings and proposed treatment plan, complete with beginning, middle and end.
What is the major difference between chiropractic and physical therapy? Why should I send a patient to see a chiropractor instead of a physical therapist?
One thing that sets the chiropractic physician apart from the physical therapist is the chiropractic adjustment or manipulation. To fully understand the difference, one must also have some knowledge about joint receptors and muscle fibers.
Golgi tendon organs (GTOs) are high threshold receptors and their input is inhibitory. This means that when they are activated, muscles relax. They have a higher threshold than muscle spindles. Recent studies show that fast stretch force of sufficient magnitude will primarily fire GTOs causing inhibition of alpha motorneurons ipsilaterally. Speed appears to be the critical factor. Insufficient speed will primarily fire low threshold muscle spindles resulting in excitation of alpha motornerons and can perpetuate increased muscle tone, spasm and pain. Fast stretch that fires GTOs activates inhibition of alphamotorneurons. Joint cavitation adds sufficient speed to result in high threshold GTO discharge. Skill of the practitioner is therefore very important. Murphy, DC, DABCO. Am. Journal of Clinical Chiropractic 1997; 7(2):23-24.
Passive stretching, exercise and massage alone are unable to achieve the effects of a skilled manipulation because they do not activate the golgi tendon organ and hence the inhibitory effect to the muscles and joint receptors is never achieved.
Newer practitioners and those who have limited training in manipulation, such as with weekend seminars and courses, do not posess the speed and skills necessary to activate GTOs to get that inhibitory effect. Their results are less than favorable, often causing additional pain and splinting of the involved muscles.
What are some of the benefits of chiropractic adjustments or manipulations to the spine?
One mechanical benefit is activation of the muscle spindle which results in a relaxation of the muscles and increased blood flow to the associated area. By moving the joint through the paraphysiological space, the associated muscle is stretched to the point of relaxation. The result is a reduction of muscle spasm and a decrease in pain stimuli to the spinal cord. This is why chiropractic is so successful in helping people with acute muscle spasms. No amount of exercise or massage therapy accomplishes this result.
By providing a joint with its greatest movement, the chiropractic doctor allows the greatest stretching of the associated muscles and ligaments. This stretching provides for a better alignment of the healing tissue. This results in a more functional spinal joint complex.
Neurologically, the greater movement a joint has, the smaller the transfer of pain impulses which produce spasm and pain. Hence, the manipulation can break the cycle of spasm and pain.
Below, are some of the effects of spinal adjustments/manipulation:
- Increased range of motion
- Decreased pain/analgesia
- Reduction of spasm
- Breaking down of scar tissue
- Reduction of painful stimuli into the spinal cord
- Breaking down of adhesions within the joint
Are there any risks or contraindications to seeing a chiropractor? What about stroke?
This is an issue which has received a lot of attention in the press. There are risks, however they are extremely rare. For example, there is a 3300 times greater risk of dying from the adverse effects of NSAIDS for those who have been taking them for more than 2 months. The relative risks of having a stroke following spinal manipulation of the cervical spine is about 1 in 5.85 million manipulations.
The summaries below have compared the risks of cervical manipulation to the risk of NSAIDS and their associated adverse effects. They are quite interesting and really put the risk into perspective. It is worth the read.
Relative Risk of NSAIDs & Cervical Spinal Adjustment Wolfe MM, MD et al. Gastrointestinal Toxicity of Nonsteroidal Antiinflammatory Drugs. New Eng J Med 1999; 340(24):1888-99. The annual number of hospitalizations for serious GI complications related to NSAIDs is estimated to be at least 103,000. Conservative estimates of NSAID-related deaths in the US is 16,500. If deaths from GI toxic effects of NSAIDs were tabulated separately, these effects would constitute the 15th most common cause of death in the US (similar to number of deaths related to AIDS & considerably greater than the number of deaths from multiple myeloma, asthma, cervical cancer & Hodgkin's disease).
Lauretti W, DC. What are the risks of chiropractic neck adjustments? What JACA 1999;36(9):42-47. NSAIDs: one study found a 4/10,000 annual mortality rate for NSAID induced ulcers in Pts treated for non-rheumatic conditions such as MS pain & DJD, extrapolates to 3,200 deaths in the US/yr. A conservative estimate of risk from death due to stroke cause by cervical spinal manipulation is at one fatality per 4 million. Summary: ½ of 2 cerebrovasculal accidents (CVA's) per million cervical treatments. One third of cases resolve with mild to no residuals. Therefore, there are about 40 or 50 SM caused strokes in the US per yr & perhaps a dozen deaths. There may be as much as 100 times greater risk of dying from an ulcer due to taking NSAIDs. If you drive 6 miles each way to get to your chiropractic visit, you have a greater risk of being killed or seriously injured in a car accident while traveling to the office than of having a serious complication from a neck adjustment.
Tramer et al. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. Pain 200; 85(1-2):169-82. Combined data from RCTs and observational studies of chronic (>/=2 months) use of NSAIDs which gave information on gastroduodenal ulcer, bleed or perforation, & death due to these complications. In a total of more than 250,000 Pts included in the trials reviewed, the authors calculated the average 1 in 1,200 patients taking NSAIDs for at least 2 months will die from gastroduodenal complications who would not have died had they not taken NSAIDs. That is 833 deaths per million Pts who use NSAIDs for 2 months or more. This is 3332 times more deaths per million than from cervical spinal adjustments.
Haldeman S, MD, PhD et al. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999;24(8):785-794. The potential risk of vertebrobasilar artery dissection after spinal manipulation is reported to be somewhere between one in 400,000 to one in 1.3 million spinal manipulation sessions. In the absence of a definitive trial, the current understanding of the exact mechanism & risk factors for vertebrobasilar artery dissection must be considered no more than speculation. Vertebrobasilar artery dissection after neck mov't, trauma, or manip should be considered a rare, random, unpredictable complication assoc with these activities.
Terrett A, DC. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation. NCMIC 2001. Age distribution of 255 cases of post-SM stroke. 1934-1999. Average age: Males 39.5; Females: 37.1. Often the words chiropractic &/or chiropractor have been used in publications to describe any practitioner of manual therapy regardless of the training of the practitioner. The 1999 J Neurology report on 10 cases in an article titled "Stroke following chiropractic manipulation of the cervical spine." These chiro maneuvers were performed by 7 orthopedists, one PT & 2 health practitioners who cannot be accurately defined (no chiropractors). In the text of the article, the words "chiropractic manipulation" were used 14 times, "chiropractic manipulations" eight times, "chiropractic maneuver" twice, "chiropractic cervical spine manipulation" once, & "chiropractic cervical spine manipulations" once. Age & gender distribution indicates no greater risk in any age range. The increased number of accidents reported in the 30 to 45 yr age grp appears to reflect the age grp most likely to seek SM. Pt's age & the presence or absence of degenerative or vascular changes don't seem important in assessing a Pt's risk. Exact age & gender are known for 233 of 255 (91.4%) of Pts. Males (n=101; 43.3%) age 7-87 with an ave of 39.5. Females (n=132; 56.6%) ages 20-74 with an ave of 37.1. Reflects the greater number of female Pts in chiro offices. Studies of chiro Pts reveal male 40.7% to female 59.3% and 44.8% to 55.2%. Pts who suffer VBS (vertebrobasilar stroke) after neck SM generally are young healthy adults, have an uneventful med Hx, have none or only a few of the stroke risk factors, cannot be identified a prior by clinical or radiologic exam & women do not appear to be at greater risk.
Terrett A, DC. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation. NCMIC 2001. In the 65 yr period 1934-1999, there are only 37 cases of death known to have occurred in the world, from all different types of spinal manipulation practitioners, with only 19 being related to DCs or chiropractic manipulation. Some may already have a stroke in evolution, & therefore had an identical outcome even if they had not consulted a DC. Yet MDs often portray DCs as a serious risk to the public. While it may be argued that yrs ago there may have been an element of under-reporting, this is now less likely with increased awareness, & claims experience indicates that significant injury will nearly always lead to litigation.
Haldeman, DC, MD, PhD, Carey, DC. Arterial dissections following cervical manipulation: the chiropractic experience. Can Med Assoc J 2001; 165(7):95-6. Review of malpractice data from the Canadian Chiro Protective Assoc (CCPA) to eval all claims of stroke following chiro care for 10 yrs between 1988 & 1997. The Dx by the treating neurologist was obtained. Results suggested that @ 134.5 million cervical manips were perfomed by DCs covered by CCPA during this period. There were 43 cases of neurological Sx following cervical manip over 10 yrs. Of these, 20 were minor & not Dx as a stroke. 23 cases of stroke or vertebral artery dissection following cervical manip were reported. There are over 4,500 DCs in Canada. The likelihood that a DC will be made aware of an arterial dissection following cervical manip is approx 1:8.06 million office visits, 1:5.85 million cervical manipulationss, 1 in 1,430 years of practice. This is significantly less than estimates of 1:500,000- 1 million cervical manip based on surveys of neurologists. It's probable that the experience of DCs does not reflect all dissections that occur following cervical manip.
Haldeman, S., DC, MD, PhD, et al. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy. Spine 2002; 27(1): 49-55. A review of 64 unpublished medicolegal records with extensive documentation describing cerebrovascular ischemia (CVI) after cervical SM. This is the largest case series of CVI assoc with cervical SM. The nest largest was only 10 cases. These 64 cases were referred to a Haldeman for review over 16 yrs from the United States & Canada. The study was unable to identify factors from the history & P.E. that would assist in isolating Pts at risk of CVI after cervical SM. CVI after spinal manipulation appears to be unpredictable & should be considered an inherent, idiosyncratic, rare complication of cervical SM. It's assumed CVI may be avoided by screening Pts thru Hx and head & neck positioning to evaluate patency of the vertebral arteries. In 27 cases, DC described screening before spinal manipulation with Pt's neck in ext/rot. None of these Pts showed adverse responses to this screening test. Current frequency estimates vary from 1 in 400,000-500,000 to 1 in 3.85 million. Most CVAs occur in Pts 30-50 yrs. There is no evidence that older Pts at risk for atherosclerotic vascular ischemia are more likely to incur complications from spinal maipulation. None of the arteriographs in 64 cases showed the presence of arteriosclerotic plaquing. Therefore, the widely accepted risk factors for arteriosclerotic & thrombotic strokes probably do not apply; screening for bruits, hypertension, DM, smoking, to identify Pts at risk for arteriosclerotic strokes does not appear to be of any benefit in determining the likelihood that a Pt may be at risk for a stroke after SM. Of 64 cases, 2 resulted in death & neither showed a pathology in the vertebral arteries on autopsy. One Pt had a hemangioma of the venous plexus in the pons which hemorrhaged & the other had a ruptured berry.
What happens if we send a patient who is not a good candidate for chiropractic treatment?
If after an evaluation, it is determined that a patient may not be a good candidate for chiropractic treatment, the patient will be sent back to the referring doctor. One common misconception, is that just because a patient may not be a good candidate for spinal manipulative treatment, there is nothing that can be done for them. There are many tools at the chiropractor's disposal which can still help that patient. Chiropractors do much more than just adjust the spine.
For example, a patient with a prior cervical spine fracture from years ago or advance osteoporosis probably should not have their neck adjusted or manipulated. Massage, moist heat, gentle stretching, gentle joint mobilization, traction, exercise, postural correction and ultrasound are all performed by chiropractors and are quite beneficial.
What does the research say about chiropractic care?
Please see the section below titled research. This is a very interesting and surprising collection of some of the research studies about chiropractic care and spinal manipulation. For example, Paul Shekelle, MD of RAND and UCLA provided an update at the Primary Care Forum V in Montreal and were reported in the Annals of Internal medicine. He reported that:
Manipulation has a clear advantage over comparison treatments when all those therapies are pooled together. "When we pool everything, both the short term effects and the long-term effects favor manipulation over all the comparison therapies in the treatment of acute pain."
What is the education and training like for a chiropractor?
Please see the link to a chiropractor's education.
Does insurance cover chiropractic treatment?
In most cases it does. Please see our insurance page.
Once a patient is seen, do they need to keep coming back forever?
No. Most cases seen by doctors of chiropractic will respond in a relatively short period of time. In certain cases, longer treatment will be recommended, but on average it may take 12-16 visits. Once the original condition that caused the pain and discomfort has been resolved, it may still be necessary for you to return from time to time for supportive care.
Our goal is to get the patient out of the office and to returning to the activities they were doing prior to their injury. Some conditions however, which have been present for years may take longer to heal and correct. An example of this may be the person who has a 20-year history of low back pain with arthritic changes in that region. Four weeks of care will not be able to "undue" the years of damage, hence, a longer period of treatment may be prescribed. The fact is, some people have neglected their ailment for years and hence, their condition may take a while to correct.