Chiropractic Unplugged - The chiropractic approach versus traditional medical approach

Chiropractic, the largest alternative medicine profession, focuses on the relationship between structure and function. Chiropractors employ specific manipulative techniques for correcting joint movement in an effort to improve the body’s biomechanics.

So how does the approach to orthopedic problems differ between a chiropractor and traditional medicine? Let’s take a look at one of the most common health problems facing the industrialized world; back pain.

Traditional Medical Approach: The medical approach focuses on symptoms rather than the biomechanical cause of the problem. Treatment often begins with over-the-counter medicine, such as ibuprofen or aspirin and bed rest. If symptoms persist, treatment progresses to NSAIDs (non-steroidal anti-inflammatory drugs), prescription drugs like Naproxen, or the newer COX-2 inhibitors such as Vioxx and Celebrex. NSAIDs come with well-known side effects like stomach irritation and ulcers, but also have some not-so-well-known side effects like swelling and increased blood pressure and the potential for liver and kidney damage (this is why your doctor may require periodic blood tests to check for liver damage). So the medical approach is to treat this biomechanical problem chemically.

Why doesn’t the medical profession treat this biomechanical problem biomechanically? Because it does not have conservative biomechanical treatments at its disposal. As was explained by Karel Lewit, MD a neurologist who is self trained in manipulation, in Manipulative Therapy in Rehabilitation of the Locomotor System, 3rd edition Oxford England Chapter 10, “Disturbed mechanics or function in the musculoskeletal system is the single most common cause of pain syndromes for patients but has never formed part of the curriculum in medical education – either in undergraduate or postgraduate specialty education.” He concludes that the chiropractic profession has grown largely because of this major gap in medical education and practice.

The Chiropractic Approach: So you must by now have guessed that the chiropractic approach to these biomechanical problems is to treat it biomechanically. This is accomplished primarily through the use of joint manipulation. After serious pathology is ruled out, the affected joint is analyzed for aberrant motion. The effected joint will then be manipulated in an effort to restore normal movement which then allows the proper healing process to begin. During the healing process, the joint is periodically mobilized to deter adhesion (scar tissue) formation and therapeutic exercises are commonly prescribed to aid in maintaining full joint range of motion as well as strengthen and stabilize the area.

What Exactly Is Joint Manipulation? This may be a bit complicated. You first have to understand the anatomy of a joint. A joint is made of two bones connected by a capsule or envelope made of ligaments. At the end of each bone is a thin, smooth layer of cartilage. This cartilage layer acts as a protective cushion between bones to absorb the stress on joints during movement. There are 4 stages in most joint movements:

Stage 1 Is the active range of motion produced by muscle contraction
Stage 2 Is the passive range of motion produced by traction or stretching
Stage 3 Is the paraphysiological range of motion (motion beyond the elastic barrier of resistance and up to the limit of anatomical integrity) produced by manipulation and accompanied by an audible release
Stage 4 Is pathological movement beyond the limit of normal anatomical integrity which damages ligaments and capsule

Joint manipulation is, therefore, movement across the elastic barrier. It is accomplished using a dynamic thrust that takes the joint slightly beyond its active range of motion causing an audible release (cavitation) in an attempt to increase joint range of motion and decrease adhesion formation. It is a highly skilled maneuver which should only be performed by well trained practitioners.

Education: If you look at the overall curriculum structure for chiropractic and medical schools you’ll find it to be very similar. The average total student hours of all US chiropractic and medical schools are 4,822 (chiropractic) and 4,667 (medical).

Basic sciences represent 25-30% in each program (1,416 hours for chiropractic and 1,200 for medical) There is a similar amount of biochemistry, microbiology and pathology. Chiropractic students have significantly more anatomy and physiology, but many fewer in public health.

Clinical science hours are similar in total – 3,406 and 3,467 respectively in chiropractic and medicine. However there is a major difference in how these are subdivided. Chiropractic students divide clinical education between chiropractic sciences i.e. learning diagnostic and treatment methods (biomechanical diagnosis of the musculoskeletal system, manipulation and other treatment methods as well as diagnostic x-ray and other imaging) – 1,975 hours; and clinical clerkship or supervised management of patients – 1,431 hours. Medical education has no equivalent of chiropractic sciences. All clinical science hours are clerkship (3,467 hours). So, on average, medical students receive over twice the number of hours of clinical experience. In addition, medical students go on to residency training in hospitals and community-based practices. This raises the total number of hours of clinical experience for medical students to 6,413 hours. Chiropractors are being prepared to be a structural specialist similar to a dentist being prepared to be a tooth specialist. They do not require the same depth of exposure to disease states as M.D.’s.

There are other appropriate differences. Subjects found in both chiropractic and medical curricula are taught with a different emphasis. For instance, first year study of anatomy in chiropractic emphasizes the musculoskeletal system (which represents 60% of the body but receives much less emphasis in medical education), neuroanatomy and their interrelationship since these are of fundamental importance to chiropractic principles and scope of practice.

Chiropractic physicians have little on pharmacology and surgery since this is out of our scope of practice by choice. This does not mean that chiropractors do not believe in the use of drugs or surgery but rather that these should remain under the scope of the MD. Chiropractors prefer to concentrate on the conservative treatment (non-drug/non-surgical) of biomechanical conditions. That is why these subjects are replaced with chiropractic sciences such as biomechanics and manual diagnostic and treatment methods for which there is little if anything comparable in medical education. This is why chiropractic physicians exist in the first place. As was explained by Karel Lewit, a neurologist who is self trained in manipulation, in Manipulative Therapy in Rehabilitation of the Locomotor System, 3rd edition Oxford England Chapter 10, “Disturbed mechanics or function in the musculoskeletal system is the single most common cause of pain syndromes for patients but has never formed part of the curriculum in medical education – either in undergraduate or postgraduate specialty education.” He concludes that the chiropractic profession has grown largely because of this major gap in medical education and practice.

Why Was The Chiropractic Profession Scorned For Many Years? You probably have the AMA, the most powerful lobbying group in Washington, to thank for that. Minutes from meetings held by committees formed by the AMA showed clearly that their sole purpose was to destroy the chiropractic profession with misinformation and clandestine activities. This is well documented and on public record. The AMA was found guilty by the United States Court of Appeals on March 15th 1990 of, “conspiring to contain and eliminate the profession of chiropractic”. One tactic used was to send letters to every guidance counselor in the United States requesting that they advise their students not to go into the chiropractic profession. The idea was that if more chiropractors died each year than there were students entering the profession, the chiropractic profession would eventually wither away and die. But the most important information that was brought out in the trial was that the purpose was not to protect the public. The reason was economic. Since chiropractic usage was steadily growing, the AMA’s goal was to have the medical profession take it over. They had already formed the North American Academy of Manipulative Sciences which documented the effectiveness of the treatment and granted blanket medical degrees to the osteopathic profession. Osteopaths would act as the medical conduit to manipulative therapy acquisition. That obviously didn’t work very well. Osteopathy has been in a steady decline since that time with a corresponding increase in the use of chiropractic.
So before 1990, members of the AMA were forbidden from associating with chiropractors, professionally or socially. They were forbidden from teaching in chiropractic schools. With its propaganda campaign the AMA literally altered the attitudes of its members, congress, the news media as well as many organizations that relied on them as a credible source of information.

Efficacy: Is chiropractic/manipulation effective or isn’t it? First, think about the sources of evidence on the chiropractic profession – how informed, biased or reliable they may be, and how much you should believe each of them. How accurate and reliable are your sources of information? How do you reconcile the conflicting good and bad news stories you still hear? In 1993-1994 government sponsored interdisciplinary panels of experts in the US and U.K. reviewed the scientific literature on the management of adults with low-back pain. These experts then published clinical guidelines supporting spinal manipulation as a first line approach to the management of most patients with back pain. However in 1995 the AMA, calling itself “the nation’s most trusted health care authority” and expressly claiming to be providing “a reliable source of information” published the AMA Pocket Guide to Back Pain, which was inconsistent with the guidelines in several major respects. It made no mention at all of spinal manipulation, manual therapy or chiropractic treatment. It’s fair to conclude that this was because the AMA wanted to support the treatments given by its members and as we all know, medical doctors do not provide manipulative therapy.

Another stumbling block to determining the efficacy of chiropractic treatment was the AMA’s misinformation campaign. It became virtually impossible to get research money from the government. Our profession was forced to spend most of its resources to combat the AMA’s propaganda and fight the legal battle to expose it. However, since that time chiropractic has made some incredible advances as was noted by a AHCPR Research Report, US Department of Health and Human Services in 1997. “In the past few decades, chiropractic has undergone a remarkable transformation. Labeled an ‘unscientific cult’ by organized medicine 20 years ago chiropractic is recognized as the principal source of one of the few treatments recommended by national evidence-based guidelines for the treatment of low-back pain, spinal manipulation. In the areas of training, practice and research, chiropractic has emerged from the periphery of the health care system and is playing an important role in discussions of health care policy.”

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