“To a certain point… we can wrap ourselves flatteringly in our giftedness, but a point comes when the talent is so utterly extraordinary that we cannot deny it as a gift it is so obviously beyond us.”
From time to time on this blog I’ll rant about pet peeves. My goal is to provoke healthy debate and discussion, and hopefully provide some impetus to long-needed change, and ultimately help patients receive a higher standard of care. Every profession has its warts; chiropractic is no exception.
In this post I tackle the ugly truth about the use of x-ray images to sell multiple-visit care packages to prospective patients. This is not what radiology is supposed to be for, yet this shameful marketing practice continues in 2015.
Getting Our Bearings
In their book Selling Sickness Ray Moynihan and Alan Cassells level a powerful indictment against the pharmaceutical industry, and the broader health care industry, for attempting to “medicalize” everything. They note that PMS has become a psychiatric disorder, hyperactive children all have ADHD and need a prescription, and most of us are “at risk” because the “safe range” for blood cholesterol levels have been so low we all qualify for a daily dose of statin drugs. And the advent of the MRI, a very sensitive imaging technique, shows so much abnormality that 3 or 4 items of diagnostic concern will be identified in over half of those imaged who have no symptoms whatsoever.
Is it against this fair and balanced backdrop that, most certainly to the chagrin of many chiropractors overusing x-rays, I lament Chiropractic X-ray Abuse.
Selling Sickness Chiropractic Style
The problem is not that chiropractors can order, perform, interpret or report on diagnostic radiographic images. I am proud of the education I received in school covering radiation physics, x-ray technique, and diagnostic x-ray interpretation while in chiropractic college. Further, neither time or space would allow me to innumerate the good that has been brought about from chiropractors who use diagnostic radiology judiciously and who have served their patients honorably, even saving lives. This post is not about the privilege of use. In fact, the chiropractic profession was born in 1895, the same year Wilhem Roentgen discovered x-rays in Bavaria, and chiropractic was among the first health care professions to incorporate “roentgenology” into clinical practice.
The problem is the use of x-rays by chiropractors to “Sell Sickness,” much like those who’s job it is to expand their profit margins by selling stuff in the medical arena. In the case of statins, for example, it is not the medical physician who sells the drug; the pharmaceutical company does this for her. How many drug commercials in America (or New Zealand, where commercials are also legal) end with: “Ask your doctor if _____ is right for you.”
How Chiropractic X-ray Abuse is Done
In some chiropractic clinics the decision to take x-rays is a foregone conclusion. It is so routine, in fact, that you might not even see the chiropractor until after a member of the clinic staff x-rays you. This is usually a postural x-ray that is obtained with you sitting or standing upright and erect with opposing frontal and lateral views. In some cases you might also be x-rayed while bending or rotating your body.
In cases where you do see the chiropractor first, it’s the same drill. You are going to get x-rays, period. The reason? The x-ray films will be placed on a view box or computer screen and marked with black (or better yet, red!) crayon (or its digital equivalent) with one and only one purpose: to prove to you that you are damaged and need repair.
To summarize, postural distortions that will be found on you x-rays and the superimposed lines are intended to scare you; to “sell” the fact that you are “sick.”
To this day many chiropractors will tell you that you have a pinched nerve, and that your vertebrae (the bones in your spine) are “out of place.” I hear this on the radio here in Denver: “If the nerve to your ______ (liver, thyroid, etc.) is pinched, it is just a matter of time before you’ll get ______ (liver, thyroid, etc.) cancer.” Thankfully this type of chirobabble is on the decline, but it’s out there. Doesn’t it seem that some of the worst elements in any given profession are the ones who are the most vocal and visible. Embarrassing. Deplorable. Weightless. Greedy. Or if sincere, sincerely wrong!
The Treatment Plan
The x-ray presentation is just the first part of your “report of findings.” You’ll be asked to bring your spouse back on a subsequent visit to discuss how broken, damaged and fragile you are, and to scare both of you some more. Then you’ll talk finances.
Some chiropractic marketing gurus teach that if the chiropractor can get new prospects to come back 3 or 4 times in short succession for a structured indoctrination (again, called the “report of findings”) they can close the sale on your life-long dependence on chiropractic care. The financing is linked to the number of visits that will be needed to correct your problem (usually dozens; among the braggadocious — 100 or more). Prepayment with a credit card always wins a discount. Always best to zip the plastic before one begins. If not, “financing is available.”
Note the Negative Consequences
First, you’re told you need x-rays. Ionizing radiation is not inconsequential. The benefits in any given situation must outweigh the risks. Using x-rays to sell a multiple-visit chiropractic plan of care is not a good reason to send ionizing radiation through people.
Second, you’re made a victim. Not the victim of criminal activity. You’ve been made the helpless, passive recipient of bad news about which you can do nothing. You have a “subluxation” and you need the chiropractor to fix it for you. And that is going to take a long time and lots of “corrections.” Weeks. Months. Or perhaps years. OMG.
Third, the idea that you are “fragile” has been reinforced. The “hand on the stovetop burner” episode from youth is a great lesson in pain. Our earliest education in the school of pain tells us that “pain means tissue damage.” Right? This belief carries over to our views toward back pain, neck pain, headaches and other common ailments seen by chiropractors. The x-ray reinforces that there is something damaged in there, and that you are fragile. You need to learn to depend on the skills of the chiropractor to help you because you are not able to help yourself. “Your low back is not stable, Mrs. Smith.” Translation: “You are fragile, broken and helpless.” It doesn’t help that the pain you are feeling is so severe that this tends to validate the chiro-story you are being told.
Fortunate or not, back pain, neck pain, and headaches are usually not signs of tissue damage or fragility. Some pain experts (e.g., Kieran O’Sullivan, Ireland) equate back pain with stomach ache. It happens as part of life experience, but it doesn’t mean your stomach is (necessarily) broken. Pain researchers (e.g., David Butler, Lorimer Moseley) teach us that feeding our fears, equating pain with tissue damage, and increasing our self sense of fragility all add up to only one sorry thing: more pain. Chronic pain.
Add the 3 items above together and what you get is a totally botched opportunity (not YOUR fault!) to get over the pain and get on with your life, free and independent of endless, ongoing passive spinal adjustments/corrections.
It Goes On!
What is unbelievable to me is this: it is 2015 and this type of thing still happens with some frequency. Happily, consumers of healthcare are getting savvy. Crap-detectors are on an all-time high; people are vigilant about hucksterism. But the take-home message is worth heeding: If you are standing in front of an x-ray view box hearing how messed up your spine is — maybe it is! But if, subsequently, you’re asked to zip your credit card for thousands and being assured it is a good deal, turn and run.
For those of you looking for ammo against the chiropractic profession, get a life. Start by looking in the mirror at your own profession. It’s fraught with problems too. Maybe I’ll post a pet peeve about it someday. In the meantime, calling attention to chiropractors who are behaving badly by no means diminishes the fact that their are the vast majority of my colleagues who do good. I hope they are willing to read this far into the post and hear and feel what I am saying. We are a clinical science. Many, if not most of us, are educated, passionate, and evidence-based. But clearly I am calling the bad apples to the carpet, here.
Some people with neck pain, back pain or headaches have a serious condition. X-rays may be entirely appropriate in the initial diagnostic workup of your problem, especially if it is severe, wakes you up and night, won’t go away, is associated with fever or night sweats, or is associated with loss of appetite, weight loss or weight gain. This blog is for informational purposes only. It is not intended to diagnose, treat, cure or prevent any disease or illness. Neither do the comments made in this blog constitute medical or chiropractic advice. if you have a question about your health, including whether you do need an x-ray examination or not, please see your chiropractor, medical physician or other health care practitioner to “ask if x-rays are right for you.” 🙂
Thanks for reading!
I want to fix stuff. Fast. My patients know it. Athletes at whatever venue know it.
What is a FIX?
Defining “fix”: Complete resolution of symptoms. Correction of correctable underlying faulty biomechanics. Accommodation for uncorrectable anatomical perpetuating factors. Restoration of predisposing length/strength/control/loading problems.
This is a tall order, of course. For athletes suffering from chronic overload who are in-season, “fixes” might be possible, and they might not. Nevertheless, these individuals hurt and they are asking for my help.
Is a purist, single-modality approach justified when the competition is upon us and there’s no time for rehabilitative exercise?Must we declare our allegiance to nothing-but-exercise when we have the opportunity to reduce or eliminate pain using approaches that have not been shown to cure a particular chronic overuse injury?
A Case to Introduce my Case
Example: Plantar fascitis. This weekend we have the Colorado State Track & Field Championships for High Schools. I saw a distance runner who will compete in three events. A simple test running outside my clinic revealed 5/10 pain immediately upon running. Both feet hurt, but one side is quite a bit more severe than the other. This problem has been brewing for several weeks, but I just yesterday saw this athlete for the first time. Examination confirmed plantar fascitis.
I did not launch this athlete into a barrage of passive therapies. I didn’t “adjust” her foot with an Activator, perform miracle manual mobilizations, or jelly up her soles with therapeutic ultrasound. But neither did I ignore the need of the moment. Using a tab-and-pull method adapted from techniques I learned from Tim Brown, DC (called specific proprioceptive response taping) I applied leukotape to lift the plantar fascia medially on both sides. Re-test running outside my clinic showed an immediate reduction of pain to 0/10 bilaterally.
Am I a miracle worker? Do I walk on water? Did I cure the plantar fascitis? No, no, and no. What did I do? I took away the pain. I solved the immediate problem. How long will this effect last? I don’t know. Was it placebo effect? I don’t know, but I suspect not. In 29 years of practice, I’ve seen this effect last for hours, sometimes days. What effect, specifically? Pain reduction or elimination during running with the tape applied a certain way. That’s all. A scientific study would undoubtedly show this technique to be non-curative. It would advise that I not consider this taping technique as a useful tool in the management or treatment of plantar fascitis. The Cochrane Collaboration would look upon my non-evidence-based practice with chagrin.
The Short-Term Goal
My hope is that when I tape this athlete just prior to competition on Thursday the effect will last long enough for the event to be completed pain-free. I make my case for the “short-term goal.”
Am I holding scientific process in contempt. Not at all! After the track meet and the season are over, let’s buckle down, look at load control, flexibility issues, strength, biomechanics issue, and anything relevant and literature-based, and let’s FIX it. But for now, I’m coloring outside the lines. I am shamefully using a “technique” to shamelessly achieve an expedient goal: comfort for competition.
Countless athletes appreciate immediate pain relief when preparing for an upcoming competition. While I will continue to learn as much as I can and adapt my practice to FIXES, I will not jettison the very wide and very helpful set of treatment procedures that I freely acknowledge to NOT be a cure. These procedures include needling, taping, poking, prodding, manual therapy, and even (hold your breath) passive modalities.
Placebo? Probably not, but if so, who cares? If the pain is gone, it is gone. A pain free athlete is a better competitor, period.
Caveats: I will not reinforce dependence upon my therapy. I will always educate toward a FIX for the problem.
I will continuously update procedures and methods to meet patients needs expeditiously and inexpensively.
I will proactively educate against any concept that equates chronic pain with tissue damage or fragility. (Assumption: that I have ruled out all pathologies that might be accompanied by real tissue damage.)
The reader will have to decide if the Short-Term Goal is worth addressing. Some will say that by doing these fun tricks with tape I’m simply prolonging the problem. I respectfully disagree. I am addressing an immediate need (effectively, I might add) with every intention of FIXING the problem once the season is over and load-control, mechanotherapy, and full exercise rehabilitation can be engaged.
In some sectors there is a lot of bashing going on about the uselessness of poking and prodding, taping, needling, etc. There are abuses, to be sure, including many within my own profession and among physical therapists/physios and technique peddlers worldwide, it seems. But the aims of most clinical trials for sports injury are clearly not focused on discovering or or reporting about immediate short-term pain relief to putatively enhance performance. Such trials are expensive enough and need to answer “larger” questions. Still, as a sports medicine specialist I’m faced with giving athletes any edge they can get so that they can be as competitive as possible.
Thanks for reading!
Why is Usain Bolt’s Foot Higher Off the Ground?
I have questions. Studying provides answers.
Somewhere during the course of my professional education as a chiropractor I became addicted to learning. The first manifestation of this was taking an extra year of training in a medical hospital, I suppose. Then three more years in the postgraduate chiropractic sports medicine certification offered by the American Chiropractic Board of Sports Physicians. Perhaps, then, it is not so strange that I love to study stuff. And in-depth studying creates an urge to teach. (But not until I really know it!)
It’s a weird thing, but I have a theory. My need to teach is so that I can make sure on the outside (I’m an extrovert) that “I truly know it” on the inside. As the adages goes, if you know it well enough to teach it, you know it. One’s level of mastery of a particular topic may be tested (and subsequently perfected?) by one’s ability to transfer knowledge to others such that they can teach others also.
Technology has created a knowledge explosion and the means to propagate knowledge instantly and virally. Perhaps there are some drawbacks to progress like this. However, clinical expertise and better patient outcomes only stand to improve when doctors stay current and keep learning. From where I sit other health professions are harnessing technology-based learning channels better than chiropractors. My profession is lagging behind. And chiropractic sports medicine as a bona fide, accredited specialty is no exception. This blog is an attempt to contribute to the solution and perhaps set a precedent for others in chiropractic medicine.
This blog hovers around sports and exercise medicine in all aspects. The content overlaps with podcasts you can link to from this site.
What Am I Selling?
Nada, baby. Nada. No sponsors. No charge.
No doubt. But none from “industry.” This is a blog. Hopefully a really nifty, helpful blog. But this is not a professional online journal.
So What’s Up With Usain Bolt’s Right Foot?
That’s the point: it’s “up.” His very first stride is longer. Explosive strength of his right hip flexor, getting those long, lanky legs out there! His legs, longer levers than his competitors’ legs, require as much or more power to move. This starting moment, at the 2012 London Olympic Games 100 meter sprint final, tells that Usain Bolt “won” the start. And then he finished the remaining 99 meters well!
Thanks to the very many (mostly British and Australian) podcasters, journals, journal editors, conference speakers, and sports science researchers who have kept me company week after week, month after month since London 2012, fueling my passion to know more and be better. I am a chiropractor who is not ashamed to say (with many of my chiropractic colleagues who are board certified in chiropractic sports medicine and carry diplomate status — the DACBSP® credential) that my approach to practice aligns more with the discipline of sports physiotherapy as practiced internationally than with the stereotyped, purist manual-therapy-only/adjust-only practice of chiropractic. Exercise IS medicine. Biomechanics matter. Cracking joints is not a panacea, and is many times contraindicated in athletic injury management.
Further, my experience around Olympic sports since the late 1990’s taught me that professional degree is secondary. The athlete’s needs are primary. In America we check our professional degree at the door, roll up our sleeves and get busy. Egos and know-it-alls don’t survive and aren’t invited back. Everybody learns from everybody. Performance matters most, whatever it takes. So the “we-they” aspect of physio vs. DC vs. MD vs. ATC vs. CSCS boils down to personal pride. And no profession has the corner on incompetence. We each have sour apples: colleagues who embarrass with their fixation on one particular theory, gimmick or technique. They’ll always be with us, and putting them in their place will not be my purpose here.
It is simply time for me to start blogging. Time to encourage and challenge my own profession to get off our collective duff and get moving. Time to expand lines of communication and collegial debate within my profession and between the talented disciplines we work with, often side by side, at sporting events and competitions worldwide, for the benefit of the athletes we serve.
There is so much controversy these days over the burgeoning science of food.
The burning question: “How then shall we eat?”
Sad to say, there is so much vitriol on the web. People get emotional about food.
Once upon a time I read, uncritically, “The China Study.” Riding on the heals of the 50-yr “high carb, low fat” binge arising from Ancel Keys’ overcooked data back in 1953, this book had a fair amount of appeal, adding more fuel to the miserable history of American food confusion. Picasso had his “blue period.” As it relates to food, fat, cholesterol, and the medicalization of everything (see “Selling Sickness” by Ray Moynihan), this is America’s dietary and nutritional “blue period.” Or worse. Perhaps the new Dark Age where the wisdom of engineered food turned out not to be so wise. (Just check obesity rates in the U.S. from 1991 until now. Yikes.)
Unfortunately I recommended “The China Study” to a friend years ago. She became vegan. Then she became sick. Then sicker. Now her body won’t accept real, nutritious food and unless she is willing to re-adapt, she’s on a slippery slope. Like Dr. Keys, The China Study cherry picks epidemiologic data to make a point. In nutrition science, we must do better.
Enter Professor Tim Noakes at the University of Capetown, South Africa. Bold in his “about-face” regarding carbohydrates, and diabetic himself, Dr. Noakes admits that he was wrong in advocating high carb, low fat nutrition plans. And I must make the same admission.
Here is a 44 minute lecture by Dr. Noakes that makes a clear, evidence-based case for a low-carbohydrate, if not carbohydrate-restricted diet. He’ll provide clear evidence that answers the chicken-and-egg question: does the high intake of refined carbohydrate cause insulin resistance, or is insulin resistance the cause of aberrant carbohydrate metabolism?
Some critics believe Dr. Noakes overreaches in his case for carbohydrate restriction and respectable amounts of dietary fat. Interestingly, most don’t argue with the data he presents. Rather, they take umbrage with the degree of zeal and his tone of absoluteness regarding his topic. Well, so be it. Let the viewer examine the data and sort it out for himself/herself. I appreciate Dr. Noakes’ salient presentation, and must encourage those who wonder what to eat to curtail their well-intentioned carbs in deference to more generous portions of fat — yes, fat — in your diet.
It takes 30 years for a paradigm to catch on. Remember, there is/was Mazola in every cupboard. Now there is GMO, MSG-derivatives, or high fructose corn syrup in almost everything we are told, by advertisers, to eat in this country. Stop, go home, and rediscover the much maligned egg for breakfast. McBanish the McMuffin and OJ. (Even 8 ounces of orange juice contains 26 gm carbohydrate. Twelve ounces of Coke — 39 gm). Did I mention I have a patient who was drinking 9 Cokes a day? Did it matter that they were Diet Coke? Was that better, or worse? Fodder for another blog.
Bottom line: The way out of the current nutritional, eat “lean everything” nutritional dark age is this: get back to eating real food. Embrace your inner omnivore, but understand that there is a reason you can chew and digest animal protein. Your pancreas has all the right equipment for that.
Enjoy Dr. Noakes, and thanks for reading. Bon apetit!
Investigators from Copenhagen University Hospital published a new study this year on the use of elastic bands to strengthen the hip adductor muscles in soccer players.
The goal of the study was to investigate the effect of 8 weeks of elastic band exercise on adductor strength. Weak hip adductors (the muscles in the inner and upper-inner thigh) may increase the risk of adductor strains/groin strains. Jensen, Holmich, Bandholm, et al state: “…increasing hip-adduction strength may decrease the stress put on the hip-adductor muscle-tendinous complex, and prevent overuse injuries and acute tears.”
The authors of this randomized controlled trial were able to show that, in NORMAL SUBJECTS, 8 weeks of eccentric elastic band exercise produced a significant gain in hip-adduction strength compared with a control group. The exercises are simple to perform and can be done at the soccer field, training room, hockey rink or football field.
Previous studies on eccentric exercise have shown a THERAPEUTIC value of these exercises for hamstring strains, patellar tendinitis and achilles tendinitis. While unproven, I suspect that eccentric exercise will be shown to be of therapeutic value for the adductors/”groin” as well.
In our sports medicine center we are concerned with long term prevention through rehabilitation, but also short term pain relief so that our athletes get on an earlier path to rehab, and therefore an earlier path to return-to-play. For this reason we will use a variety of techniques to assess and treat the acute groin injury. Assessment will not only include the painful muscle(s) and their associated tendons, but supporting myofascial structures as well as the movement of nearby joints, including the sacroiliac and coxofemoral (or “hip joint proper”) joints. While there is an ongoing debate as to whether the sacroiliac joint is capable of movement, manual therapy mobilization techniques (aka “chiropractic adjustments”) often result an athlete self-report of greater comfort. Is this report due to a placebo effect? Perhaps, but probably not. Is it rather a desensitization of pain perception at the cerebral cortex? Probably — and then some. Is there an actual increase in excursion of the ilium relative to the sacrum, or vice versa, within the sacroiliac joint itself? I don’t know. However, in “ancient” literature (Colachis, et al) there is evidence that the sacroiliac joint does, in fact, move. And other clinicians smarter than me (Cassidy, Kirkaldy-Willis, Giles) hold that the sacroiliac joint is subject to movement restrictions that are amenable to manipulation, resulting in improved movements. But I digress.
Our comprehensive evaluation includes an assessment of fascial tissues at some distance from the site of groin pain as well. Often the adductors collectively, and gracilis most predictably, contain palpable “lumpy bits” (trigger points, fascial adhesions, etc.) that are well-localized and produce a perception of intense local discomfort, often with radiation to the site of injury, or radiation distally to the knee. These lesions, whether truly within the muscles themselves or within the fascial network surrounding the muscles, can be appreciated by untrained laypeople as well as trained clinicians, and even by the athlete herself. These entities are not entirely subjective or mysterious. In fact, one researcher working with Dr. Jay Shah, MD at the National Institutes of Health, found that musculoskeletal ultrasound imaging could reveal these “lumpy bits” through the use of high frequency vibration during ultrasound examination. While the tissues surrounding the “trigger point” would respond to the vibration with a homogeneous appearance, the more dense — and painful-to-palpation — trigger point appeared as a well-demarcated zone of NON-VIBRATION (or, at least, discernibly different vibration.) These and other attempts to define these clinically observable (and treatable!) “lumpy bits” were presented at the University of Salford, Manchester, England at a conference in March of 2012. Remarkable stuff, and encouragement to me and my colleagues at our center to identify these intramuscular dysfunctions early on, treat them quickly, and restore the athlete to comfort and full competition as soon as possible.
Along these lines we also use a most gentle form dry needling, thought to enhance the local physiology of tissue repair, and certainly another way to perhaps desensitize the nervous system so that earlier functional gains can be achieved through rehabilitation.
Finally, while the investigators from Copenhagen University (see top of this post) are recommending an open chain approach to strengthening the adductors, I borrow from the wisdom of Dr. Alison Grimaldi who recently earned her PhD in the topic of lateral hip pain. Extrapolating from her work on rehabilitating acute and chronic gluteus medius tendinosis, we consider closed chain lateral/medial sliding exercises — carefully — to be a rational approach in the progression of adductor/groin strains. More from Dr. Grimaldi on a recent BJSM podcast here.
To summarize, groin strains are pretty easy to diagnose, but can be frustrating to recover from — often having a protracted course. That said, a comprehensive musculoskeletal evaluation and treatment approach is, I believe, more likely to result in a faster and more complete outcome, with earlier return to competition and greater satisfaction for the athlete. These statements are unsupported by randomized, controlled clinical trial, but like much of what we do, expert opinion and 30 years of experience may count for something. And along those lines, I’m always open for correction, for new learning, and anything that is better than I am currently doing for the benefit of my patient-athletes!
The Askling H-test is used to determine when a hamstring-injured athlete is ready for safe return-to-practice and return-to-competition. It is a repeated, rapid hip-flexion-to-full-range apprehension test that asks the athlete to grade the severity of their level of fear or apprehension from 0-100 (100 being most severe) three successive maneuvers. The non-flexing hip is stablized to the table or plinth manually or using straps or belts.
Once symptoms of hamstring tear have resolved with walking and light, slow-speed, controlled running (forward and backward (retro-running), and once hamstring strength is restored, particularly with eccentric loading, this test is the last test used to assess the athlete’s fitness to return.
For the high performance track and field sprinter, where hamstring loads are intense, a subjective Askling H-test score of 1 or more (that is, with ANY apprehension whatsoever) the sprinter should not run at maximum capacity. However, for an (American) football player, a score of 1-10, or perhaps 15 would not preclude the athlete from engaging in practice due to the lack of maximum eccentric muscle activity in 1 sustained effort as is done in a 100 meter sprint.