by Gerard Hall
Having a typical degree education in a British medical school usually means that there are gaping holes in one’s general medical knowledge. This especially applies to those professions that are variously termed “non-traditional” “paramedical” “complementary” or even “alternative”. Some of these really are alternative and probably don’t need much attention – I’m talking of the various mumbo jumbo mind-body therapies. But others have huge evidence base, beg our attention but remain essentially ignored by the traditional medical community. In my field, rheumatology, there are several such complementary groups and one we are perhaps most guilty of ignoring is chiropractic.
In medical school we are taught that the management of spinal pain should centre on trying to make a definitive diagnosis based on the understanding of underlying pathologies and then applying appropriate treatments. Typically, this would include dealing with predisposing and propagating factors (such as the workstation), prescribing drugs and referring the patient for rehabilitation exercises from a physiotherapist. Physio is the most alternative a UK physician usually gets. We don’t really understand what physios do either but they inhabit our hospitals so they must be legitimate. We generally avoid chiropractic, osteopathy, acupuncture and others. Why? Some of us may indeed be bloody-minded and arrogant but almost all of us are ignorant in our understanding of these specialties. So we leave them all well alone. This is not just a shame but is ultimately to the detriment of the patient who may have missed out on a rapid, easy and cheap pain-relieving treatment and instead be channeled into a lengthy treatment programme of drugs and physiotherapy.
One of the many benefits of working in the private sector is that other options become available to the practitioner. Suddenly we are able to communicate with the complementary crowd and learn what they have to offer. I am now working in a Clinic in the City of London where we try and focus on a holistic approach to neuro-musculoskeletal medicine. We have our traditional team composed of rheumatology, neurology, sports medicine and surgery and our “complementary practitioners” who are made up from the specialties of chiropractic, osteopathy, acupuncture, massage, exercise medicine and meditation. Having all under one roof allows for better communication and an understanding of how each other practices. I can now see that there is so obviously a role for manipulation in the management of spinal pain. I confess that my bias against chiropractic has been deeply entrenched but, with time, the bias fades. Patients report success, often after very few sessions. Our practitioners are very sensible and won’t continue with unlimited treatment faced with a non-responding patient, which I find reassuring. Back in the teaching hospitals, we are taught that manipulation carries a high risk of serious harm and that practitioners are indiscriminate in their approach to patients with back pain frequently resulting in neurological catastrophe. Of course this was always likely to be nonsense but it’s still reassuring to see that chiropractors practice their skills appropriately and safely and know how to identify the patient with significant neurological complication. They integrate closely with other practitioners and are quick to cross refer so that we can reach a successful treatment regimen for an individual patient depending on which modalities they respond to best. This saves the patient time and gets them back to fitness promptly. This is what a health service should be.
There is a good evidence base favouring spinal manipulation, something else that has previously been almost hidden from view in teaching hospitals. But now that NICE have recently included manipulation in their 2009 Back Pain guidelines, I think that we will see a different attitude within the medical community – I hope so. In our cost conscious country, simple effective methods of treating back pain must no longer be ignored – we distantly trail our European neighbours in this respect. I was convinced enough by my recent working experiences to send my wife to our Clinic chiropractor. She had fallen off a horse and had an SIJ problem, or a “wonky pelvis” as she called it. One consultation and her disabling pain had resolved. She now refers to him as “miracle man” and she won’t be returning to the physio that I once sent her to, in the olden days.
Dr Gerard Hall MBBS FRCP