WHAT IS YOUR SCOPE OF PRACTICE?

The word 'chiropractic' is often seen as synonymous with 'manipulation', while 'chiropractic treatment' is also equated with a manipulation-only approach to health. However, 'chiropractic' is simply the name of the profession, and 'manipulation' is just one tool amongst many treatment options. Of course, manipulation is also used by physiotherapists and orthopaedic specialists, so it is not uniquely restricted to chiropractors. However, a tool is only as good as the knowledge that underpins its use, and this is where diagnostic expertise is crucial.

At Spine Partners Wahroonga we understand the importance of appropriate patient selection. Spinal disorders are complex and varied, and the associated research literature is expanding with the same ferocity as any other field of medicine. That is why we maintain a tight focus of expertise in spinal diagnostics and pain. We also appreciate the benefits of collaboration, and maintain good relationships with local physicians, surgeons and interventional radiologists.

IS THERE AN OVER-RELIANCE ON PASSIVE TREATMENT?

Treatment dependency is a problem that faces clinicians of all persuasions, including chiropractors. Indeed, there is a strong perception that their approach is largely passive, and that exercises do not feature strongly in overall management. At Spine Partners Wahroonga we see physical movement and exercise as the central pillar of recovery. However, even a cursory review of the rehabilitation literature will quickly highlight the differences of opinion that exist about the role of exercise.

Traditional management of spinal pain has evolved over recent decades. The initial paradigm emphasising rest gave way to methods of strengthening spinal muscles, particularly the so-called 'core' groups. This was subsequently refined to a tailored approach, in which specific exercises were individually designed for the deficits that a particular patient might exhibit. But has all of this refinement led to better outcomes?

Perhaps not.

There is now a growing undercurrent of dissatisfaction in the literature with tailored exercise programs, and a re-evaluation of our thinking about what exercise actually does for spinal pain patients. Our attempts to specifically target individual muscles that are deemed to be weak/tight/sluggish does not seem to improve outcomes. The human brain stores motor patterns in terms of desired functions (such as walking, typing, or swinging a golf club). As such, targeted exercises that aim to strengthen the gluteus maximus, or activate the transverse abdominus, or strengthen the ‘core’ while lying on an exercise mat, do not seem to help the next time we go for a walk, or bend to remove our shopping bags from the car boot. In essence, the human brain needs to practice performing real-world functional movements and not the individual sub-components of a larger activity.

For this reason, we emphasise a realistic, functional approach to exercise - allied with a thorough education program. Patients need to understand the reason for their pain, so that they can develop a sense of control.

Unfortunately the reasons for spinal pain are legion, but we must seek to understand these factors from the outset. An individual who exhibits joint hypermobility and connective tissue laxity will be managed entirely differently to someone more robust. Similarly, the patient with osteoporosis requires a gentle touch and tailored advice. Of course, the complexities of the chronic pain patient go much deeper, and we are often faced with those who are genetically geared to suffer longer. For these individuals the role of education, counselling and exercise must come to the fore. Finally, the patient with recurrent pain episodes needs to understand where their 'weakness' really lies, and it is usually a problem of muscular control, not simple strength.

ARE ALL PATIENTS X-RAYED?

Not at all.

Our reasons for using imaging are quite straightforward. We will only use an imaging modality if it will help us to answer a question that we couldn't resolve some other way.

We do not like the routine use of ionising radiation and, in many cases, the clinical workup is sufficient for a reliable diagnosis. However, there are cases where we simply cannot proceed without more information. For example, a patient may present with clear evidence of a disc herniation and radiculopathy. The clinical examination is typically accurate enough to localise the level of lesion, and the extent of sensory or motor deficit. But we cannot answer the important questions of:

• Size and shape of the herniation (which affects prognosis)
• The composition of the extruded material (which affects the likelihood of resorption over time)
• The grade of nerve root compression (which also influences the probability of surgery)
• The presence of other confounders, such as Modic changes (which further reduces the effectiveness of conservative measures)

For these reasons we may ultimately use MRI in preference to X-ray. Given MR's ability to detect fluid concentrations, it is also highly valuable in identifying facet joint effusion and other inflammatory processes. This is useful for planning management and specifying the target for injection procedures.

Chiropractors can refer for plain-film X-rays and MRI scans. We use them judiciously, and always with diagnostic intent.

IS CERVICAL MANIPULATION DANGEROUS?

Cervical manipulation has garnered its fair share of criticism over the years. However, an unbiased look at the literature shows that the truth is more nuanced than the headlines might suggest.

There can be no dispute that any treatment may cause harm if applied indiscriminately. As such, it is the responsibility of the clinician to ensure that their patient is a reasonable candidate for the proposed treatment. Spinal manipulation is no different, and there are both relative, and absolute, contraindications to its use. We are very aware of these factors, and our practice is conservative as a result.

Chiropractors typically use a variety of manual treatments, and spinal manipulation is only one such technique. Furthermore, the word 'manipulation' is simply an umbrella term that describes a range of joint mobilisations. It is not a 'one size fits all' modality, and all techniques are graded according to the tissue integrity of the patient. Such considerations include the connective tissues that we directly address, as well as potential complications of the vasculature.

The possibility of vertebral artery dissection following neck manipulation has been a persistent concern over many years. However, the vexing problem of association versus causation appears to be very real. The literature documents many known dissection triggers, including hair-washing at a beauty parlour, yoga, painting a ceiling, and reversing a car. Each of these inciting events has been linked to vertebral artery dissection - but only in an individual already predisposed. There is no suggestion that hair-washing is independently dangerous.

The literature has highlighted many risk factors for vascular fragility, including Ehler's-Danlos syndrome, Marfan's syndrome, fibromuscular hyperplasia, hyperhomocysteinaemia, oral contraceptive use, and even migraine. Furthermore, affected individuals are liable to initiate a vertebral artery dissection through innocuous daily activities. Unfortunately, such dissection typically produces neck pain and sub-occipital headache prior to stroke, driving the sufferer to seek out help and thus drawing chiropractors (or even massage therapists) into the pool of known possible triggers. Indeed, the most convincing evidence now suggests that the primary role of the chiropractor in such situations is one of concerned bystander, not causal agent. Of course, it is possible that an over-zealous chiropractor may aggravate an underlying lesion, or fail to make the diagnosis when such patients present. But this is a far cry from the persistent theory that neck manipulation is capable of producing a dissection in an otherwise healthy individual.

Urgent appointments are available, so please do not hesitate to phone our office on 02 9487 2161. Otherwise, please use the Priority Referral Form below and we will contact your patient directly.

For convenience you can book appointments online using the portal below. If you have any difficulties using the service then please call our office on 02 9487 2161.