A Common Conversation

I had a conversation with a patient the other day, one that I've had all too frequently in the past. The patient, someone with chronic neck pain, had gotten impatient with the length of time it was taking her to heal, and had discontinued care. Now she was back in my office, after visits to the MD, PT, and the radiologist.

"I finally found out what was wrong with my neck," she said.

"That's great," I replied. "What is it?"

"I have arthritis!" she said. "My doctor took x-rays." She pulls out a manila envelope and hands it too me. "Maybe if I'd known a little sooner, I could have gotten this fixed."

I left aside for a moment the concept, always a little odd to me, that somehow I wasn't her doctor. I know, it's a chiropractic thing.

"Yeah, you probably do," I said. I ignored the manila envelope. "Doesn't really make any difference, though."

"What do you mean?" she said.

"Look, Sarah, you're 50 years old," I said. "Of course you have arthritis, everybody does by 50. Arthritis is just a medical term for wear and tear on the joints, and if after 50 years you don't have any wear and tear, that would be the surprising thing."

She just looked at me, clearly upset that I didn't share her enthusiasm for her newfound diagnosis and her (real) doctor's "discovery."

"Here's the thing of it," I said. "Those of us who treat a lot of this stuff know that there is often very little correlation between what an x-ray or MRI tells us and the pain and symptoms patients experience.

"Heck, studies show us that 30% of the population is walking around with a bulging disk in their lumbar spine, but most of them have no back pain. I've seen x-rays that showed massive amounts of 'arthritis' and disks that are virtually missing in action, but those findings had absolutely nothing to do with the patient's pain," I said.

"That's why I rarely bother with x-rays or CT scans or MRIs unless I see a red flag when I examine you. In most cases, it's not worth the radiation exposure or cost, because the 'arthritis' isn't the source of your problem."

"That's not what my doctor said," Sarah replied.

"I know," I said. "Let me ask you this -- what did your other doctor do after he found the arthritis?"

"He prescribed some painkillers for me, and I've been going to see the physical therapist."

"Great," I said. "How's it working out?"

"Well, sort of ok," Sarah said. "The painkillers were giving me a stomach ache, so my doctor put me on a different pill, but they aren't really much better than Tylenol. The physical therapy really helped at the beginning, but it's not been doing so much lately."

"Ok," I said. "Here's the thing. The wear and tear you've got isn't really the problem. Chronic pain like yours rarely comes from a single source. It's usually 2, 3, or 4 things all going on at once. If you don't tackle all of them at once, you won't really find a solution."

From that point, I went on to describe a suggested treatment plan -- one that I would have implemented a couple of months ago, had the patient not withdrawn from treatment prematurely.

The problem with this treatment plan is that it requires some lifestyle changes. Regular rigorous exercise, not a few lifts and stretches under the supervision of a mildly bored PT aide. Changes in diet, giving up some favored foods.

These protocols do work for chronic, degenerative conditions. But for so many people, the mental/emotional pain of change -- even healthy change -- is greater than living with physical pain.

By the time I was finished, I could tell Sarah was still unsatisfied with me and my answers. I understand her reluctance. It is much easier to hang your hat on a simple diagnosis -- "I have arthritis" -- than it is to tell your friends "I have a metabolic/muscle movement pattern dysfunction with inflammatory overlays."

Despite my 30 minutes of explanation, Sarah left that day without making any further appointments. I don't know if I'll see her again, but it's likely that if I do, her condition will be that much more farther advanced and more difficult to treat.

Over the years, I've had many patients like Sarah. And sometimes they do come back, and often, with committed efforts on both of our parts, we make inroads.

Sometimes, it's just too late.

It Happened. Again.

Sometimes I kind of feel bad about always pointing out the shortfalls of my medical colleagues, as I noted a couple of posts ago. But then I get yet another reminder or two of why I just can't get the warm fuzzies about them. My most recent bout of slap-me-Emma-I-must-be-sleeping medical foolishness began late last week, when a patient told me that her MD did not mind her seeing me, so long as I was not trying to treat disorders like diabetes and asthma.

Screeech! Back that up a second and replay it. Don't treat diabetes? Or asthma?

I'm sorry, but the most common form of diabetes, Type 2 diabetes, is the quintessential lifestyle disease. It is caused by a combination of couch potatoism and a lousy diet, usually leading to obesity. Any doctor, medical, chiropractic or otherwise, should know that fact, since just about everybody else in America does.

And, frankly, I'm the quintessential lifestyle doctor. To say that my knowledge, skills or tools are inadequate for the treatment of diabetes is like saying that a Porsche is an inadequate car for the Autobahn. OK, even to me that sounded a little cocky. But you know what I mean.

I don't think I even need to point to the research here, except to remind my readers that time after time, the research has demonstrated that lifestyle intervention should be the first line of therapy for diabetes. Ergo, the first stop for someone with this disorder ought to be a doctor board-certified in, nutrition, perhaps?

I'll grant you, however, that alternative treatment of asthma might be a little obscure for the average MD to have picked up on. But the research is there.

For example, in October, 2002, Ray Hayek, PhD, released the results of his 420-patient study at the International Conference on Spinal Manipulation. Dr. Hayek found that patients treated with spinal manipulation for asthma improved not only symptomatically, but demonstrated positive immunologic and hormonal changes in laboratory testing. (For you citation mavens, the abstract may be found here.)

Another study, albeit of small size, found that children combining chiropractic treatment with medical management of asthma experienced a substantial decrease in symptoms with an increase in their quality of life. (Look here for details.)

Which brings me back to one of my earliest experiences as a chiropractic physician. A little over a year after opening my first practice, a patient came busting through the door of my office, clearly in distress.

She was having an asthma attack, and communicated to me that she had left her inhaler at home. I had my assistant call for an ambulance, but I also knew that the arrival of a volunteer squad in my rural town might not be quite timely enough. Having heard the stories as a student doctor of chiropractic physicians treating asthma, I did that which I was best trained to do.

I had the patient lay face down on the treatment table, while I palpated the thoracic vertebrae for restrictions, and adjusted them with a quick thrust.

As quickly as it began, it was over. The patient sat up, already exhibiting patent relief, and within a minute was breathing normally.

I lectured her on the foolishness of being asthmatic and wandering about without her inhaler. When the ambulance arrived, she refused the ride and went home to obtain the missing pharmaceuticals.

So can chiropractic physicians treat asthma? Yes, and apparently quite well, thank you very much.

That said, it is clear that asthma is one of those disorders that lies at the intersection of conservative and pharmaceutical care, and patients with asthma would probably benefit best by appropriate employment of both forms of care.

It's just a crying shame that medical doctors, unaware of the research and informed only by longstanding bigotry, would advise our common patients to avoid the treatments which may help them most.