Wednesday, June 4, 2014

Chiropractic Diagnosis and the Elephant in The Room

The following comes courtesy of Dr Matt Long at CDI (Clinical Development International).
The Diagnostic Imperative
September 03, 2013 by Dr Matthew D. Long
Since its inception the chiropractic profession has had an uneasy relationship the word 'diagnosis'. While there were strong historical reasons for this, largely based upon establishing a separate and distinct lexicon to avoid being jailed for practicing medicine without a license (1), there remains an undercurrent of concern about the word itself.

What are the implications of using this word? For one thing, a diagnosis allows us to understand the
extent and character of a condition. We can then choose our management wisely, even if our clinical application remains focussed upon the chiropractic adjustment. After all, if I know that the patient in front of me has an annular tear then I might approach the delivery of an adjustment differently to that of someone suffering from a facet synovitis or meniscoid extrapment. How would the presence of a disc protrusion alter my decision-making? Or an extrusion? Or a sequestration? How would such knowledge alter my approach and improve patient safety and outcomes?
Because it should.
The recent discovery that vertebral body degeneration visible on MRI (type I Modic changes) may actually be due to an infection of Propionibacterium acnes from the mouth (2,3) further clarifies the importance of diagnostic specificity. If we know that such degeneration might actually be infectious in nature it significantly changes management.

We should also bear in mind that even if we limit our descriptors to the word 'subluxation' to quantify a spinal problem, we are
still making a diagnosis. We are attaching a label to a patient and deciding to intervene based upon it. However, a term like ‘subluxation’ leaves out the very important element of the tissue in lesion - and it is the connective tissues of the spine that must ultimately bear the forces that we wish to impart with our adjustments. After all, the bones of the spine are nothing more than levers that we use to stretch connective tissues and fire the receptors embedded within. It makes sense that we understand the nature of the tissues that we interact with. A subluxation is a model. It is a representation of various functional aberrancies in the spine, but like all models it is an approximation. An accurate diagnosis gives us clarification.

Making a rigorous diagnosis also grants us a
What is the chance of resolution of a grade 3 lumbar nerve root compression? How much time have you got to try out your conservative management before you close the window of recovery forever and condemn the patient to a life of chronic pain? 1 month? 3 months? 6 months? Would identifying the at-risk patient early make a difference? Absolutely.

Diagnosis gives us clarity. It also gives us a place in the health care system. The world does not need better therapists. It needs better problem solvers. It needs better clinicians. It needs better diagnosticians.

Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)

1. Keating, Joseph C Jnr. B.J. of Davenport: The early years of chiropractic. Davenport, IA: Association for the History of Chiropractic; 1997.
2. Albert, H. B., Lambert, P., Rollason, J., Sorensen, J. S., Worthington, T., Pedersen, M. B., et al. (2013).
Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? European spine journal, 22(4), 690–696. doi:10.1007/s00586-013-2674-z
3. Albert, H. B., Sorensen, J. S., Christensen, B. S., & Manniche, C. (2013).
Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. European spine journal, 22(4), 697–707. doi:10.1007/s00586-013-2675-y