problem with our endorsing (tacitly or otherwise) a profession that too frequently sees patients with serious medical illnesses like asthma, ulcer or cancer as treatable by manipulation of the spine. Recognizing the increasingly powerful political factors involved in professional alliances I believe that CMAJ has done itself a disservice. Drew A. Bednar, MD, FRCSC, FAAOS Assistant professor of orthopedic surgery McMaster University Hamilton, Ont.
I read with interest Dr. Waugh's article and was disheartened and frustrated to be reminded that most physicians still live in the dark ages and are content to remain prejudiced against the chiropractic profession. There is no question that our profession has its share of questionable practitioners, as has the medical profession. However, there are a good number of responsible, ethical chiropractors out there. When patients present to this clinic they are given a full orthopedic and neurologic examination, if required, and are subjected to a thorough history-taking. The chiropractor described in the article apparently practises a form of applied kinesiology, which is an extremely controversial type of diagnosis and treatment. I find Waugh's description of his experience insulting and irresponsible, since it no doubt clouds the view of many CMAJ readers as to what the chiropractic profession is all about. Perhaps in the future if he chooses to write about chiropractors he can consult the Canadian Chiropractic Association. (If I were to write about every irresponsible physician I have been to or my patients have described I would probably fill a large binder.) I think that chiropractors and physicians alike are, for the most part, dedicated, hardworking proJUNE 15, 1992
fessionals. Don't paint us all with ing each other for the betterment the same brush just for the sake of of patient care. sensational journalism. Brian McWhirter, DC Thompson, Man.-
Having read Dr. Waugh's article I am dismayed by his implications. Although he does not conclude this outright, Waugh implies that the assessment he was given represented that at any chiropractor's office, and he therefore concludes that the chiropractic profession has nothing to offer sufferers of low-back pain. If Waugh's description is accurate the assessment was both unsound and incomplete. There are many specialists in medicine - e.g., neurologists, orthopedic surgeons, physiatrists and rheumatologists - to whom patients with low-back pain or other soft-tissue pain are referred. However, the majority of these specialists have no training in the management of pain of softtissue origin. As a physician and student of the management of soft-tissue pain syndromes I have studied the techniques of physiatrists in Montreal and Paris. I have thus become familiar with the medical approach to the assessment of these syndromes and to their treatment, including manipulation. I am certain that most physicians practising medicine, possibly including Waugh, have absolutely no exposure to the science and art of manual medicine and therefore consider practitioners of these techniques to be "alternative health care" providers. There is already a great deal of needless hostility between physicians and chiropractors in most communities in Canada. This article can only foster these sentiments. I believe that it is time for such professionals to begin working together and educat-
Hillel M. Sommer, MD Senior resident Department of Physical Medicine and Rehabilitation University of Manitoba Winnipeg, Man.
I can only bemoan the lost opportunity for the chiropractic profession when Dr. Waugh went for his first chiropractic visit. Great strides are being made in chiropractic research and in the development of standards of care, but it is apparent that there remains a great deal of work to be accomplished. I applaud Waugh for deciding to visit the "enemy camp." Such visits are becoming more and more common, to the betterment of both groups and, more important, to the benefit of our patients. Interprofessional research is also becoming more common; there are chiropractors in the newly constituted study being performed under the auspices of the American Association for Health Care Policy and Reform, a recent RAND study' included multidisciplinary practitioners, and the journal that I edit regularly publishes papers written by medical professionals. With regard to lowback pain, there is considerable debate over the use of most treatments, including laminectomy, fusion and manipulation. Manipulation is still one of the most studied methods. I believe that Waugh's chiropractic physician did not follow a reasonable standard of care and erred in a number of ways. There is no evidence that he performed a physical examination, and for atypical low-back pain that is the least I would expect. No one would treat low-back pain solely on the basis of the results of radiography and computed tomography (CT). Apparently this chiropractor performed simple muscle-testing procedures from CAN MED ASSOC J 1992; 146 (12)
2133
the discipline called "applied kinesiology." I do not believe that the weight of available scientific evidence supports such clinical use. We are now in the process of making such procedures acceptable through the examination of scientific evidence and consensus methods such as nominal group and Delphi procedures. The recent Mercy Conference in California, which brought together opinion on standards of care from a wide range of chiropractors, was an important stop along the way. I hope that such work will ultimately lead to my profession's discarding any procedure unable to meet
basic scientific criteria. I sincerely hope that Waugh will not judge an entire profession by his experience with a single caregiver. We have our bad and our good. Rather than visit an acupuncturist when next your low-back pain flares up, please, see a good chiropractor.
chiropractic is partly due to the medical profession's failing to follow Paget's reasonable suggestion. Although Dr. Waugh's piece is amusing, the real joke - if any - is on the medical profession, which historically has ignored one facet of dealing with back pain: spinal manipulation. Michael Livingston, MD Richmond, BC
References 1. Livingston MCP: Spinal manipulation causing injury: a three year study. Clin
Orthop 1971; 81: 82-86 2. Paget J: Clinical lecture on cases that bone-setters cure. BMJ 1867; 1: 1-4
Dr. Waugh's article illustrates traditional medicine's lack of interest in the musculoskeletal system. It also shows the unfortunate ignorance of physicians that there is a group of well-trained family medical practitioners who make a point of dealing with the problems incurred in the musculoskeletal Dana J. Lawrence, DC system. These physicians are Editor knowledgeable in the art of maJournal ofManipulative and Physiological nipulation. Furthermore they are Therapeutics competent in several injection Lombard, Ill. techniques, such as nerve blocks, Reference trigger point injections and epidural blocks. Such physicians fill a 1. Shekelle PG, Adams AH, Chassin MR void between "practitioners of alet al: The Appropriateness of Spinal health care" and surManipulation for Low Back Pain, ternative RAND Corp, Santa Monica, Calif, gery, something that Waugh is obviously unaware of. 1991 It is high time that the tradiIt is true that chiropractic treat- tional medical training in Canment can be amusing and even adian universities included orthodangerous.' However, can we real- pedic medicine. This subject has ly be satisfied with the training of been included for a number of medical students in the examina- years in the curriculum of the tion and management of common faculty of medicine at the Univermusculoskeletal problems? sity of Rochester, Rochester, NY. A distinguished surgeon, It is taught by family physicians James Paget, suggested 125 years who are already certified or have ago that we "learn then to imitate obtained a fellowship in orthowhat is good and avoid what is pedic medicine according to the bad in the practice of bone-set- precepts developed by the late ters."2 The medical profession, ex- Dr. James Cyriax. To complement this, one may cept for a few people such as Cyriax, Mennell and Marlin, ig- attend an osteopathic school of nored this advice. The rise of medicine to acquire another di2136
CAN MED ASSOC J 1992; 146 (12)
mension in the art and science of manipulation. It is hoped that dissemination of this knowledge in the medical community will bring about better understanding of the sound principles of orthopedic medicine. Yvon Bourdeau, MD, CCFP Orleans, Ont.
I enjoyed the article by Dr. Waugh. The success of chiropractic manipulation is a fact well recognized by many practising orthopedic surgeons. My concern is that Waugh describes his problem as an extremely painful hip. From his description of the pain I suggest that what he was actually experiencing was severe pain in his buttock. Many patients are referred to orthopedic surgeons with "painful hips," and it becomes apparent after the first 10 seconds of history-taking that the the pain is in
the buttock, having nothing whatsoever to do with the hip joint. I propose that it is high time medical practitioners appreciated the more-than-subtle difference between hip pain and buttock pain. Hip pain originates from the hip joint or the proximal femur and classically is felt in the groin, anteriorly. Buttock pain, experienced posteriorly, invariably originates in the lumbosacral region. With our extensive training and knowledge in the field of anatomy I do not feel that it is too much to ask that physicians call a spade a spade. Hip is hip, but buttock is low back. Let's not forget it. Gerald P. Reardon, MD, FRCSC Assistant professor Division of Orthopaedic Surgery Dalhousie University Halifax, NS
[The author responds.] I am gratified that so many readers took the time to write about LE 15 JUIN 1992
I read with interest Dr. Waugh's article and was disheartened and frustrated to be reminded that most physicians still live in the dark ages and are content to remain prejudiced against the chiropractic profession. There is no question that our profession has its share of questionable practitioners, as has the medical profession. However, there are a good number of responsible, ethical chiropractors out there. When patients present to this clinic they are given a full orthopedic and neurologic examination, if required, and are subjected to a thorough history-taking. The chiropractor described in the article apparently practises a form of applied kinesiology, which is an extremely controversial type of diagnosis and treatment. I find Waugh's description of his experience insulting and irresponsible, since it no doubt clouds the view of many CMAJ readers as to what the chiropractic profession is all about. Perhaps in the future if he chooses to write about chiropractors he can consult the Canadian Chiropractic Association. (If I were to write about every irresponsible physician I have been to or my patients have described I would probably fill a large binder.) I think that chiropractors and physicians alike are, for the most part, dedicated, hardworking proJUNE 15, 1992
fessionals. Don't paint us all with ing each other for the betterment the same brush just for the sake of of patient care. sensational journalism. Brian McWhirter, DC Thompson, Man.-
Having read Dr. Waugh's article I am dismayed by his implications. Although he does not conclude this outright, Waugh implies that the assessment he was given represented that at any chiropractor's office, and he therefore concludes that the chiropractic profession has nothing to offer sufferers of low-back pain. If Waugh's description is accurate the assessment was both unsound and incomplete. There are many specialists in medicine - e.g., neurologists, orthopedic surgeons, physiatrists and rheumatologists - to whom patients with low-back pain or other soft-tissue pain are referred. However, the majority of these specialists have no training in the management of pain of softtissue origin. As a physician and student of the management of soft-tissue pain syndromes I have studied the techniques of physiatrists in Montreal and Paris. I have thus become familiar with the medical approach to the assessment of these syndromes and to their treatment, including manipulation. I am certain that most physicians practising medicine, possibly including Waugh, have absolutely no exposure to the science and art of manual medicine and therefore consider practitioners of these techniques to be "alternative health care" providers. There is already a great deal of needless hostility between physicians and chiropractors in most communities in Canada. This article can only foster these sentiments. I believe that it is time for such professionals to begin working together and educat-
Hillel M. Sommer, MD Senior resident Department of Physical Medicine and Rehabilitation University of Manitoba Winnipeg, Man.
I can only bemoan the lost opportunity for the chiropractic profession when Dr. Waugh went for his first chiropractic visit. Great strides are being made in chiropractic research and in the development of standards of care, but it is apparent that there remains a great deal of work to be accomplished. I applaud Waugh for deciding to visit the "enemy camp." Such visits are becoming more and more common, to the betterment of both groups and, more important, to the benefit of our patients. Interprofessional research is also becoming more common; there are chiropractors in the newly constituted study being performed under the auspices of the American Association for Health Care Policy and Reform, a recent RAND study' included multidisciplinary practitioners, and the journal that I edit regularly publishes papers written by medical professionals. With regard to lowback pain, there is considerable debate over the use of most treatments, including laminectomy, fusion and manipulation. Manipulation is still one of the most studied methods. I believe that Waugh's chiropractic physician did not follow a reasonable standard of care and erred in a number of ways. There is no evidence that he performed a physical examination, and for atypical low-back pain that is the least I would expect. No one would treat low-back pain solely on the basis of the results of radiography and computed tomography (CT). Apparently this chiropractor performed simple muscle-testing procedures from CAN MED ASSOC J 1992; 146 (12)
2133
the discipline called "applied kinesiology." I do not believe that the weight of available scientific evidence supports such clinical use. We are now in the process of making such procedures acceptable through the examination of scientific evidence and consensus methods such as nominal group and Delphi procedures. The recent Mercy Conference in California, which brought together opinion on standards of care from a wide range of chiropractors, was an important stop along the way. I hope that such work will ultimately lead to my profession's discarding any procedure unable to meet
basic scientific criteria. I sincerely hope that Waugh will not judge an entire profession by his experience with a single caregiver. We have our bad and our good. Rather than visit an acupuncturist when next your low-back pain flares up, please, see a good chiropractor.
chiropractic is partly due to the medical profession's failing to follow Paget's reasonable suggestion. Although Dr. Waugh's piece is amusing, the real joke - if any - is on the medical profession, which historically has ignored one facet of dealing with back pain: spinal manipulation. Michael Livingston, MD Richmond, BC
References 1. Livingston MCP: Spinal manipulation causing injury: a three year study. Clin
Orthop 1971; 81: 82-86 2. Paget J: Clinical lecture on cases that bone-setters cure. BMJ 1867; 1: 1-4
Dr. Waugh's article illustrates traditional medicine's lack of interest in the musculoskeletal system. It also shows the unfortunate ignorance of physicians that there is a group of well-trained family medical practitioners who make a point of dealing with the problems incurred in the musculoskeletal Dana J. Lawrence, DC system. These physicians are Editor knowledgeable in the art of maJournal ofManipulative and Physiological nipulation. Furthermore they are Therapeutics competent in several injection Lombard, Ill. techniques, such as nerve blocks, Reference trigger point injections and epidural blocks. Such physicians fill a 1. Shekelle PG, Adams AH, Chassin MR void between "practitioners of alet al: The Appropriateness of Spinal health care" and surManipulation for Low Back Pain, ternative RAND Corp, Santa Monica, Calif, gery, something that Waugh is obviously unaware of. 1991 It is high time that the tradiIt is true that chiropractic treat- tional medical training in Canment can be amusing and even adian universities included orthodangerous.' However, can we real- pedic medicine. This subject has ly be satisfied with the training of been included for a number of medical students in the examina- years in the curriculum of the tion and management of common faculty of medicine at the Univermusculoskeletal problems? sity of Rochester, Rochester, NY. A distinguished surgeon, It is taught by family physicians James Paget, suggested 125 years who are already certified or have ago that we "learn then to imitate obtained a fellowship in orthowhat is good and avoid what is pedic medicine according to the bad in the practice of bone-set- precepts developed by the late ters."2 The medical profession, ex- Dr. James Cyriax. To complement this, one may cept for a few people such as Cyriax, Mennell and Marlin, ig- attend an osteopathic school of nored this advice. The rise of medicine to acquire another di2136
CAN MED ASSOC J 1992; 146 (12)
mension in the art and science of manipulation. It is hoped that dissemination of this knowledge in the medical community will bring about better understanding of the sound principles of orthopedic medicine. Yvon Bourdeau, MD, CCFP Orleans, Ont.
I enjoyed the article by Dr. Waugh. The success of chiropractic manipulation is a fact well recognized by many practising orthopedic surgeons. My concern is that Waugh describes his problem as an extremely painful hip. From his description of the pain I suggest that what he was actually experiencing was severe pain in his buttock. Many patients are referred to orthopedic surgeons with "painful hips," and it becomes apparent after the first 10 seconds of history-taking that the the pain is in
the buttock, having nothing whatsoever to do with the hip joint. I propose that it is high time medical practitioners appreciated the more-than-subtle difference between hip pain and buttock pain. Hip pain originates from the hip joint or the proximal femur and classically is felt in the groin, anteriorly. Buttock pain, experienced posteriorly, invariably originates in the lumbosacral region. With our extensive training and knowledge in the field of anatomy I do not feel that it is too much to ask that physicians call a spade a spade. Hip is hip, but buttock is low back. Let's not forget it. Gerald P. Reardon, MD, FRCSC Assistant professor Division of Orthopaedic Surgery Dalhousie University Halifax, NS
[The author responds.] I am gratified that so many readers took the time to write about LE 15 JUIN 1992
