Chiropractic case studies

The case rests, m'Lud:

http://www.telegraph.co.uk/health/healthnews/6216559/One-in-six-NHS-patients-misdiagnosed.html

Gaaaagggghhhh, what the pfwwwth. That’s it. I’ve had it up to here with these lot.

I’ve got a patient at C1 who’s got a raging sacroiliac joint and low-lumbar posterior facet syndrome (see this earlier post: http://chiropractor.blog.co.uk/2009/08/21/posterior-facet-syndrome-what-is-it-and-can-chiropractic-help-6775867/)
He had to go and see his GP so that his BUPA cover can be validated (which alone makes me spit - and see why later). The patient said, in an equally exasperated tone as this post, that the GP failed to look at any of his notes from his previous GP, who, incidentally, agreed with the chiro diagnosis. He then told the patient that the diagnosis and treatment we’d been advocating was wrong and that he should start stretching and get some exercise – on a sprained joint with some PFS to boot! Good grief, that’d be like me telling you to stretch an acute sprained ankle and walk about a bit on it. He then added that the only practitioners the patient should see should be osteopaths and then only those with a medical background (such as the one his wife was seeing). Good God, so the MSc level training is not enough to cover musculoskeletal issues such as this. Tellingly the patient, a wise man, said to me:

“I wanted to hit him and was thinking I do not like you now”

and, God bless him, he got up and walked out.

Well this was irritating enough but add to it this gem of resent research and I’m still gritting my teeth. There have been two bits of work done recently in the really solid journal Spine:

The first: Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine 2009; 34(11): 1218-1226.

The second: Orthopaedists’ and family practitioners’ knowledge of simple low back pain management. Spine 2009; 34(15): 1600-1603.

The background for these studies is that low-back pain (LBP) patients usually first consult with their GP (and then perhaps a specialist). Back pain is the most common musculoskeletal reason for consulting a GP. So you’d think it would be sensible if these GPs had a pretty high level of competence in managing these patients. However these studies show that, taken together, those who are consulted first (in most cases) for LBP are not managing this condition in an evidence-based manner.

The Buchbinder study compared GPs with no special interest to those with a special interest in LBP. Those with a special interest were more likely to believe that complete bed rest (17.8% vs. 9.2%) and work avoidance (24.5% vs. 15.8%) are appropriate management approaches for acute LBP!

The studies showed that:
• 53% of surgeons incorrectly recommended treatment with cyclooxygenase-2 (COX-2) selective NSAIDs as their preferred treatment, versus only 8% of GPs;
• 67% of surgeons and 46% of GPs recommended some form of bed rest;
• Although both groups acknowledged the potential benefit of spinal manipulation, 51% of surgeons and 57% of GPs incorrectly suggested that it was appropriate in all cases of LBP;
• 29% of GPs and 46% of surgeons failed to rate patient explanation and encouragement as “extremely important”;
• 53% of surgeons and 8% of GPs felt imaging was always necessary;
• Overall, seniority was not related to questionnaire scores, and surgeons performed significantly worse (roughly 25%) than GPs (p < 0.0001).
The authors, rightly, then state: “Taken together, these results provide strong evidence that poorer beliefs about management of back pain is driven by a special interest in LBP. These findings raise serious concerns about how back pain is currently being managed among general practitioners with a special interest in LBP.”

Also, it is particularly terrifying that orthopaedist knowledge surrounding simple LBP is lacking, especially when you consider the major risks and poor prognosis linked to their primary intervention (the dreaded and dreadful surgery).

And there is a great quotation in the review where it says that there is a “disappointing picture of medical management of simple LBP.”

More details are available at:

http://www.researchreviewservice.com/content/view/1031/131/

And you wonder why I rage at idiots like this GP.

And breathe

Chiropractors successfully treat a wide variety of paediatric health conditions. The evidence for this care rests primarily with clinical experience, descriptive case studies and very few observational and experimental studies. A good recent review done by two chiropractors examines this very elegantly. The review was done on the biomedical literature from January 2004 to June 2007 and it was designed to get a feel for the extent of new evidence about chiropractic manipulation for a wide range of paediatric health problems over that period. The review updated a similar, previous review published in 2005.

Tellingly, this systematic review concluded that:

1. There is no convincing evidence that spinal manipulation alone can affect the duration of infantile colic symptoms; (look a colon, you don’t see many of those about there days!)

2. The effect of spinal manipulation on sleep time, parental anxiety, quality of life and the number of infants meeting diagnostic criteria for colic could not be determined using available evidence;

3. The potential harm from the spinal manipulation of infants with colic could not be determined using evidence available from controlled trials.

There were also two trials carried out on enuresis one involving 171 children and the other 46 children. The first trial concluded the study results do not support the claim that chiropractic care in enuretic children is effective. However, the second trial concluded that the study results strongly suggest the effectiveness of chiropractic treatment for primary nocturnal enuresis!

There is a fair amount of evidence but it is clinically based and consists of 177 descriptive studies which are mainly single case reports and, so, interesting but not significant.

So we have some negative and a few positive results depending which way you are looking at the whole thing and what are we to make of it all?

The key thing is this: there is just not enough science out there to make a real judgement for and against and, as the chiropractic profession will freely and regularly admit, far more work is needed. Disappointingly the study added that there has been no “substantive shift in this body of knowledge during the past 3 1/2 years”. However it is worth bearing in mind that this is far from core business for the profession and far, far, more research is being carried on other subjects such as low-back pain in adults over the same period.

But if you are a practitioner who has numerous successful outcomes on single case basis you may arrive at some ‘premature’ conclusions and with some justification. However, generalizing such premature conclusions to larger patient populations is a position not well grounded in science and should be avoided if possible.

The health interests of paediatric patients would be advanced if more rigorous scientific inquiry was undertaken to examine the value of manipulative therapy in the treatment of paediatric conditions.
Let’s get it done.

Chiropractic manipulation in pediatric health conditions – an updated systematic review

Allan Gotlib and Ron Rupert
Canadian Chiropractic Association, CMCC Homewood Professor,
30 St. Patrick St. Suite 600, Toronto, Ontario, M5T 3A3, Canada
Parker College of Chiropractic, 2500 Walnut Hill Lane, Dallas, Texas 75229, USA

Rebecca Strange, one of our sports massage therapists, writes:

Sports massage treatment during training. The pre-event massage is most effective up to two days before any event. A sports massage can help the muscles perform at a high level during the event and during run-up training without over training and injury.

Use a sports massage to aid in warming up the muscles just before training or before the event. A sports massage can help stretch the muscles as well as stimulate blood flow and relaxation. By having the muscles well stretched and relaxed it can help prevent sports injuries.

Sports massage after the sporting event This is done to help in muscle recovery. A post-event sports massage can also aid in reducing muscle spasm and soreness. Post-event massages are short and direct lasting only 10-15 minutes. The post-event focuses on the muscles used specifically for the sport.

Sports massage is useful not only for its physical benefits but also for its psychological benefits. Using a sports massage can improve the performance of the serious athlete as well as the recreational athlete. By reducing body tension and increasing confidence through massage therapy an athlete can reach its potential.

We’ve had a few of you ask what core exercises should you be doing. Now, there are reams about this on the web but my spin, based on experience and study, is get the foundation right and you can build a really legendary back – mess up the first steps and the thing will fail.

Firstly let’s cover the don’ts as they are stuffing loads of backs up and a lot of good work is being thrown away. Here they are:

1. No more sit-ups, never, ever. Crunches, yes; sit-ups no, and for good biomechanical reasons that I can explain another time if you ask me to.

2. No more dorsal raises. Ditto.

So here are the things we, and Professor Stuart McGill (uber back Guru), suggest you start off with. I’ve searched the web a bit for youtube examples of the exercises we suggest as pictures speak a thousand words and this should make the explanation a bit clearer. These seem good examples of the exercises.

Always start with 6 cycles of these to 'neurologically' warm up your low-back:

http://www.youtube.com/watch?v=CXRsjICsGnc

then start the core stability exercise itself THE PLANK (whoop, whoop):

or have a look at this:

http://www.youtube.com/watch?v=9Ar2iRusnnc

Each plank/bridge position you do should be done to the point that you start shuddering (which usually is a neurological control issue rather than a muscle fatigue problem) or until you reach the 20 second point and rest for a bit and then do it again, and again. The next time you do the exercises try to increase the time you are in the bridge position with the goal being that you can crack 30 seconds in the plank.

How often, as often as you like and more the merrier.

Then tell me and we can go to the next step. Hope this helps.

There, done it. My patient from last week with BPPV came in today and said "Great, I've not felt dizzy all week-end". Now I know this may just be luck, timing or placebo but it seems to me that if you follow the protocol you do get success. Give it a go.

Benign Paroxysmal Positional Vertigo, or better BPPV, sounds crazy but it is what it says on the tin, it’s just that the language on the label could be Russian for all it mans to you or me. However, benign is a good word, it is one of those words you want to hear when anyone is talking about medical things about you, and I suspect we are all pretty familiar with it. Paroxysmal means that the condition occurs in attacks rather than as a steady problem. Positional means it’s all related to what you do with your body, in particular with your head. And vertigo is a nasty feeling of relative movement, usually spinning, between you and your surroundings and has recently been described to me as “I feel like I’m falling backwards and to the right”.

Now it may be benign but it can still be horrible with you, in some cases, stuck in bed because any movement causes you to throw up. In the later stages it leads to episodes of vertigo each lasting less than 60 seconds but all of this may settle after a couple of weeks. However, sometimes, it does not.

There is a beautiful test for it called the Dix-Hallpike test. And here it is in this cracker of a link:

http://www.youtube.com/watch?v=eOuzUi5ckrk

I recently had a patient with undiagnosed, or more accurately un-treated vertigo. After a detailed history to rule out the other forms of vertigo I subjected her to this test and her reaction was a case-book response. I asked her to sit on the bench and rotate her head to the right. I then lowered her back towards the end of the bench where her head hung over the edge a bit. There was a second where nothing happened giving her enough time to say: “I feel OK” and then her eyes went crazy and she then went very quiet for about 20 seconds before saying “Ugg, that felt horrible”.

The problem was a post-traumatic one for her as she was involved in a nasty crash some time ago (2 years!). The condition is caused by ‘debris’ in the semicircular canals of the ears which move about in response to gravity and so stimulate the position detecting structures in your ears giving a false reading. This is a bit like motion sickness where your eyes are out of synch with your body.

The cure is a bit tricky. You can’t open these structures up and wash the debris out, at least not yet, and you can’t take drugs to dampen down your nervous system as you’ll spend most of your time flat on the floor. However, luckily, there are slight bulges at the ends of each of your canals that with some cunning manoeuvres you can get the debris to float (sink?) into and not stimulate your canals. The manoeuvre is the Epley manoeuvre. Now, this is a tricky manoeuvre and should be done by someone on you, so in this case by me, her chiropractor, not by you with a bit of paper in your hand. And I’d suggest that if you are about to do it on a patient then practise on a well friend first off a couple of times to get it right. Once you’ve got the hang of what you are doing then lay it on.

Look at this appalling article for an example of rubbish dressed up as science:

Safety of Chiropractic Interventions: A Systematic Review
Gouveia L, et al.
Department of Neurology, Hospital de Santa Maria, Lisbon, Portugal
Spine 2009; 34(11): E405-13.

Now, I’d have been really ashamed to publish such a thing and to attach my name to it. It is also a real shame that it got into ‘Spine’, which is usually a great journal, without some questions being asked about the quality of the science behind the article, though it will be interesting to see what the editors say when the letters start to pour in.

The utterly rubbish authors indicated that recent reviews on the effectiveness of chiropractic said that the efficacy of spinal manipulation was not demonstrated for the treatment of “any condition”, citing a chiropractic clinical practice guideline that was published in the Journal of the Canadian Chiropractic Association (the JCCA). However, there was no such statement in the JCCA article. What the guidelines actually said is:
“Treatment recommendation 2: Based on all the evidence…we also recommend manipulation…for patients with acute or chronic pain…”
Which I’d have suggested is about as far from “any condition” as you can get.

In the article they provided background information on chiropractic, citing negative reviews by a known chiropractic detractor (namely Professor Edzard Ernst) which is fair and should happen but only if positive reviews are not ignored, which, you’ve guessed it, they were. This prejudicial handling of the evidence set the tone for the entire review.

There were a series of shockers in the article:

1. A literature search identified 151 potentially relevant articles, so a good number that should reveal something. However, a staggering 110 of these had to be discarded because the patients had an underlying disease that predisposed them to adverse reactions and other reasons. So, far form a glorious start.

2. Only one RCT was included and the shockingly bad authors referred to it as “…the only randomized controlled trial published.” This gives the impression to the reader that only one RCT has ever been done in chiropractic. This is bonkers. There are loads of chiro RCTs and most of them have commented on the number of adverse events that occurred and therefore, you’d have thought would have been included in this shoddy review.

3. In the study six other studies were included. The manipulations were by physiotherapists, osteopaths and manipulative therapists in two of them, so 33% of the study. It has just got to be inappropriate to include adverse events attributed to other types of practitioners in a study reporting on chiropractic safety, surely.

4. And they ‘missed’:
Rubinstein SM, et al. The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study. J Manipulative Physiol Ther. 2007 Jul-Aug; 30(6):408-18.

Which says:

“Adverse events may be common, but are rarely severe in intensity. Most of the patients report recovery, particularly in the long term. Therefore, the benefits of chiropractic care for neck pain seem to outweigh the potential risks.”

5. However, the most unpleaseant error is an intentional, or not, misquote of an article by Michael Haynes who actually reported that “…there were perhaps fewer than five cases of manipulation-related stroke per 100,000 patients who had received cervical manipulation from a chiropractor.”
Gouveia and cronies turned this to read:
“5 strokes/100,000 manipulations”
Which in anyone’s book is a huge difference from what Haynes reported. To add insult to injury, this inaccuracy was repeated 4 times including the abstract. It has been reported that the typical chiropractic patient in North America is seen 12.8 times on average (7) and other studies have reported even more. Using the 12.8 figure, the statistic becomes fewer than 5 strokes per 1,280,000 manipulations.

A review of this article said:
“Being so riddled with flaws, one cannot apply any of the findings of this article to clinical practice.”

Which I have got to say I agree with.