Choosing a good spine care provider
by Serge MAKOVETZ, MD
Finding a good spine-care provider particularly difficult and it’s a complex decision, because spine-care thoughts have unusually large variety of philosophies and techniques.
A good idea to start with is to ask friends, co-workers and neighbors for recommendations. However, even if someone says they have a “great chiropractor or osteopath” he might not be right for you.
Try to find a specialist whose practice is specializing in treatment of back pain, neck pain and other musculoskeletal problems. In the past medical doctors did not work together closely with chiropractors and osteopaths, today many medical doctors recognize the benefits of appropriate chiropractic and osteopathic treatment. Such GP may be able to refer you to a good spine care provider.
Remember that although manipulative therapy has value in treating back pain and may relieve other musculoskeletal conditions, chiropractors and osteopaths are not the only source of manipulative therapy. Physiotherapists and a number of medical doctors do it also. However, both the physiotherapist and medical doctor have to be qualified and trained to manipulate.
Registration with the appropriate National or State registration body is a very good sign and guarantees that the therapist has adequate training and experience and practices safely.
The following are guidelines on things to look for and things to avoid when choosing a good spine care provider.
Start With a Phone Interview
If you do decide to consult a spine-care provider, take some time to perform a telephone interview with any prospective therapist during which you explore the specialist’s attitudes and practice patterns. If you call and the doctor is not available, set up a time that is mutually convenient to have a discussion. Ask the doctor when he feels it’s appropriate to refer patients to other specialists. Ask about technique and practice patterns, and what kind of experience he has with patients who have similar problems as you.
When you come into the office, get a general impression about the place. Like any doctor’s office, it should be clean, well-maintained and professional looking. The staff should treat you with courtesy and professionalism.
You’ll probably be asked to fill out a few forms focusing on your problem and past history. Then you should have a private interview with the doctor to discuss your particular problem in detail, as well as to get a picture of your general health history. This should be followed by a problem-focused examination that includes vital signs (e.g., temperature and blood pressure), a range of orthopedic and neurological tests, and an analysis of the structure and function of your musculoskeletal system. If the doctor says that X-rays or laboratory tests are necessary, ask why they are necessary in your particular case. He should be able to explain why clearly and concisely, with reference to the list of reasons.
The focus of the exam should be to determine whether or not you have a functional muscular or joint problem which is within the scope of his practice, or if your problem requires a referral to another medical specialist for treatment or further investigation.
After the history and examination are complete, you should receive a complete report of findings. The doctor should explain your problem in clear and understandable terms, discuss options for treatment, and outline a customized treatment plan including specific therapeutic goals and an estimate of the frequency and number of visits your condition will require before you can expect to feel better.
Avoid any specialists who sees his profession as being opposed to the medical profession, or who denies his responsibility to diagnose and refer appropriately, as you should avoid any medical doctor opposed to chiropractic or osteopathic care.
Avoid anyone who shows a dogmatic attachment to any one technique or “school of thought” (ex., “Specific Chiropractic,” “Applied Kinesiology,” etc.) or who tries to sell you on his practice because he has some “magical machine” or practices some “unique technique.”
Avoid specialists who insist on taking X-rays because it’s “routine” or because “all patients require them”. The majority of patients who see chiropractors or osteopaths should not require X-rays.
Avoid practitioners who try to convince you to pay a lump sum up front for “extended” or “lifetime” care. Also, any spine-care provider whose fees seem much higher or much lower than the typical fees in your area should also raise a warning flag.
Avoid therapists who claim to be the only ones with a “special new technique” that no other specialists can use.
Finally, look for a spine-care provider who has good communication skills, who you feel comfortable talking with, and who seems eager to answer your questions.
Most patients who seek spine-care have conditions resulting from stiff and tight facet joints in the spine or extremities, and muscles that are tight and in spasm.
Spine care providers work hands-on using a wide variety of treatment techniques, improving mobility and relieving pain.
In addition to manipulation or stretching of tight muscles or joints, spine-care provides commonly use heat or ice packs, ultrasound treatment, electrical muscle stimulation or massage. They may also recommend a home exercise program.
Some spine care specialists may prescribe dietary supplements, homeopathic products, or herbal products for the treatment of disease. You should check the therapist who prescribes any of these products is trained to do so. For dietary supplements advice, however, the best sources are physicians, homeopaths and dietitians.
For most conditions, you should see significant progress after only a few visits, although patients with more chronic or severe conditions may require more extensive treatment before they can expect progress.
Back pain and neck pain can sometimes be a sign of a serious underlying condition. Fortunately, the majority of pains that usually bring patients into chiropractic or osteopathic offices are rarely indicative of a serious disease.
Understand that some manipulative treatments involve significant risk. In theory, spinal manipulations involving sudden movements have greater potential for injury than more conservative types of therapy. The most frequently reported complications include vertebrobasilar accidents and cauda equina syndrome; in practice, however, the complication rate is low, at one complication per 1 million treatments. (4) For proper perspective, the risks of manual treatment should be compared to the risks of other treatments for similar conditions. For example, even the most conservative “conventional” treatment for neck and back pain, prescription of Non-Steroidal Anti-Inflammatory Drugs (NSAID), may carry a significantly greater risk than manipulation. One study (5) found a 4/10,000 annual mortality rate for NSAID induced ulcers among patients treated for non-rheumatic conditions such as musculoskeletal pain and osteoarthritis; that extrapolates to 3,200 deaths in the US annually.
Seeking a provider who is properly qualified and registered with the appropriate National or State registration body will ensure that those particular conditions where these risks may arise as a result of high velocity thrust type of spinal manipulation will be recognized by the practitioner and either an alternative and safe manipulation technique will be selected or the patient will be referred for appropriate treatment elsewhere.
Following these guidelines is no guarantee, but they should help you in choosing a specialist who will provide you with safe, rational and effective care.
Christenson MG, Morgan DRD. Job Analysis of Chiropractic: A Report, Survey Analysis, and Summary of the Practice of Chiropractic within the United States. Greeley, Colorado: National Board of Chiropractic Examiners, 1993. This report is based on the responses by 4,835 full-time chiropractors who responded to a 1991 NBCE survey about their practices during the previous two years. The figures included: Activator Methods 51.2%, applied kinesiology 37.2%, acupressure/meridian therapy 65.5%, acupuncture 11.8%, cranial adjusting 27.2%, and homeopathic remedies 36.9%. “Nutritional counseling, etc.” was listed by 83.5%. Although the data don’t indicate what this involved, it is clear that a large percentage is inappropriately prescribing dietary supplements.
Chiropractors. Consumer Reports 59:383-390, 1994. This included a survey of 476 chiropractors chosen randomly from the American Chiropractic Association membership directory. Nearly one quarter of the 274 who responded sent material stating that spinal misalignments and “interferences” threatened overall health, and 35% implicated the spine in disorders of the body’s organs.
Assendelft WJ, Koes BW et al. The relationship between methodological quality and conclusions in reviews of spinal manipulation. JAMA 1995 274: 1942-1948.
Assendelft WJ, Bouter SM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. J. Fam. Pract. 1996 42: 475-480.
Fries, JF. Assessing and understanding patient risk. Scand J Rheumatol 1992; Suppl. 92: 21