Editor's note: This is the second part of Dr. Cooperstein's two-part coverage of the American Back Society meeting in San Francisco, December 12-14, 1996. Part I, "Restoration of the Intervertebral Disc," was published in the Feb. 10, 1997 edition of Dynamic Chiropractic.
Among the points made by Dr. Glassman:
Dr. Arthur Schuller spoke on sympathetically maintained pain (SMP), pain that is attributable to sympathetic efferent function in peripheral tissues. When the alpha-1 receptors are activated by the release of norepinephrine from the sympathetic terminals, nociceptors are activated and pain is the result. Central neurons concerned with pain sensation become sensitized such that input from low-threshold mechanoreceptors also evoke pain. Although Dr. Schuller acknowledges that the evidence for SMP is largely anecdotal, he believes it should be considered whenever a patient has severe pain that cannot be otherwise explained. The quality of the pain is perceived as burning or electrical, and is unrelated to mechanical movement. Patients may have dysesthesia, causalgia, allodynia, hyperalgesia, and vasomotor and sudomotor changes; pain provoked by mild cooling is especially suspect. There may also be atrophic changes in the skin, muscle, and bone. Anesthetic sympathetic blockade is useful in the diagnosis. The incidence of SMP among patients with spinal disease is not known, but probably under-recognized.
Cailliet and the Neurophysiological Basis for Back Pain A voluntary movement unleashes a pattern of activity that is already programmed in the central nervous system. For example, we don't so much learn how to stand, as improve upon a pattern that is inherent in the CNS from the beginning of life. There are intrinsic control patterns in the muscular system as well, coordinated through the GTOs and spindle fibers. There are, however, "perturbers" that may interfere with these patterns: fatigue, errors in judgment during activity, emotional condition, etc. Improper use of the body results in nociceptor output back to the cortex that registers as functional derangement, or malfunction. Finally, we develop pain as the result of a process of impaired neurological function. It is amenable to improvement through treatment and learning improved movement patterns that reset the proprioceptors.
Silverman on Electrodiagnostics
Although we chiropractors have bet the family farm on treating "nerve interference," we receive very little undergraduate training, if any, in directly measuring neurological function, or even interpreting neurologist reports. Hoping it would help fill in the void, I attended a workshop on electrodiagnosis conducted by physiatrist Judy Silverman. After lulling me into a false sense of security with a detailed but otherwise routine description of what a neuron is, she rapidly left me in the dust while discussing the specifics of how one directly reads the nervous system. Two of the medical doctors in the audience had questions about the surface EMG studies their patients bring in from their chiropractors. Dr. Silverman stated that although surface EMG might be useful in a biofeedback setting, where a small or large response helps the subject gain control over a muscle group, it should not be used for left/right comparisons. More specifically, in a chiropractic setting, there would be too many confounding factors to conclude that the paraspinal muscles on one side of the body were more active ("spasmed") than on the other side.
Haldeman on Credentialing
Dr. Scott Haldeman spoke on the topic of credentialing of health care providers. After declaring that "managed care is here to stay, whatever you may think," he described how credentialing could potentially ensure the compatibility of patient, doctor, and provider needs. Patients want effective care delivered by good doctors, without undue interference from the insurance carrier, while doctors symmetrically want to render effective care, without undue interference. The managed care organization, like any other consumer of a service, wants to balance low cost and high quality, and furthermore understands that high patient and doctor satisfaction is essential to effectively compete in the marketplace. Although utilization must be reduced, the quality of care must be increased. This will require more trust by all concerned parties, less paperwork, and more uniformity of care. The gatekeeper concept is losing ground in favor of direct access to all different types of specialists; the care will be protocol, not gatekeeper, driven. "Provider credentialing should be balanced among all disciplines and specialties."
[As a side note, this presentation confirmed the implicit wisdom of a joke I have heard frequently, the one about how managed care wants to makeover doctors' offices according to the fast food model "Mary, let's stop off and have a physical at Doc in the Box on the way home." Dr. Haldeman emphasized how much the health care industry could learn from a McDonald's restaurants he recently visited in Russia, that serves a hamburger identical to one from his own Southern California.]
According to Dr. Haldeman, we fought managed care because we didn't like it, but we lost and therefore it is here to stay. Now we must become the agents of change and adopt a position of enlightened, not angry, self-interest, so as to facilitate the development of guidelines, perform research, and establish quality assuredness. He believes that a doctor who is credentialed may help avoid unnecessary care, receive reasonable reimbursement, and provide the least expensive, most effective care. Facilities as well will have to be credentialed. We need a system where there is:
Dr. Haldeman returned to explain that spinal manipulation is a good example of how outcome-based research can lead to the widespread acceptance of a treatment method. Thermography, by comparison, is an equally good example of how one's favorite procedure could easily get excluded from the managed care system. Some 20 years ago the NIH found little evidence in support of spinal manipulation, whereas the recent AHCPR and Quebec Task Force reports found enough outcome based research to support it, along with only a few other treatments, for low back pain. The parameters that have been measured include relief of acute pain, various physical measures, cost effectiveness, early return to work, and patient satisfaction.
What happened to thermography? Although it had been widely used (and paid for), thermography turned out to be too expensive and lacked even one outcome study showing that it changed either the treatment rendered or the outcome of care. Many papers came out showing asymptomatic patients had abnormal thermograms, and that positive thermograms may not correlate with the location of the pain. Moreover, correlation with EMG and CT imaging was also very low. In the case of SMT, by comparison, the chiropractic profession had the wisdom to recognize the need for establishing guidelines. It set into motion a process that led to the Rand reports and the Mercy guidelines, the principal points of which have been reiterated by the AHCPR guidelines. "That's how you protect what has been legitimized," according to Dr. Haldeman. "We all have our favorite techniques, what we believe to be valuable, but if we want them to be paid for and to be included in algorithms, then we are going to have to [provide outcome-based evidence for their clinical utility]."
Dr. Becker's favorite psychological test is the pain drawing. (Note the irony in calling a pain diagram a psychological test.) Subjective complaints that are not consistent with physical findings give rise to "diagnoses of frustration" by the doctor: chronic fatigue syndrome, fibromyositis, fibromyalgia syndrome, etc., all unicorns, according to Dr. Becker. Although some of these unicorns may actually exist, it is an oxymoron to claim that a particular patient has fibromyalgia syndrome, but is not really depressed; there is no magic involved in the fact that both "just happen to respond" to the same antidepressant drug. This only begs the question. How do you know the person does not really have clinical depression? The goal of care is to accept reality, realize that cure may not be possible, devise appropriate care, and definitely discontinue inappropriate care.
Dr. Becker finished his presentation with his trademark slide, featuring a red herring that is changed into an albatross by an unnecessary surgery.
Dr. Jacob J. Parker conducted a particularly compelling workshop on spinal imaging. His was the first such workshop I have ever attended in which the primary emphasis was not on the diagnostic interpretation of the images. He emphasized the clinical guidelines for the use of diagnostic spinal imaging; the cost-effectivity of imaging; and the nature of the pathological processes that eventually progress to what is seen in the image.
Dr. Parker began his talk with a price list for the different types of images, and ended his talk (echoing Dr. Haldeman) with the comment "managed care is here to stay ... If we don't contain costs, our goose is cooked."
He described how the discovery that a very high percentage of asymptomatic subjects are walking around with disk bulges and worse has led to a "denial frenzy" among insurance companies, who are now refusing compensation for advanced imaging procedures on that basis. (I guess every profession has its own Mercy guidelines problem.) He thought this unjustified, because there are not enough prospective studies on the long-term natural history of such asymptomatic disk bulges. He believes the risk for these subjects developing spinal problems is much greater than in the case of bulge-free subjects.
Dr. Simmons described a study in which 39 MRI standard studies and then MRI myelograms were independently reviewed to determine the need for surgical decompression. MRI myelography reduced the number of levels indicated from 147 to 96, dispelling the stereotypical belief that MRI myelography will overestimate the need for surgery. It may also show areas of CSF penetration below what might otherwise be construed to represent a complete block, and furthermore delineates the root sleeves. The procedure is cost effective, since there is no additional charge beyond standard MRI.
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
