Respectful Insolence

A brief history of chiropractic

Chiropractic has origins in mysticism and vitalistic thinking. Given its popularity and seeming mainstream acceptance, it’s easy to forget that these days. Fortunately, Daryl Cunningham reminds us of the history of chiropractic, including its philosophical underpinnings and potential complications:

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Comments

  1. #1 Delurked lurker
    August 23, 2011

    Thanks for the links Orac. Always nice to find quality ammo.

    BTW is this the right room for an argument :)

  2. #2 MikeMa
    August 23, 2011

    Great strip. Loved the history. Forwarded it to my chiro-using daughter.

    Several chiros jumped in on Darryl’s site to defend themselves, their cash flow and their profession. Maybe they will pass by here to juice the comments!

    As massage therapy, chiropractic is okay I suppose but I sure wouldn’t set my expectations any higher or let one touch my neck. The altie branch of the profession doesn’t help those searching for respectability either.

  3. #3 lilady
    August 23, 2011

    Lest we forget this comment from our colleague in Australia:

    “Just as an aside.
    We had a very sick patient into my hospital today.

    it turned out he had serious bleeding from torn intercostal arteries as the result of chirpractic manipulation.

    We saved his life by that wonderful aspect of applied human biology called medicine otherwise known as shit that works.

    Posted by: Shane in Aus | August 18, 2011 10:09 PM”

    (The Yale Journal of Medicine and Law blows it big time on alternative medicine)

  4. #4 augustine
    August 23, 2011

    Lilady via Shane aus

    We saved his life by that wonderful aspect of applied human biology called medicine otherwise known as shit that works.

    If he had died, does that mean “shit known as medicine didn’t work”?

    Lilady, you lack critical thinking skills. You’re just a cheerleader, not a thinker.

  5. #5 Calli Arcale
    August 23, 2011

    Ooooh, another one of his strips! Lovely!

  6. #6 peicurmudgeon
    August 23, 2011

    We Canadians have invented or developed some amazing things. We have also been responsible for some horrendous shit. I apologize on behalf of my fellow citizens for the actions of Daniel David Palmer. We are not all charlatans.

  7. #7 DrWonderful
    August 23, 2011

    I would like to point out one significant error, although several more are present. Chiropractors are trained in differential diagnosis and are highly capable in determining whether a condition is musculoskeletal based or not. There is a subset of DC’s, estimated 15-20%, that simply refuses to utilize this training in practice, due to some obscure philosophical ideology. I agree they are a potential problem for the public and remain a thorn in the side of the majority of profession. But they are no way representative of the typical chiropractor as is alleged in the comic.

  8. #8 _Arthur
    August 23, 2011

    It’s been tested in Canada:

    Take a few healthy children, have them tested and declared healthy by 3 separate doctors.
    Then bring them to 5 chiropractors, and all 5 will find something troubling in the kid’s spine, something that will require regular visits every other month. $$$.

    The opposite test should be done. Take a kid with a known (non-spinal) illness, show him to several chiros, and check if they act as a generalist (as they claim the can), and orient the kid toward proper doctors.
    Odds are, they will attempt to cure the kid by massaging his spine, no matter what’s the illness.

  9. #9 MikeMa
    August 23, 2011

    @DrWonderful,
    I do not doubt that some chiros take their medical ethics seriously. What I doubt is the percentages you claim do not. I suspect 15-20% bad apples is a trifle low.

  10. #10 bob koepp
    August 23, 2011

    Yes, it is certainly the case that “Chiropractic has origins in mysticism and vitalistic thinking.” Then again, so does biomedicine. The question is whether a discipline can outgrow such origins.
    This is not a brief for chiropractic.

  11. #11 DrWonderful
    August 23, 2011

    @MikeMa- I was speaking specifically to the percentage that refuse to differentially diagnose or “treat” any particular ailment but rather ONLY clear the body of innate energy inhibiting subluxations. When I was told it’s still around 15-20% who practice this strict philosophical approach I was surprised to learn the estimate is still that high. All DC’s, even from the crappiest of schools, must pass 4 National Boards where basic science and diagnosis is paramount. We estimate about 15-20% do not practice this way once they are in the field.

    The number of chiropractors who are practicing, as you say, with high standards of “medical” ethics is probably 15-20% in the other direction! The middle 60% (as they are known) probably fall somewhere along a broad spectrum between the two extremes. The top and bottom could not be further apart and we essentially are now two separate professions.

  12. #12 Calli Arcale
    August 23, 2011

    MikeMa, Dr Wonderful is talking about the proportion of “straight” to other chiropractors (which is discussed in the comic, actually, so refer to that for more information). What he means is that 15-20% of chiros actually disavow any influence of medical science at all — or anything besides chiropractice, generally. However, “mixers” (the majority of chiros) also would tend to practice dubious science. Most will still consider most complaints to be spine-oriented, even though medical science has found the actual causes of the conditions, and would likely do a poor job of differential diagnosis. You’d have a better bet of good health care from a mixer than a straight, but there’s still a huge range of quality among the mixers.

    And that, in my opinion, is the crux of the problem. A chiropractic adjustment may be helpful for some forms of back pain, but how do you know if a particular chiropractor is competent, given this huge range of quality available? It seems the profession itself is not yet interested in policing itself adequately, since straights and mixers both get the same licenses and are treated as equally valid.

  13. #13 Art
    August 23, 2011

    Chiropractic, like a lot of other things, is a mixed bag. It started with a lot of bull like vitalism, reiki, and mysticism. But it also tapped into some good stuff, like controlled spinal manipulation for acute injury.

    I’ve had some jobs that were tough on the back like construction, and furniture mover. I have a couple of local chiropractors that I use. The key is to lean on their strengths and avoid their weaknesses. When I go in they do an adjustment that stops the spasms. This usually works about as well as going to the docs and taking a muscle relaxer. Without the side effects. It also helps that it is both quicker and cheaper.

    Although the chiropractors all want to get me on a long term care plan, and most want to ‘align my chachras’, ‘restore my energy flow’, or offer nutritional support I avoid it. The New Age feel of their offices is nice but I’m not there for the ambiance.

    I think of it like an auto mechanic that does some jobs well and other jobs poorly. Good at brake jobs and use them as needed for that. But when they offer to chase the evil spirits out of my gas tank I give it a pass.

    A quick pop, and I’m out of pain, able to move, and back at work. Sometimes that same day. Cheap at $80. The times I go to regular doctors it’s an hour or three wait, north of $100 to get in the door plus X-rays, a script for muscle relaxer that is going to run $40 and another hour to get, and I spend a week either buzzed out of my mind or unable to move. Either way it is the ice, heat, and time that ultimately does the healing.

    In forty years I’ve gone through perhaps a dozen serious episodes. The times I went to a medical doctor it was a waste of time and money. When I went to a chiropractor, and carefully avoided the woo, it has worked well enough to justify the expense. Sometime exceedingly well. A couple of times I walked in bent over and in pain and walked out upright and without pain.

    Wheat-chaff, baby-bathwater.

  14. #14 kd
    August 23, 2011

    If he had died, does that mean “shit known as medicine didn’t work”?

    Only in Augieland, where a perfect 100% success rate is required for a modality to be defined as “working.”

    Augie, if you suffered a complex fracture of your femur, would you decline medical attention on principle because of the remote chance that the bone might not set properly, choosing instead a permanent crippling deformity (assuming you survive the inevitable infection)?

    Actually, never mind the part about infection. I assume you’d have to turn down antibiotics as well (even if you did have your bone reset and your leg stitched up), because the first course of therapy might not be sufficient, and the chance of some diarrhea or other GI upset is unacceptable as an alternative to staph infection or gangrene.

    Lilady, you lack critical thinking skills. You’re just a cheerleader, not a thinker.

    Wishful thinking. Augie, you should peddle your nonsense to an audience that actually does lack critical thinking skills. You’re just a troll, not a debater.

    Hmm, maybe the folks at AoA would take you seriously. Go bug them.

  15. #15 kd
    August 23, 2011

    Ug, I meant “intervention,” not “modality.” WTB edit button. :)

  16. #16 lilady
    August 23, 2011

    @ kd: Thanks, but no need…still ignoring ignorant filthy-mouthed troll.

  17. #17 Krebiozen
    August 23, 2011

    Prof. Ernst blogged about this subject yesterday here. It seems that a substantial number of Canadian chiropractors still believe they can successfully treat non-spinal illnesses, despite evidence to the contrary.

  18. #18 Robert M
    August 23, 2011

    I’m still amazed that people buy into old timey quackery, I think more people would be skeptical of chiropractic and homeopathy if they knew how they got started. I suspect many casual users would be disillusioned to know some guy made it up, more or less as it is today, in the era of leaches and snake oil.

  19. #19 DrWonderful
    August 23, 2011

    @Krebiozen- I think I understand the spirit of your comment but I just want to make sure we’re on the same page. We prefer to say “musculoskeletal conditions” rather than “non-spinal.” Chiropractors have a high level of proficiency in differential diagnosis and treatment of musculoskeletal conditions, not only of the spine, but including the extremities as well.

  20. #20 Phillip E
    August 24, 2011

    How very sad to see such depth of ignorance in the comments, let alone the cartoon.

  21. #21 Travis
    August 24, 2011

    Phillip E,
    How very sad to see such lack of content in your comment. You do not point out a single error, or example of ignorance that you claim to have seen.

  22. #22 Jamie
    August 24, 2011

    Phillip,

    You should be well versed in ignorance – both your website and your thesis are drenched in it. The fact that only 3 publicly funded universities in Australia offer degrees in chiropractic and osteopathy should tell you what the rest of us rational, evidence based scientists and researchers think about your “profession”.

    And is there any reason that there’s not a SINGLE reference from a nationally recognised, peer reviewed publication in your paper? Every single reference is from chiropractic magazines, rather than actual scientific journals written by, well, actual scientists.

  23. #23 Jamie
    August 24, 2011

    Phillip (from your website – I love that your three favourite articles are ones you’ve written yourself!)

    Subluxation has been ridiculed on-line by a medical practitioner and mis-understood by others. It was well received when presented as a platform presentation to a chiropractic audience at the International Medical University in Kuala Lumpur in 2009. I like the intellectual challenges it presents

    That dealing with subluxation “intellectually challenges” you says it all for me. Who needs the germ theory of disease when we have intellectual giants like Phillip?

  24. #24 Krebiozen
    August 24, 2011

    @DrWonderful #18

    I think I understand the spirit of your comment but I just want to make sure we’re on the same page. We prefer to say “musculoskeletal conditions” rather than “non-spinal.” Chiropractors have a high level of proficiency in differential diagnosis and treatment of musculoskeletal conditions, not only of the spine, but including the extremities as well.

    A substantial percentage (>30%) of the clinical faculty at the Canadian Memorial Chiropractic College claimed that chiropractic is beneficial in treating the following conditions: asthma, cerebral palsy, chronic pelvic pain, constipation, depression, dysmenorrhea/PMS, hypertension, infantile colic, nocturnal enuresis, otitis medice and vertigo.

    If you categorize all these as musculoskeletal conditions, I’m afraid we are definitely not on the same page. We may even be reading a different book entirely.

  25. #25 Dianne
    August 24, 2011

    Chiropractors have a high level of proficiency in differential diagnosis and treatment of musculoskeletal conditions, not only of the spine, but including the extremities as well.

    So how would you work up a patient with lower back pain? What about unilateral thigh pain?

  26. #26 DrWonderful
    August 24, 2011

    @Krebiozen- by saying “extremities” I meant things like elbows, knees, ankles shoulders, etc. You know, extremities.

    @Dianne- After a detailed history we would perform a standard orthopedic and neurologic examination with imaging if indicated.

  27. #27 titmouse
    August 24, 2011

    Dr. Wonderful, chiropractors are not trained in “differential diagnosis” as you claim. That is outside their scope of practice.

    The chiropractors began using the term “wellness” to get around the legal issues associated with claims to diagnose and treat illness with chiropractic.

  28. #28 lilady
    August 25, 2011

    @ titmouse: Of course Dr. Wonderful only means spinal differential diagnoses…not medical differential diagnoses. Many states limit the practice of chiropractors to the spine only…no tennis elbow, no shoulder pain, no knee pain, no carpal tunnel pain or osteoarthritis of the hand.

    If you are having repeated digestive problems it is because your spine is out of alignment…headaches?…cervical spine misalignment. It always comes down to spinal misalignment and the treatment of choice…spinal manipulation.

    Just how many times do these spine manipulators misdiagnose a patient due to their inability to do a real medical differential diagnoses?

    Why does a young child go to a spinal manipulator, when the child’s pediatrician checks out the child for any spinal deformities and would have referred the child to a pediatric orthopedist…a real doctor? I wouldn’t allow any chiropractor to get within striking distance of my spastic quadriplegic son or my healthy daughter.

  29. #29 augustine
    August 25, 2011

    nurse lady

    I wouldn’t allow any chiropractor to get within striking distance of my spastic quadriplegic son or my healthy daughter.

    What medicine or pediatrician checkup keeps either of them alive or healthy, in your opinion.?

    Do you believe that the HPV vaccine is neccesary for your “healthy” daughter?

  30. #30 DrWonderful
    August 25, 2011

    @titmouse and Lilady- I think you both have a little more homework to do. Your definition of chiropractic is as narrow as the 15-20% of the profession I discussed above. Simply not acknowledging the rest of the profession doesn’t change anything.

    Yes, chiropractors are trained in differential diagnosis but practice primarily in the musculoskeletal world. Yes, chiropractors treat extremities and nearly every state includes this in their current scope of practice. Actually, I don’t know of any state who no longer allows this. Chiropractors are recognized as be very proficient in the sports medicine world, and obviously that would include the treatment of things like arms and legs.

  31. #31 augustine
    August 25, 2011

    Why does a young child go to a spinal manipulator

    Why does a young child go to a “real doctor” and get unnecessary Hep B vaccines?

    Almost all Hep B vaccines are unnecessary! THAT’S quackery!

  32. #32 Dianne
    August 25, 2011

    Yes, chiropractors are trained in differential diagnosis but practice primarily in the musculoskeletal world.

    But you’re not willing to make any statements about how you would approach a patient with something basic like lower back or leg pain? Interesting.

  33. #33 lilady
    August 25, 2011

    @ Dianne: I went a “number of rounds” with Dr. Wonderful a few months ago on this blog and you will never get an answer about medical differential diagnoses…which is beyond chiropractors scope of practice.

    Still ignoring boring ignorant filthy-mouthed troll.

  34. #34 augustine
    August 25, 2011

    What medicine or pediatrician checkup keeps either of them alive or healthy, in your opinion.?

    The nurselady

    Still ignoring boring ignorant filthy-mouthed troll.

    Answer: None.

  35. #35 DrWonderful
    August 25, 2011

    @Dianne- I did respond to your comment but it was held up for approval by the moderator. Not sure why, probably a glitch.

    I’ll try again…I would approach your scenario the same way any health care provider should. After a detail history I would perform a thorough orthopedic and neurologic examination with imaging if indicated. Pretty simple, no reason to dodge that.

    @lilady- Chiropractors are trained in differential diagnosis. If the core curriculum of the colleges, content of National Boards, state licensing scopes, and hundreds of millions of data points in the insurance industry databases demonstrating a broad range of ICD-9 codes utilized by DC’s are not enough for you then I really don’t know what would be.

    Again, you guys are myopically focused on the 15-20% of the DC’s who cling to a failed model of past and yet you just ignore the majority of the profession you criticize. It’s very discriminatory and biased.

  36. #36 titmouse
    August 25, 2011

    So Dr. Wonderful,

    How would you work up a patient presenting with low back pain as a chief complaint?

  37. #37 Dianne
    August 25, 2011

    After a detail history I would perform a thorough orthopedic and neurologic examination with imaging if indicated.

    Sounds reasonable. “Obtain a detailed history” is almost never wrong, unless the patient is comatose. So, suppose the patient comes to you with a complaint of right thigh pain for the past 3 days. He has no significant past medical history but had a bad flu last week, from which he is now recovered. He complains that the leg hurts and it seems to be swollen. On physical exam the right thigh is larger than the left, red, and tender to the touch. Vital signs are normal, physical exam otherwise unremarkable. Where would you go from there?

    I’m not thinking of anything obscure, but rather a fairly typical problem that causes pain in the extremities. It might appear on a USMLE but would probably be too easy for a medicine board exam.

  38. #38 DrWonderful
    August 25, 2011

    @titmouse- I believe I answered the question. Am I not fully understanding what you are looking for?

    I work up a lower back cases the same way any health care provider should…beginning with a detailed history followed by an orthopedic and neurologic exam with imaging if indicated. Possibly order blood or neurologic testing if indicted, although that would be rare.

    Did I pass you brutal test?

  39. #39 Science Mom
    August 25, 2011

    @MikeMa- I was speaking specifically to the percentage that refuse to differentially diagnose or “treat” any particular ailment but rather ONLY clear the body of innate energy inhibiting subluxations. When I was told it’s still around 15-20% who practice this strict philosophical approach I was surprised to learn the estimate is still that high. All DC’s, even from the crappiest of schools, must pass 4 National Boards where basic science and diagnosis is paramount. We estimate about 15-20% do not practice this way once they are in the field.

    I’m curious as to where you derived this figure since Dr. Ernst, as recently as last year reported 95% of chiropractors reviewed made unsubstantiated claims. http://www.ncbi.nlm.nih.gov/pubmed/20389316

  40. #40 lilady
    August 25, 2011

    @ Dr. Wonderful: Perhaps you would like to enlighten us about:

    “@lilady- Chiropractors are trained in differential diagnosis. If the core curriculum of the colleges, content of National Boards, state licensing scopes, and hundreds of millions of data points in the insurance industry databases demonstrating a broad range of ICD-9 codes utilized by DC’s are not enough for you then I really don’t know what would be”.

    How many of of the ICD-9-CM Diagnostic Codes and how many of the ICD-9-CM Procedure Codes are used by chiropractors for insurance company reimbursement? Notice, I haven’t asked for the number of CPT Codes including CPT Code 97010 (application of hot or cold packs prior to spinal manipulation), for which chiropractors have been denied insurance reimbursement).

    You might want a few days to have your “billing staff” count up the numbers of ICD-9 Diagnostic and ICD-9 Procedure Codes…and they don’t add up to “hundreds of millions of data points in the insurance industry databases demonstrating a broad range of ICD-9 codes utilized by DCs”.

  41. #41 Calli Arcale
    August 25, 2011

    To clarify for Dr Wonderful — I believe he is referring not to the percentage of chiros which never make ridiculous claims but to the percentage of “straights”.

    If one is feeling cheeky, one can simplify this as “the percentage of chiros who *always* make ridiculous claims”. A straight chiro may occasionally accomplish something useful, but they base it all on the theory of the innate. The remaining 75-80% of chiros will admit chiropractic ain’t everything — they’ll also offer iridology, reflexology, acupuncture, herbal medicine, homeopathy, and, on rare occasions, a referral to an MD. In other words, DrWonderful is right. And so is Edward Ernst. The 20% tells you the worst of the worst, the chiropractors who still cling to DD Palmer’s original teachings.

  42. #42 DrWonderful
    August 25, 2011

    @Dianne- based on the scenario you described, with the edema in the leg and recent flu and otherwise normal ortho/neuro exam, I actually wouldn’t be going anywhere with this patient. There would be no indication for me to treat. I would be on the phone with his PCP and let him/her coordinate care. This case, based on the info you have provided, does not appear to be musculoskeletal based. If the PCP referred back to me after further diagnostic work up and more definitive differential then we’d go from there.

  43. #43 DrWonderful
    August 25, 2011

    @ScienceMom- I honestly have never read a study or article or anything from Enrst that is not biased and just a horror show with the purported facts. He also tends to reference himself, and usually only himself, which sort of bogifies his position too. But anyway, I wasn’t talking about the “claims” chiro’s make so the point is moot.

    If it matters, I was talking about the minority of the profession that refuses to diagnose even after being forced to study DDx and pass National Boards based predicated on DDX. We’re an odd lot, not doubt.

  44. #44 lilady
    August 25, 2011

    Hmm Dianne.. Dr.Wonderful said “based on the scenario you described, with the edema in the leg and recent flu and otherwise normal ortho/neuro exam, I actually wouldn’t be going anywhere with this patient. There would be no indication for me to treat”.

    He then describes a call he would place to the PCP and possible referral back to him by the PCP (all hypothetical, IMO)

    “I would be on the phone with his PCP and let him/her coordinate care. This case, based on the info you have provided, does not appear to be musculoskeletal based. If the PCP referred back to me after further diagnostic work up and more definitive differential then we’d go from there”.

    Let us assume that the patient has no PCP…would you order tests or provided any treatment or make a referral for a specialist?

    What if the patient has no health insurance (he/she has been paying for your care out of pocket)…what would be your next recommendation be, for this indigent patient?

  45. #45 DrWonderful
    August 26, 2011

    @lilady- your inability to stay on topic is a bit tedious. You’re in over your head. Just so you know, there is a difference between being “uninsured” and “indigent”. I’ll leave it to you to learn the difference but will answer to both scenarios anyway.

    *If the patient had no PCP of their own I would refer him/her to one I work with. There is one I respect greatly in my building and either myself or staff would bring the patient there ourselves. Not a totally uncommon event.

    *If the patient were uninsured and had no PCP I would still do the same thing (if they’re seeing me then they can go see someone else too).

    *If they were actually “indigent” they likely wouldn’t be in my office in the first place but if they were I’d get the to the free clinic downtown.

    The point is… with the case as presented by Dianne I’m not treating the patient. Plain and simple. Just because I would DDX something like phlebitis, a blood clot, an insect/animal bite, etc does not mean I would treat it. You obviously still have a lot to learn about chiropractors.

  46. #46 lilady
    August 26, 2011

    Hmm. a little testy are we? And, how long did it take you to figure out this simplest of MEDICAL diagnosis that would probably never appear on the USMLE..too easy?

    Dianne really threw you a softball question with the patient h/o of flu the prior week…any medical doctor would be able to figure this out rather quickly as being classic signs of DVT…not superficial thrombo-phlebitis. and send the patient immediately to the ER, for ultrasound and/or MRI and or venography…before the thrombus threw a clot to the lung.

    I, of course know the difference between uninsured and indigent…a hospital ER accepts patients who are both…for the potentially life-threatening condition. “Send him to the free clinic downtown”? Not so fast Dr. Wonderful. I’ve worked in public health clinics which offer care to non-emergency patients who are uninsured or indigent and if you telephoned ahead (common practice whenever you refer a patient) any and all doctors or nurses there would tell you to send the patient to the ER immediately.

    We know who’s “In over their head” here. The hypothetical patient should be glad that you didn’t offer a spinal manipulation or a leg “adjustment”…while you were wasting time trying to find a ICD-9 Diagnostic or Procedure Code to bill him/her for.

    BTW, we are waiting for the ICD-9 Diagnostic and ICD-9 Procedure Codes that your office uses for billing while working up the patient or treating the patient after you’ve made a “differential diagnosis”. Can’t you stay on topic?

  47. #47 DrWonderful
    August 26, 2011

    @lilady- I don’t typically associate thigh swelling without ANY lower leg symptoms with a DVT but agree it is possible. I guess actually visualizing what Dianne described would have been helpful. At that point referral for emergent care would be appropriate. Fortunately, I have a walk-in urgent care clinic and radiology center in my building which is where we would have brought the patient.

    In 20+ years of practice I have picked up 2 DVT cases and both were sent to the ER but they each had lower leg signs and the visual presentation was pretty obvious and Homan’s test wasn’t even needed. Homan’s test is performed as part of the standard examination anyway.

    With regard to ICD-9 codes I think you’ll need to do the homework yourself. The data is available and is widely used to measure the trends among all health care providers. Finding the studies for you right now, I fear, would be a waste of my time.

    In summary, chiropractors use physician-level E/M procedure codes and the broad spectrum of diagnostic codes available thus demonstrating a differential diagnostic workup. You’d see the ICD-9 Dx codes pretty much match what we treat…musculoskeletal conditions. The CPT procedures would be clustered in that direction too. Data on referrals show utilization of a broad range of diagnostic tests but also clustered toward musculoskeletal conditions.

    Anyway, are you so far removed from the realities of modern chiropractic that this silly exercise is really necessary?

  48. #48 lilady
    August 26, 2011

    @ Dr. Wonderful: Let’s return to Dianne’s hypothetical patient and the fact that you totally avoided the question and then supplied a nebulous response. You dug yourself even deeper by stating:

    @lilady- I don’t typically associate thigh swelling without ANY lower leg symptoms with a DVT but agree it is possible. I guess actually visualizing what Dianne described would have been helpful. At that point referral for emergent care would be appropriate.

    You may not “typically associate thigh swelling without ANY lower leg symptoms with a DVT”…but any medical student doing an internship makes that association immediately…even without the broad hint that Dianne provided of a recent medical h/o of influenza. Indeed, when I did rotations and an internship prior to graduating with a BSc-Nursing and licensing as an R.N., I could have made that diagnosis. As I recall my written Nursing Boards, that question wasn’t one of the “giveaway” questions, because of the all too obvious correct diagnosis.

    You apparently have never heard of DVT occurring in the thigh…and seemed to imply IF a DVT was present in the thigh that you would see signs in the lower leg and would use the Homans’ sign:

    “I have picked up 2 DVT cases and both were sent to the ER but they each had lower leg signs and the visual presentation was pretty obvious and Homan’s test wasn’t even needed. Homan’s test is performed as part of the standard examination anyway.”

    Homans’ sign terminology was first used in 1944 and has come in to wide disuse because of its poor positive predictive value and poor negative predictive value.

    You first stated in your posting at #19 above (regarding differential diagnoses):

    “Chiropractors have a high level of proficiency in differential diagnosis and treatment of musculoskeletal conditions, not only of the spine, but including the extremities as well.”

    Dianne, presented her hypothetical case and you didn’t reply. I rephrased the question and also asked you which of ICD-9 CM Diagnosis Codes and which of the ICD-9 Procedure do you use in your practice.

    It seems that you have zero proficiency in differential diagnosis codes as applies to the extremities.

    Regarding my second question about your statement of proficiency and familiarity with your the ICD-9 codes as applies to your chiropractic codes, you now state:

    “With regard to ICD-9 codes I think you’ll need to do the homework yourself. The data is available and is widely used to measure the trends among all health care providers. Finding the studies for you right now, I fear, would be a waste of my time.”

    I’ve done the homework and I again state that you are avoiding every question asked of you. Let me rephrase that. How many of the more than 14,000 ICD-9 Diagnostic Codes and how many of the more than 4,000 ICD-9 Procedure Codes do you use for billing because as you have stated innumerable times:

    “Chiropractors have a high level of proficiency in differential diagnosis and treatment of musculoskeletal conditions, not only of the spine, but including the extremities as well.”

    Let me fix that last statement for you:

    “Anyway, are you so far removed from the realities of modern chiropractic that this silly exercise is really necessary?”

    I know only too well the “realities” of modern chiropractic…that is why this discussion is taking place.

  49. #49 Dianne
    August 26, 2011

    There’s no shame in saying “This is outside my scope of practice” and referring a patient elsewhere, so I agree with Dr. Wonderful’s assessment that s/he shouldn’t be treating the patient I described but should send him/her back to the medical care system. However, the PCP is not the appropriate referral unless s/he can see the patient right away. As Lilady and others mentioned, it’s probably a DVT. It’s not unusual to see a patient with a DVT and subtle symptoms. In fact, I debated leaving out the swelling and calling it just thigh pain-a perfectly typical, but not classic, presentation. The patient should go to the ER or, if possible, clinic for an immediate ultrasound.

  50. #50 DrWonderful
    August 26, 2011

    @lilady- have you worn yourself out yet? The patient lived. I DDX’d a blood clot. Should I have put my clown nose on and say “you adjust C2 on the right!” to make you happy? Does it hurt to have your knickers bunched up so tight? Have you proven in anyway, on any level, that chiropractors are not trained in differential diagnosis? This is like a game of “gotcha” with a rabies infected pit bull.

    If it were an actual clinical test, where I actually saw the patient (instead of jabbering away on a blog forum while watching baseball and helping my kid with her IPad) maybe I would have been clearer about sending the patient for emergent care instead of their PCP. But no, I failed. You got me. I am dead in your arms.

    With regard to your constant harping about ICD-9 codes what exactly is your point? What is the actual point? Did I say, or even infer, that Chiropractors use all 14,000 ICD-9 Dx codes or all 4,000 procedure codes? Did you take my comments earlier to even insinuate that? To answer your question, over the course of a year I probably use 30 Dx codes and 8-9 different procedures codes. So what?

    My point was, if you look at the billing records you will see that DC’s use physician level E/M code (which require a differential diagnostic work up) and refer for diagnostic testing (again, to formulate a diagnosis) and perform procedures that demonstrate more than “bone cracking.” You can, just like the experts, use this body of data to support the conclusion that…the vast majority of chiropractors differentially diagnose. That is all I meant by even mentioning billing codes.

    How on earth is this so difficult for you and why do you have such a massive bug up your ass? Can you admit you are biased to the point of being completely unreasonable? So, now, what is the point and meaning of this? And please show how chiropractors are not trained in differential diagnosis. Prove YOUR point please.

  51. #51 Dianne
    August 26, 2011

    As I recall my written Nursing Boards, that question wasn’t one of the “giveaway” questions, because of the all too obvious correct diagnosis.

    I thought I was making it too obvious…Ok, slightly harder one. Patient presents with lower back pain. No history of trauma, no prior lower back pain. His job does not require repetitive motion. He weighs 100 kg and has had an intentional loss of 10 kg over the past few months. Review of systems is otherwise essentially negative. How do you proceed in the workup of this patient?

  52. #52 DrWonderful
    August 26, 2011

    @Dianne- thanks for the pass. I honestly though the intent of the question was to see if I would treat the patient and was just sloppy beyond figuring that I would not. when you said all physical exam findings were normal I assumed this meant pulses, etc. I do refer for Doppler in suspected DVT but still use Homan’s as a quick screen for any case with lower extremity pain. Why? Because the PCP or radiologist still typically asks if we did it and so it should be noted in the report. I refer maybe only 1-2 per year for Doppler and, you are correct, in 20+ years of practice never once for the thigh. Nonetheless I wasn’t touching the patient.

  53. #53 DrWonderful
    August 26, 2011

    @Diane- again, detailed history followed by ortho/neuro exam. Imaging if indicated.

    How old is the patient? Night pain? How long has the pain been present? Last complete physical? Any recent blood work? Flank pain? Blood in stool or urine? Recent PSA or colonscopy? When does the pain occur (functional)? What provides relief? Quality of pain? Radiculopathy? Severity? Frequency? Recent fevers? Difficulty breathing? Smoker/non smoker? Intentional weight loss of 20 pounds over several months is not immediately alarming without any red flags but has he recently initiated new diet or workout regimen?

    What are the PE, ortho, neuro, functional examination findings? The rest would be determined based on the information provided.

    DDx’s range anywhere from simple mechanical lower back pain (functionally related), aneurysm, colon, prostate, bone CA or infection, secondary mets, etc.

    If no red flags are surfaced and the musculoskeletal exam provides findings then proceed with conservative course of therapy for 2-3 weeks. If no progress consider imaging (unless was indicated during initial work up) at that point or make appropriate referral.

  54. #54 DrWonderful
    August 26, 2011

    @Dianne- same always…detailed history, PE, Ortho/neuro exam and imaging if indicted.

    I wrote a longer and more detailed response including the types of questions in the history but that post was again held up by the moderator. Typical DDX’s are mechanical LBP, OA, prostate CA, colon CA, bone CA or infection, kidney infection, aneurysm, possibly gall bladder or pancreas, etc, etc, etc. Pretty standard for everyone except looney chiro’s. I would need hx and exam finding to worm through that list.

    If mechanical LBP then initiate conservative care for 2-3 weeks and if no improvement consider imaging or referral based on any new findings.

    Leaving for the weekend to prep my summer house for the hurricane so I may have to come back to this later. Peace all.

  55. #55 Healthy
    August 30, 2011

    Haha, I’d bet everyone has to visit a chiropractic sooner or later during their lifespann. That it’s origins has some homeopaty smell is just because it’s mechanism were hard to explain but some prove to work and some don’t which separates them.

    To find research funding, peers and ideas please check the non-profit Aging Portfolio.

  56. #56 Chris
    August 30, 2011

    “Healthy”, why are you spamming here?

  57. #57 Fairfax chiropractors
    May 17, 2012

    Your work article, blogs I mean over all contents is must read stuff.

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