Do GPs refer to Chiropractors?

CHIROPRACTORS and GPs should take a team approach to treating their patients to optimise treatment, according to experts.

A study published online today by the MJA on the clinical practices of chiropractors found patients had been referred to a chiropractor by a GP in 4% of consultations. The Chiropractic Observation and Analysis Study (COAST), based on chiropractors in Victoria Australia, was the first of its kind in the world.

Professor Marc Cohen, of the School of Health Sciences at RMIT University, said the lack of cross-referrals and communication between GPs and chiropractors may lead to suboptimal care and reduce the effectiveness of the therapeutic relationship.” Professor Cohen said a lack of understanding across the many different health disciplines, along with real or perceived competition between them, hindered interdisciplinary communication. He said patients were likely to benefit from a coordinated care approach where they felt free to discuss all their treatments with their practitioners, and their treating practitioners collaborated to provide the safest and most appropriate care. Professor Peter Brooks, director of the Australian Health Workforce Institute at the University of Melbourne and chair of the Australian Acute Musculoskeletal Pain Guidelines Group, said chiropractors should be part of the primary care team but all members of the team should espouse and practise evidence-based care. “At least an exchange of information between [GPs and chiropractors] would assist treatment and diagnosis”, he said. The study authors said most people who saw a chiropractor also consulted a medical practitioner. They suggested further research “to maximise the patient benefit that can be gained through a team approach to primary care”. Dr Liz Marles, president of the Royal Australian College of General Practitioners, said it was important for GPs to know if their patients were receiving chiropractic treatment to ensure treatment plans were not conflicting. Chiropractors are encouraged to refer to a GP when it was in the best interests of the patient and this should be a two way street, but all too often the best interests of the patient is ignored because of ignorance about chiropractic treatment. “Patients with musculoskeletal conditions will benefit from managed or integrative care, particularly where the patient wants a drug-free approach or wants to consider all options before surgery.” Professor Cohen, who is past president of the Australian Integrative Medicine Association, said the snapshot of chiropractic practice provided by the study was useful to GPs. “Knowing that many of their patients are seeing chiropractors may prompt GPs to open discussions about chiropractic care and communicate with chiropractors about reinforcing evidence-based lifestyle recommendations”, he said. “Mind you, a lot of back pain will get better whatever we do”, is often the option of many Gp’s, however this attitude has lead to the increasing cost of treating low back pain. With many GP’s misunderstanding what chiropractors actually do it remains difficult to build professional bridges. Manipulation is not used to correct misalignment of bones, because that is impossible. As a chiropractor I spend hours trying to educate patients and correcting such myths, the biggest myth is disc slipping out of place. It is totally impossible for disc to slip but everybody has heard about slipped discs and expects a chiropractor to be able to manipulate it back into place. Here is a classic negative comment printed in medical journals of today which chiropractors have to endure. “During my orthopaedic training I assisted my boss at the spinal unit to reduce a C5-6 unifacet dislocation. Despite general anaesthesia with muscle relaxant, image intensifier control, a patient with known acutely torn ligaments, and over 200 kg of orthopod hanging off his head; it was very difficult to manoeuvre the spine by 5 mm. My eminent spinal surgeon boss mused wanly on how the chiropractors managed to manipulate the spine under less favourable circumstances.” Modern attitudes do prevail and common sense does prevail, comments such as this from a surgeon. I am a surgeon who believed once that chiropractors were all quacks. But now, as a regular patient, I look forward to my visits and feel my chiropractor has a significantly better understanding of anatomy of the back than I do. I get her to explain her manipulations to me, and they make sense. Chiropractors do not believe that all disease is caused by misalignment of the spine. This sort of disinformation only increases the gap between the professions. Regardless of what GPs say, people keep returning to chiropractors for back care because it works for them, otherwise the profession would decline instead of grow. I am a medical practitioner and have found that chiropractic works best for me when I have acute lower back pain. Medicine clearly does not have all the answers, so patients will continue to seek what works for them.Chiropractic care doesn’t deserve the bad reputation that organised medicine promotes. Certainly, more evidence for it’s efficacy would help chiropractic, but to vilify a profession the way that organised medicine does is unprofessional at least and smacks of turf grabbing at worst. As I chiropractor I work hard to keep up to date with recent research regularly exceeding the CPD requirements for the profession. I am saddened by the apparent lack of up-to-date commenters. There is a mountain of research linking nerological benefit of normal range of motion. There is evidence that GP and physio care actually makes back pain outcomes worse and some that shows it improves outcomes. Most of my patients have been to their GP first and usually have had NHS physio, which often delays treatment for months and not uncommonly years in some cases. There are much better ways to assist your patients than we had in the past and improved outcomes is the main objective right? Chiropractors don’t push bones in that have moved out of place Is it not plausible that a joint may demonstrate abnormal motion following sustained poor posture, trauma, degeneration or other abnormal load? As a result of the abnormal motion at the joint, it is not plausible that this could result in some local pain? Where there is pain at the joint, is it not plausible that putting a high velocity force into that joint might elicit a stretch reflex, fire the golgi tendons in the muscle spindle? Can pain modulation result from direct inhibition of the anterolateral system though mechanoreceptor stimulation of interneurons in lamina II and V thereby synapsing with other nociceptive afferent axons? Would that not release met-enkephalins thereby inhibiting nociception presynaptically? I wonder if there could be any result from spino-thalamic activiation releasing endorphins? I wonder if such stimulation of those afferents, the periductal grey matter and nucleus raphe magnus could excite interneurons through the descending serotonergic pathways to cause post-synaptic inhibition of the preganglionic sympathetic neurones of lamina VII thereby restoring vasomotor control? Could that sympathic inhibition reduce nociceptor stimulation and decrease substance P release? For the benefit of patients, health care providers should collaborate and coordinate care. I suggest that interested medical doctors attempt to work with chiropractors that are patient-centered and evidence-based providers.