You might think that there is some kind of standard of care when you go to a doctor. For the most part, there’s not. Doctors within the same specialty can vary significantly and often there are many different treatment options available for the exact same conditions.
It can be hard to know what you’re going to get when you go to a doctor. Will they listen? Will they offer you options? Will they explain things? How much will it cost?
The treatment you get is very significantly determined by the philosophy and clinical thought process of the doctor you see. This can be a very good thing and a very bad thing. You might think there is a standard of care that has been shown to be the best for your condition. Sometimes there is, but for most things, there is not. Commonly, financial motivations play a role, sometimes a very large role – but I’ll leave that as a separate issue.
A couple examples
Did you know that a lot of doctors prescribe statin drugs (cholesterol lowering) as a preventative measure against heart disease because they feel it’s safe and a good preventative measure? Nevermind that statins disrupt energy production on a cellular level (ATP for the geeks) and have been shown ineffective as a general preventitive measure (1,2).
Did you know that dentists don’t agree on when to drill and fill a cavity? Some are aggressive and some are conservative. (3)
It’s not that often that we get insight into how and why a doctor does what they do. We assume and hope that they’re keeping up with research and that they have our best interest at heart.
I want to give insight on my clinical thought process and treatment strategy based on a recent case in which someone came to me with low back pain.
Two Chiropractors, Same Profession…
Completely Different Thinking…
I recently had a patient come in with a lumbar disc herniation that seemed to have happened from a recent bout of work on the farm where he performed a lot of bending, lifting, and twisting.
What really happened was that years of prolonged sitting in a lumbar flexed and often rotated position caused degeneration, or we could even say, thinning of the outer disc layer. Couple that with uninformed movement mechanics as he lifted numerous hay bales, and you have the recipe for this injury. It’s like hitting your thumb with a hammer over and over, and then slamming it a few good times. Only with the back, people usually don’t know what the hammer is.
On the first visit, he told me about one of his co-workers who was having what seemed to be the exact same symptoms, in the exact same location, even on the exact same side. The symptoms were low back pain with radiating pain to the sacro-iliac/upper glute region. There are other problems that can show the exact same symptoms, but it won’t change the point. She told him that she went to a chiropractor who adjusted the very top bone in her neck, called the atlas or C1.
I’m not sure how many treatments this took, and I certainly don’t know all the details of treatment, but what seemed apparent is that she became relatively symptom free and was apparently quite happy with treatment.
You might be wondering what adjusting the upper neck has to do with the opposite end of the spine. Here’s a picture to sort of illustrate the PHILOSOPHY of the connection. I emphasize philosophy because this is a completely theoretical model with a lot of holes in it. But to the person who feels better, who cares, right? I agree.
Upper cervical specific treatment is interesting from a number of directions. There is some interesting research and numerous anecdotal reports of very successful treatment with headaches, migraines, ear infections, vertigo, and even lowering blood pressure. The very plausible reason is that the area is so close to the brainstem wherein lies much of autonomic nervous control as well as the cranial nerves. There is also plausible reason to believe that upper cervical area joint/muscle manipulation can have pain inhibiting effects anywhere in the body. I won’t go into the neurology lesson.
So, from a pain and symptom relieving standpoint, there is no particular fault to the upper cervical approach.
The problem with the upper cervical approach and many other symptom-based approaches and one of the ways that most sets my practice style apart is in considering the actual problem. The person with the disc herniation doesn’t have a pain problem; it’s hard to see that when you’re in the midst of it, but the pain is a good thing. They don’t have a muscle imbalance problem or a short leg problem. All those things might be present, but what they have is a movement problem and an education problem. The hands on manual therapy is great to reduce pain, expedite healing, decrease perception of threat, and generally make a person feel better. But if you stop there, you have a person who most likely doesn’t know how they hurt themselves, if it will happen again, or what to do to prevent it from happening again. From a business perspective, it’s great to create a situation where people rely on you, but it’s an inferior model to what could be practiced.
My Approach and What I do differently
Let’s start with these three questions.
People generally want to know:
1) What’s wrong?
2) How long is it going to take to fix it?
3) How much is it going to cost?
In the case of an L5 disc lumbar herniation, can we reasonably say thatwhat’s wrong is that a person has an upper cervical misalignment? Just because there is symptom relief doesn’t mean we addressed the problem. There are all kinds of explanations for symptom relief; but have we addressed what is wrong?
We cannot reasonably conclude that the primary problem is one of upper cervical misalignment.
In my approach to this issue, with consideration to the model shown below:
- I use manual therapy and adjustments to mobilize tissues and joints and reduce pain,
- address the daily fault(s) and look for reasonable solutions,
- address movement related to more demanding tasks of physical labor such as work, exercise, hobbies, or picking up your kids – and then we practice.
In the process we will strengthen muscles if they need to be strengthened. In the end, my approach should leave you with an understanding of how and why you were in pain, relief from your pain, and confidence that you are stronger and more capable and much less likely to be reinjured. This generally resonates very well with most people, but I’ve had a few people where it seems to be outside of their paradigm. I say my piece, but I don’t try to force them into my box.
Working with humans is rarely, if ever, black and white. Humans are complicated. They have different wants, needs, goals, priorities, etc. Specialists either recognize their narrow scope and do great work within it, or they start trying to fit everyone into their tiny little box. You know the saying, “If your only tool is a hammer, everything starts to look like a nail.” While there is certainly an important role for the upper cervical specific chiropractor, they tend to get a bit carried away. In large part that comes from the general notion that most of these practitioners are more interested in philosophy and vitalism than they are in science. Even though they love when science validates their approach, it doesn’t really matter because they are believers in their approach not because of science but rather regardless of science.
If you like this kind of post then you will enjoy – Do you have a short leg and does it matter – Why I stopped using short leg checks and a better way.
Sources
- Littarru G. P., Langsjoen P. Coenzyme Q10 and statins: biochemical and clinical implications.Mitochondrion. 2007;7((suppl)):S168–S174. Epub 2007 March 27.
- http://www.ncbi.nlm.nih.gov/pubmed/20585067
- Do Dentists Agree About Cavities?
