J. Michael Menke, MA, DC, PhD
Several years ago, I was invited to present a 30-minute continuing education program to the medical doctors at my community hospital. (Many thanks to Microsoft PowerPoint for its assistance!) In the question-and-answer period following the presentation, the doctors had some specific concerns: Should chiropractors see patients with sciatica? Herniated discs? Degenerative disc disease with spondylosis? Carpal tunnel syndrome? Migraine headaches? Which types of headaches? These were legitimate questions, based on their preconceptions that chiropractic is a manipulative treatment, not a system of managing patients. How could manipulating things always be good - especially with median nerve demyelination within the carpal tunnel? How could spinal adjusting be good for a pronounced spondylosis of the lumbar or cervical spine? And what about spinal stenosis? From their perspective, adjusting such conditions seemed unlikely to help, and perhaps likely to harm.
My answers were careful and considered. I explained what our own chiropractic research points to (the efficacy of spinal manipulation trials). When research did not exist, as in treatment of specific lumbar or cervical degenerative disc disease or carpal tunnel syndrome (CTS), I explained the pathogenesis of the disease, and how manipulation or management may or may not help. I also explained that many CTS cases are simply misdiagnosed, as no "gold standards" for diagnosis really exist. Indeed, CTS could be an expression of a nerve entrapment in the lower cervical region or elsewhere "upstream," and thus simply be pain referred or caused by lesions other than in the wrist. I did not use any terms they did not already understand. I used the common vocabulary of health care physiology and diagnosis. I note this not to inflate my own ego, but to outline an approach that works for communicating with MDs.
Where does chiropractic fit in the scheme of health care? Does it fall outside of health care altogether? Is chiropractic a therapy or a profession? Is chiropractic alternative, complementary or integrative? Clearly, chiropractic involves more than only the spinal adjustment in the management of patients. In this sense, chiropractic is a profession, not just a therapy or type of treatment. It is a total perspective and approach to patient care that differs from the biomedical one. As to whether the profession is alternative, complementary or integrative, it is probably all three, with each chiropractor choosing the extent to which he or she participates in general health care delivery.
Alternative suggests "instead of" medicine. Complementary implies "along with" medicine. Integrative implies a degree of cooperation between the two professions. In addition, integrative, or integrated, chiropractors will employ approaches that are in harmony with medical science and understanding: diagnosis; referral accompanied by a finite treatment plan; an outcome basis to determine patient improvement; and discharge or referral.
One could say that new precepts and principles of integrative medicine will emerge - ones that will mirror the standards medicine expects from itself. Mostly, this comes down to "patient-centered care" - what is best for the patient is the modality used. In an integrated-medicine environment, the chiropractor should actually see all of the back pain patients first, and probably the headache patients, too.
Measurement of treatment success depends on what you measure. In medical circles, the subluxation is a highly suspect lesion; it appears only chiropractors can detect it, and only chiropractors know when it has disappeared, and sometimes only after long and expensive chiropractic treatment. Health outcomes that measure health status, pain and dysfunction generally are more acceptable to medicine.
Outcome measures will always be somewhat different, since chiropractors see the body and health via a different model than medicine. To medicine, health is the elimination of disease by interrupting its natural course (Jonas, 1999). To chiropractic, health is restored by re-establishing the body's ability to recover. The former is the mythical Aesclepian approach, which awaits the disease process to intervene; the latter is the "Hygienic" approach, which looks at enhancing host capability to overcome disease. These approaches are not opposites, but complementary, because a disease process may be amenable to treatment through restored balance or "hygiene" during the time when the body is not overwhelmed. When a disease progresses beyond the body's ability to restore itself, bring on the surgeon.
The wisdom, as they say, is "to know the difference" - when to refer a patient out for medical/surgical intervention. These are the two general models, and the two basic differences between the chiropractic and medical approaches to health.
This is the strength of an integrative approach to health care. Virtually every chiropractor would like to have "first crack" at back pain and headaches. Indeed, guidelines in such places as Stanford University's emergency department recommend spinal manipulation for uncomplicated low back pain, though I doubt many ED (formerly known as ER) patients receive acute care management with spinal manipulation. Until (and unless) MDs work more with chiropractors, they will not know the advantages of referring or co-managing patients with a chiropractor.
When integrated chiropractors find conditions beyond their capabilities, they promptly refer out to the appropriate providers. When a chiropractor brings a patient to a "permanent and stationary" plateau, and the progress is unsatisfactory to the patient or the employer, the chiropractor refers to the next best (safest and most effective) provider. And when treatment is complete, chiropractic treatment should be better than no treatment at all; save dollars; reduce iatrogenic risks; and improve health outcomes over other forms of treatment.
It just so happens that chiropractic is popular with consumers, who often make the decision themselves: They have a "mechanical problem," so they go to the chiropractor. They also seem to know when they have a "medical problem" and refer themselves to MDs. Whether or not this is good health care is questionable, as they may have misunderstandings and prejudices not based on the facts.
Fortunately, chiropractic has had an active research program for two decades or so. Compelling information and research exists to favor chiropractic treatment of some conditions for which medicine has little to offer. This is where the integration potential exists, and where chiropractic needs to go to become integrated.
Thus, chiropractic has an added responsibility for its future prosperity: to improve communication with allopathic medicine in continuing education; interdisciplinary research conferences; inter-referral communications; and patient co-management.
Resource: Cherkin DC, Deyo RA: Nonsurgical hospitalization for low-back pain: Is it necessary? Spine 1993;18:1728-1735.
J. Michael Menke, MA, DC
Palo Alto, California
