MD, PhD, FMedSci, FSB, FRCP, FRCPEd

I just came across this article which I find remarkable in several ways. Here is the abstract:

OBJECTIVE:
The purpose of this report is to describe 2 patients with coronary artery disease presenting with musculoskeletal symptoms to a chiropractic clinic.
CLINICAL FEATURES:
A 48-year-old male new patient had thoracic spine pain aggravated by physical exertion. A 61-year-old man under routine care for low back pain experienced a secondary complaint of acute chest pain during a reevaluation.
INTERVENTION AND OUTCOME:
In both cases, the patients were strongly encouraged to consult their medical physician and were subsequently diagnosed with coronary artery disease. Following their diagnoses, each patient underwent surgical angioplasty procedures with stenting.
CONCLUSION:
Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.

I FIND THIS REMARKABLE FOR AT LEAST 3 REASONS:

  1. I don’t remember coming across the term ‘medical physician’ before. It is clear what the author meant by it. But it is also quite clear that such phraseology is nonsensical. My Oxford Dictionary defines ‘physician’ as: “A person qualified to practise medicine, especially one who specializes in diagnosis and medical treatment as distinct from surgery.” Therefore, a ‘medical physician’ would be ‘a medical person qualified to practise medicine.’ This begs the question why this term is used in a chiro-journal. The answer is probably quite simple: they want to arrive at a point where we all accept that there are two types of physicians: medical and chiropractic. But, using again my dictionary, this would be not just a little confusing. A chiropractic physician would be ‘a chiropractor qualified to practice medicine.’ And for that you need to go not to chiro-college but to medical school.
  2. The two case reports are remarkable in themselves, I find. They show that “patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.” The remarkable thing about this is that such basic knowledge ever merited a mention and publication in a journal. It should be clear to anyone who is in healthcare! I even know shop assistants who have called an ambulance because a customer suffered from what might have been misdiagnosed as a muscular problem in the left arm but was in truth due to coronary hear disease. The fact that chiros and editors of their journals feel that it worthy of publication seems a bit worrying and begs the question: how many other elementary things about the human body (known even to shop assistants) are unknown to the average chiro?
  3. Lastly, I must praise the chiro-profession for the progress they now seem to start making. About 120 years ago, DD Palmer, the founding father of chiropractic, famously treated a man with coronary heart disease by adjusting his spine. The author of the above article did not do that! Yes, progress was painfully slow, but the above article seems to indicate that at least some chiros have come around to agreeing with real physicians that the Palmer-gospel is based on little more than wishful thinking.

19 Responses to Are chiropractors about to start comprehending some of the very basics of healthcare?

  • I’d say there is a big difference between someone in a clinic who presents with low back pain with “secondary complaint of acute chest pain” to someone in a shop who has left arm and chest pain necessitating a call for an ambulance, which would have to be severe, along with a few other signs to warrant such emergency action. So I would be inclined to disagree that it is OBVIOUS to even a shop keeper.

    The article brings to light to the fact that patients present to Chiropractic clinics with all kinds of symptoms, that can seem benign but in fact indicate more sinister pathology. Chiropractors are trained to know what the difference is between musculoskeletal and visceral pathology, and what to do if red flags are detected.

    Perhaps the article seems “unnecessary” to you, but I believe it is necessary to demonstrate to the public that these things happen. People may not think that we encounter serious pathology in practice, but it happens sometimes, and when it happens, we take the correct action.

    I have been the practitioner who has been the first to discover Pneumonia, Lung Cancer (which I diagnosed with a chest X-ray), Severe Hip OA, Diabetes, stress fractures, hernias, AAA, and Hypertension in my patients, who had refused to see their GPs. I referred them all, and got them on the right track to improving their health.

    Please can we not be so one-sided and start to respect each other a little more? There will always be people in every profession who are immoral or unethical in their behaviour. This is a human condition, not a profession-specific one.

    • “Perhaps the article seems “unnecessary” to you, but I believe it is necessary to demonstrate to the public that these things happen.”
      this does not make any sense either: the article was published in a chiro-journal which is read by chiros and NOT by the public.

    • what about the ‘medical physician’ issue? do you find this respectful to real physicians?

    • @Non Cherry-Picker

      The important part of your comment are the words “…in my patients, who had refused to see their GPs.” If bogus, pseudo-medical practitioners were not permitted to set themselves up as primary contacts for medical care, then the avenues of escape for someone with a serious medical condition to avoid seeking attention from a trained doctor would be reduced.

      You might argue that your marvellous record in being the first to discover the conditions you describe shows you provide a beneficial outlet for patients who fear their GPs. But the publication in the OP shows the chiropractor misdiagnosed his first patient and proceeded to give four sessions of manipulation before the diagnostic penny dropped. Chiropractors, homeopaths and the like should NEVER set themselves up as ‘primary care physicians’.

    • @Non Cherry-Picker

      Your arguments fall on deaf ears here. They will tell you that your personal experiences have no real value in an argument but then they will share an individual story to lump the entire profession together. Despite the easy to find documentation that chiropractors complete just as many total classroom hours as medical doctors, they will claim that we must learn rubbish. They use incendiary language against chiropractors such as quack, charlatan, pseudo-science, and cult before claiming to be the rational ones in the conversation. They believe that any beneficial result that a patient experienced after a chiropractic “manipulation” is the result of the placebo effect (as if the patients are all stupid enough to be tricked into thinking a chronic pain syndrome has resolved) or a ridiculously well timed self-resolution. The only time they admit that a chiropractor does have an effect on an individual is when they claim he or she hurt someone.

      Just last week a patient came in to my clinic after being released from a hospital due to injuries sustained during a car accident. No x-rays were taken at the hospital, he was given drugs for the pain and told to rest. After x-rays were taken in my clinic, I referred the patient back to the hospital due to an 8mm ADI to rule out transverse ligament rupture at C1. The “real doctor” reviewed the x-rays and told the patient that I was incorrect. At this point, I referred the patient for a CT scan (because the government recognizes me as a doctor and I can do that) that confirmed my diagnosis.

      We all have stories, Dr. Ernst. However selective they may be.

      • Derry Merbles wrote: “They believe that any beneficial result that a patient experienced after a chiropractic “manipulation” is the result of the placebo effect (as if the patients are all stupid enough to be tricked into thinking a chronic pain syndrome has resolved) or a ridiculously well timed self-resolution.”

        @ Derry Merbles

        Many patients and CAM practitioners make entirely wrong assumptions about healthcare outcomes. CAM practitioners, including chiropractors, nearly all of whom rely on ‘patient satisfaction’ in order to earn a living, seem to be particularly averse to learning if it was definitely their intervention that produced a positive result. The late Barry Beyerstein wrote at length about alternative medicine and common errors of reasoning in his classic essay, ‘Social and Judgmental Biases That Seem to Make Inert Treatments Work’. It’s worth having a slow read through it:
        http://www.ebm-first.com/a-close-look-at-alternative-medicine/153-alternative-medicine-and-common-errors-of-reasoning.html

        It’s also worth bearing in mind that the scientific data are increasingly indicating that spinal manipulation is a placebo:

        http://edzardernst.com/2015/08/chiropractic-spinal-manipulation-placebo/

        http://www.bodyinmind.org/spinal-manipulative-therapy-a-slow-death-by-data/

      • @Derry Merbles on Monday 18 April 2016 at 22:51

        “@Non Cherry-Picker”

        No irony there.

        ‘Your arguments fall on deaf ears here. They will tell you that your personal experiences have no real value in an argument but then they will share an individual story to lump the entire profession together.”

        Yawn, again.

        “Despite the easy to find documentation that chiropractors complete just as many total classroom hours as medical doctors, they will claim that we must learn rubbish.”

        If that is the case, why are they not doctors? The question has been asked before and more than adequately answered. When you cut skin, you will have a claim, otherwise, zilch.

        “They use incendiary language against chiropractors such as quack, charlatan, pseudo-science, and cult before claiming to be the rational ones in the conversation.”

        Do you mean descriptive language; based on the gold-standard, the evidence in Cochrane?

        “They believe that any beneficial result that a patient experienced after a chiropractic “manipulation” is the result of the placebo effect (as if the patients are all stupid enough to be tricked into thinking a chronic pain syndrome has resolved) or a ridiculously well timed self-resolution.”

        For someone who, supposedly, has equivalent “medical training”, you seem to know very little about the placebo effect. Were you not taught the terms “regression to the mean” or “self-limiting”? Does chiro training preclude the digesting of information that might render your profession less?

        “The only time they admit that a chiropractor does have an effect on an individual is when they claim he or she hurt someone.”

        Were you also not taught “do no harm” in your equivalent “medical studies”?

  • @Edzard

    Many readers will possibly miss the heavy irony of your comments. But they are possibly understated. I was able to access the full publication via my institution.

    Re your point i: you have correctly assessed the tautology of the term ‘medical physician’ The author repeatedly uses ‘chiropractic physician’ to differentiate himself from ‘medical physicians’. An example is the following quote. “Chiropractic physicians should carefully assess and monitor patients who present with acute musculoskeletal chest complaints until nonmusculoskeletal and cardiac-related causes are excluded.”

    Re your point 2: having written this sentence in his introduction, the author goes on to show he didn’t follow his own wisdom with the first patient. His purely musculoskeletal investigations and palpations led him to “an initial clinical [sic] impression of mechanical thoracic spine pain… After 4 treatment sessions over 2 weeks focusing on thoracic spine manipulation/mobilization and soft tissue therapy, the patient experienced mild subjective improvements.” Only at the fourth session of chiropractic did the author encouage the patient to consult with his ‘medial [sic] physician’ for further investigation and cardiac assessment, and only at the fifth session did he strongly advise the patient to seek proper medical help. The chiropractor author of this paper apparently did not have the wisdom of some shop assistants.

    Patient 2 was advised to consult a proper physician on his first visit, but “The patient hesitated and did not consult with his medical physician.” Three weeks later the patient called an ambulance after three attacks of progressively worsening chest pain.

    Re your point 3: I do not see any cause even for ironic praise of the chiro-profession for making progress. The case reports (and the lengthy discussion; a basic primer in the differential diagnosis of thoracic pain) illustrate eloquently what is wrong with allowing people untrained in medicine to ‘play doctors’. Both patients and their chiros were seemingly confident that chiropractors know best: in the same way as all believers in various faiths ‘know’ their ignorance and credulity ‘make sense’.

    Comments are often made on this blog to the effect that ‘medical physicians’ often get things wrong. How much greater are the chances that people pretending to be doctors will mess up?

    • point taken:
      considering the real danger of mis – or too late diagnoses by quacks pretending to be competent primary care doctors which this article documents so well, irony might indeed be misplaced.

  • Non Cherry-Picker wrote: “People may not think that we [chiropractors] encounter serious pathology in practice, but it happens sometimes, and when it happens, we take the correct action.”

    @ Non Cherry-Picker

    No, you don’t always take the correction action.

    The following is lifted from a report made by a medical doctor who went undercover to investigate chiropractic:

    QUOTE
    “About six months later, having shaved my beard, I returned to the clinic without an appointment, identifying myself as an uninsured construction worker with episodic left-sided chest pain that radiated to my left shoulder and upper arm. I stated that the pain was frequently associated with shortness of breath and often occurred during my job as a framing carpenter. I also indicated that I was a 2-pack-a-day smoker for 20 or so years and a heavy drinker. Any competent practitioner should suspect that my symptoms were caused by insufficient blood flow to the heart that would place the patient at high risk for sudden death. The chiropractor asked several questions related to my symptoms and initially expressed concern that they might be related to my heart. However, after using her hand to feel my left shoulder and shoulder-blade area and the front of my chest, she concluded that some of my ribs were “out”, meaning that the ribs had “lost their normal range of motion” and could possibly be the source of my problem. Then she placed a stethoscope on my breastbone, listened intently for a few seconds, and said, “Your heart sounds OK, I mean its not beating weird.” Based on this finding, she said she was able to rule out cardiac origin of my complaint. She concluded that the “ribs out” were the most likely cause of my symptoms and recommended a course of chiropractic therapy at $38 per visit to return the ribs to their normal “range of motion”.”

    Ref: http://www.chirobase.org/02Research/jwk.html

    • even the paper I used for my blog shows how wrong the assumption is. one patient was adjusted several times before he was advised to see a real doctor. my check-out girl would have drawn the right conclusion not in weeks but in minutes; and with CHD minutes can decide over life and death.

    • If a patient presented to my clinic with those symptoms Blue they would not make it past the reception desk! I would be calling an ambulance immediately. Called two last year and in both cased I had to bully the patient into staying put and calling the ambulance! The hospital A & E called the next day in regards to the second patient to thank me as 30 more minuted and the patient would have been dead!

      • @ Critical_Chiro

        I suspect that you are the exception to the rule. Others are very badly let down by chiropractors. For example, here’s what happened to tetraplegic chiropractic victim, Sandra Nette, when she visited a chiropractor, asymptomatic, for ‘maintenance’ adjustments:

        QUOTE
        “She developed symptoms during the neck manipulation. She told the chiropractor she was feeling pain and dizziness. She had to sit down for a while before she could leave the office. He failed to recognize a medical emergency; he suggested massage might help; he let her leave the office alone. And she didn’t just have a damaged artery – she had tears in both vertebral arteries, and one tear was 3 inches long.”

        Ref: The SkepDoc on 17 Jun 2008 at 7:53 pm
        http://theness.com/neurologicablog/index.php/chiropractic-lawsuit/

        • Critical_Chiro thinks he/she is the exception to the rule. He can’t see anything wrong with chiropractic that (s)he can’t reform.

        • @BW
          Treating is easy Blue! Knowing when not to treat and referring if far more important IMHO!
          I have discussions about cases like this on a regular basis with my chiropractic network and we all have called ambulances and picked up serious pathology! I have even queried radiologists reports where they have missed something serious!
          @FO
          Heavily involved in the reform process for 20+ years Frank! Reforming the critics is far more of a challenge! 😉

  • The first check point is what treatment can a chiropractic successively achieve? As that appears, from present evidence, to be zero then misdiagnosis and actual injury caused by chiropractics make them very dangerous.

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