Chiropractors Warwick

This is a little post in follow-up to the previous one (as follow-ups tend to do).

It is in response to some ridiculous statements I have been reading on some of the blogs of so-called sceptics. I know, I probably shouldn’t really spend my time on these things and it makes very little difference as people will always believe what they want to believe, but I did identify one very interesting problem with their logic. Research has been done for many years into the treatment of back pain. They assessed the effectiveness of manipulation, exercise, medication and doing nothing at all. Compared it to one another and decided what was best. Manipulation came out looking good-ish but not great-ish. Because chiropractors manipulate spines these so-called sceptics came to conclude that chiropractors are only good-ish at treating back pain and no better than physiotherapists or medication and only marginally better than not doing anything at all. What they do seem to miss the point of is that chiropractors don’t just manipulate. They often do but that’s because they selected those patients presenting with back pain which is likely to respond to manipulative therapy and told those who wouldn’t to see someone else. Basically of those 100 patients presenting with back pain they selected those who would be happy with their results by just manipulating them. Then they took those who needed more than just manipulating and told them they needed orthotics, a heel raise, a dental splint or any combination of things. This may or may not have been combined with manipulation.  Then they took those they couldn’t help and told them they should see a surgeon or a pain specialist. The second problem with their logic is that there is no research into this approach. None. Not a cumberland sausage. So according to the sceptics I have no evidence to claim to treat asthma and colic (which I don’t), and very weak evidence to treat back pain. Personally I feel that I have no good evidence for treating back pain at all, but I can tell you one thing: when I do what I do the very vast majority of people suffering with back pain problems stop suffering with back pain.

What I also do know is that this approach seems to work and those chiropractors who work like this end up with very good reputations, very happy patients and very little time to get onto blogs. Personally I feel that it is worth having this discussion, because any patient thinking that I know everything and know everything for sure should know that this is not the case. As a clinician I do my best to understand what is going on with you and find out what the best way is to get you out of this mess and feel better. The guarantee I got is one way of telling you that I more or less get it right most of the time but more importantly that you won’t be wasting your money.

I hope you found it interesting and let me know your thoughts.

Kind regards,

Stefaan Vossen

I love a good sceptic, no, really, I do. Scepticism is about thinking about what you do and why you do it. I am my own biggest sceptic and critic. My wife occasionally says I am too much so. So much for the sympathy vote. Point is; I often get asked by patients “why didn’t my GP refer for this?” or “Why is this not available on the NHS?” or “What do you make of that article in the Daily Mail?”

The problem is that we, chiropractors, as a profession haven’t established base-line standards any further than they were a decade ago. We have been comfortable, working away making more people better than not and advancing the profession in this way. Over the last few years I have been working away at understanding what makes a good clinic and what makes a great clinic, and although the hallway still looks like a building site, the clinic is turning into a great one.

So here’s a quick one for the sceptics:

Of the last 100 patients who presented to the clinic:

the average duration of complaint was 7.2 years

93 were offered treatment

30% were required to wear orthotics

20% were required to use dental splints

the average cost of care was £288

out of 93, 93 have improved

I could go into the detail as to how that is possible, but for now suffice to say that the biggest mistake being made by professionals in the back pain field is to think that all back pain is caused by back problems which originate in the back .

A new blogpost soon to follow!

Take care

Stefaan Vossen

I have decided that because Google looks at blog titles and gets you to read this article, I would start putting ridiculous titles up. The real title is:

Chiropractic, the Prince of Wales and the critics

It is interesting times for the chiropractic profession. Some people may be aware of some of the debate surrounding the validity of chiropractic care, a topic I am particularly interested in. Here I will share with you my views on the ongoing debate.

Much discussion has been created by the interventions by Professor Edzard Ernst, from Exeter University and the science writer Simon Singh. They produced some very good research analysis in which they concluded that amongst others the chiropractic profession does not have much in terms of scientific evidence to support some if not most of its claims. This has been made synonymous with there being evidence of non-effectiveness and that therefore the claims made by chiropractors have been shown to be bogus. I have had some interesting (to me and my geeky brain) debates with Ernst and a number of other interested parties. Ernst himself did concede to my point that proof of lack of evidence is not the same as proof of ineffectiveness but made one very valid point with which I fully agree: if there is no proof to support a treatment modality, then we have to establish whether or not there are risks associated and weigh up proof of benefit versus proof of risk.

The primary risk often spoken of is the risk of a person not seeking effective treatment. Say for example that I claimed to treat cancer and a person then decided to not seek effective, proven chemotherapy. If I have no proof of being able to help this person it would constitute a severe risk to them to ignore proven methods. This seems obvious to me as it does to all UK chiropractors. I am aware that there are some people in the world who make similar claims and I consider that to be criminal. But because there are some people who make these claims, all chiropractors and similarly other complementary and alternative practitioners, are being tarred with the same brush. This is a very serious problem for us as it does not actually represent our profession’s view but because these people are making loud noises and publishing widely people are on occasion thinking that it does represent us.

Secondly they speak of risks directly associated to treatment. Not many chiropractors publish these issues on their websites and I think that this is a failure on our behalf, but that issue too is being confused by some. I deal with musculo-skeletal pain of biomechanical origin, meaning that I help people who suffer from pains that are due to abnormal movement patterns which are caused by problems which are making them move badly. In effect you may have back pain, which is due to excessive stress on a buttock muscle on the left, which you have because you are hobbling on the left leg because you have a thorn in your right foot. So I take the thorn out of your foot and let you go about the business of naturally getting better.

Often times, especially when conditions are chronic (which is something I specialise in) movement patterns have been abnormal for such a long time that muscle tone, firing patterns and condition have been reconditioned in adaptation to the abnormal movement pattern. In reversing the movement patterns I will actively seek to reactive those muscle groups which have become underactive and vice-versa. This does cause some discomfort and anyone who asks me whether they might struggle at first will hear a resounding and entirely unsympathetic “yes” from me. Some people have called such responses “adverse reactions” but in my view real progress requires this change.

The real problem is that there is on occasion real risk: when we are changing the load-bearing capacity of say a disc or a joint a chiropractor may be doing so at a pace that the structure in question is not able to cope with. In those cases injury may result. This is why we in those cases have to be careful and stage the progression slowly so that the structures can adapt to a gradual rather than a sudden build-up. This does carry risk and in these cases skill, expertise and clear communication of these facts are required.

There is also much discussion about the risk of stroke being associated to manipulation of the neck. There is very little evidence to even support the notion. Current statistics show that the likelihood of you suffering a stroke is as high after visiting a chiropractor as it is after visiting a GP. People suffer strokes and however unfortunate that is, there is very little to say that it has anything to do with manipulation. But there are some (albeit very few) very convincing tales out there which are serving those people who wish to associated the two together. The problem is: the chances of you having a stroke times the chances of you going to a chiropractor just before having a stroke (one of the presenting symptoms of pre-stroke syndromes is severe neck pain and headaches) is about the frequency of these convincing events happening. It’s a little like the odds of you bumping into your friend whilst just thinking about them; seems unlikely butis in directproportion ot the frequency withwhich they are close to you geographically and how often you think of them, nothing more mystical than that. In fact it does seem that chiropractors in the UK have been very good at picking up those cases where neck pain was in fact due to these pre-stroke syndromes and referred out, thereby oddly enough reducing the likelihood of strokes occurring or doing extensive damage. But still I will quite happily tell my patients there is a small risk, although there is no evidence of this.

So what are the benefits? Well, so far so good. In my clinic I pick up a number of undiagnosed life-threatening presentations every year who are then swiftly referred and helped by the medical system. Of those people I decide I can help the vast majority of people have been helped significantly (I pick my battles). In fact so many have been helped that I had no problem (showing a 98% success rate on 2000 cases) getting the insurance company to under-write the patient care insurance policy (aka your money-back guarantee). Since it has been in place they haven’t had to pay out once (approx 150 cases). The problem is: I work in a certain way and by certain methods and this may not be representative of all chiropractors, but it does for a lot of them, which is why they are getting annoyed with the negative press.

So what does all this have to do with the Prince of Wales?

The Foundation of Integrated Health (FIH) is looking to provide better integration of complementary therapies where possible, an idea which when done well should result in better, cheaper results if there is any truth to the efficiency of those therapies. The problem with showing whether there is any truth to a therapy means that it must be tested and trialled. This is not easy and not cheap. Particularly when you realise that chiropractors don’t treat “back pain” but rather people with back pain. These people may have back pain for a myriad of reasons. Which means that to research this, an equally large myriad of clinical study groups would have to be assessed. That said I am in the process of designing a pathway to acquire the data… the things I entertain myself with (I am glad my wife still likes me). Finally, the notion of researching chiropractic manipulation for back pain as an entity rather than a syndrome is a bit of a non-sense anyway: you may have back pain because you are flatfooted, obese, have a back problem or even a problem with your teeth closing. Manipulating someone’s back when they need to loose weight will always have poor outcomes…

I hope you found this interesting and please do feel free to let me know your thoughts. Kind regards,

Stefaan Vossen

AC Milan’s ageing stars arrive for their Champions League clash with Manchester United straight from… the Lab of the Gods

It was a funny day yesterday as I had three patients of mine tell me about an article they had read in the daily mail. The journalist wrote about the way that Milan Lab, AC Milan’s secretive high tech lab, was prolonging and boosting the lucrative careers of their star football players.

It was funny because I was there only a little while back on a visit to my uncle and had been on the phone to him only the evening before but he had ommitted to tell me about the article.

I read the article and was nothing short of pleased that, since David Beckham is playing for AC Milan the British media have been paying attention to the work this man has been doing for the last 40 years and have for the first time (as far as i am aware) acknowledged he is a chiropractor.  Our family is one of the biggest chiropractic families in the world (in fact I am trying to get my sister to come and work along side me next year) and one thing that this does is that you are being spoonfed the basic principles of the profession from an early age onwards. Jean-Pierre (the chap at the centre of the article), his passion, dedication and passion is one of the main reasons I got into chiropractic myself and he taught me a thing or two about the basic principles of chiropractic. He was also the first one in our family to take on the profession.

In a nutshell: I am hijacking the Beckham-craze based opportunity to send you a blog about why this strange voodoo magic called chiropractic actually just is common sense:

Milan lab is built around the basic principles of chiropractic. Admittedly the multi-million pound execution of it, but the basic principles never the less.

Health, performance and wellbeing are all the produce, and the potential end-result of biomechanical, biochemical and psychological health. Problems in one area may affect another area but will definitely affect the whole. The point is that you can look at health and wellbeing as the mere absence of disease or a state of optimum wellbeing in each of those areas. That is your individual choice. Although there are substantial cultural reasons for these variations in attitudes. It’s only recently (I blogged on this topic before) in our social-cultural evolution in the West that we are even in a position to consider making that choice as it is really only in the last 25 years that medicine and technology have caught up with this dream; simply put before then we just had to make do with what we got and be happy if that ended up meaning a nice healthy long life, whilst all the while accepting that the statistics were stacked against this ever happening.The British (unlike the Italians who in the view of this country seem to be hand-bag slinging hypochondriac nancies) in particular are very good at maintaining the Victorian values of “getting on with it” with little if any expectation that it will get you anywhere. It took me a while to get used to you Brits, but after nearly 13 years i think I have sussed you out… Stiff upper lip and all that.

Chiropractic has been talking about this dream for over a century, and although mistakes were made over the years (one being that all disease would be caused by spinal problems… don’t get me started) it is still this dream we are trying to realise. One of the problems is of course cost of execution. When you have a vested interest in keeping a person at their optimum performance and that it costs you less to provide that then not to (it cost 70 million Euros to just set up Milan Lab but it has saved over 200 million) then it makes perfect sense to do so, but when on the other hand it is the general public we are talking about, value becomes relative. Players have a value. Hard cold cash. Purchase, performance and retail. When they don’t play they cost more than they would if they did. You, me, most people on this planet of course have just as much value, but not many people will be willing to pay for it… and if you don’t work there is social security. So, at least for now, the costs involved in making this dream work are prohibitive.

My personal dream is to provide this service to the general public. I won’t be able to buy the incredibly expensive equipment and treatments that they offer at Milan Lab, but there are cheaper, allbeit not quite as accurate approximations (my five year plan but then you, me, most people on this planet don’t need to be 100%, we can afford to be 80% and in the context of our lives it would make very little if any difference. To illustrate the point two recent new patients of mine will need to spend approximately £3000 each on corrective dental care. That’s a lot. in the meanwhile (or until they win teh lottery) I keep them going with dental splints which cost just under £15 each, but bearing in mind that they had spent a small fortune on care and treatment over the years before seeing me, you could argue that they should have had this treatment done years back and they would have in actual fact saved money by now.

The wonderful benefits of hindsight…

So back to the chiropractic vision: keeping in balance biomechanical, biochemical and psychological well-being to achieve optimum health (resulting in reduction of likelihood of injuries and maximising longevity). The problem with this vision (in my not so humble opinion) is that this requires one practictioner to be good if not excellent at all three. Take it from me, being any good at just one of them is very hard work. Chiropractic practice (as opposed to “the vision”) is really quite good at biomechanical health. In fact chiropractors are really over-qualified in this regard, but we need to be because we are under constant scrutiny and there are some very vocal people out there and ready to critisize us at any given opportunity. So we tend to practice mostly as “back fixers” or whiplash-guys. The fact is though that that is not what we actually are here to do. It is what you, the public, hear we are good at and come to us for. One day there will be true chiropractic clinics, which I envisage will be the first truly holistic preventative polyclinics and will involve a number of clinicians helping you be your best, but until then I can only thank Jean-Pierre Meersseman DC, for keeping the dream alive.

I frequently get asked my opinion on MBT’s,  who more than anything have to justify their looks, let alone their cost (£120+)  with some solid evidence of benefit before my patients would be happy to wear them!This cooky looking shoe company have started advertising their virtues as “the anti-shoes”. “MBT” stands for Masai Barefoot Technology. They were invented and developed by a Swiss engineer called Karl Müller in the early 1990s.Their development was based on two pivotal experiences: on a visit to Korea he noticed that walking barefoot over some soft paddy fields alleviated his back, knee and Achilles tendon problems. He also was told that the Kenyan Masai tribesmen don’t suffer from back pain and are famous for their perfect posture. Putting these two pieces of information together, Muller reasoned that this was because they walk across ground that yields underneath their feet. He deduced from that that walking on hard surfaces, such as pavements that don’t have any give “does our back in”. Not to mention our knees and ankles.

Muller decided that the answer was a shoe with a curved sole, effectively with no heel, which mimics the rocking motion of a foot walking on soft sand or grass.

The claims of the MBT manufacturers are pretty bold. With correct usage, they say, MBTs will activate neglected muscles, improve your posture and gait, tone and shape your body, ease back, hip, leg and foot problems and help with joint, muscle, ligament and tendon injuries. There have also been claims that MBTs can help get rid of cellulite and burn extra calories (although these claims are no longer made by the manufacturers, the rumour persists, which may be why MBTs are predominantly bought and worn by women). In fact, the shoe has been so successful despite their hefty £”129 price tag that other shoe manufacturers have taken up the idea. The FitFlop, launched last year, claims to lengthen and tone the leg with the sandal’s built-in “micro-wobble board”, which means the leg muscles have to work harder to stay balanced.

So that’s the story and the claims, but do they really work? A Sheffield Hallam University study concluded that wearing MBTs was better for the knees, hips and ankles than wearing conventional shoes. “There was some reduction in strain on the body while walking in MBTs,” says Tim Vernon, who led the study. “Also, if you walk properly in MBTs you should be making shorter strides than if you were wearing normal shoes and the more strides you take, the more work you’re doing.”

In effect MBT’s may work in people where walking a little differently some of the time. And that is in fact quite obvious. However, recently there has been speculation that logically concluded that MBTs may not be for everyone. “The claims as to assisting posture, back, hip and knee problems are not supported by evidence or any good rational explanation,” says Dr David Johnson, consultant orthopaedic surgeon at St Mary’s Hospital in Bristol. “Indeed the instability provoked [by the shoe] will increase the muscle activity and energy required to walk – thus increasing fatigue and tiredness”. Technically, the increased need for this muscular activity in stabilising is neither “natural” nor “physiological” as MBT claim and would in certain circumstances increase rather than decrease stress and pressure on all these areas of the body which, rather than be helpful, may be detrimental.

So it is more of the usual: overstating the evidence in the hope of increasing sales. MBT’s elicit the same physiological response as taking smaller, but more steps, on an uneven surface, which has merit in people who basically need more tone and more postural awareness but not in people who have real problems and who end up worse off by the additional challenge that walking like this puts on their back.

I hope this post helped clarify this issue for you and look forward to any questions you may have!

Stefaan