Acupuncture: Anticipating the visit.

I will next delve into the field of acupuncture.  Acupuncture originated in China over 5,000 years ago.  It is based on the belief that there is a vital life energy called “chi” present in all life forms.  Chi circulates along 12 major energy pathways called meridians. These meridians are linked to specific organs and systems.  There are purportedly over 1,000 acupoints along the meridians which can be stimulated to enhance the flow of chi. Needles can be inserted into these acupoints for pain relief and to restore health. Acupuncture is used to treat a long list of conditions including both acute and chronic pain, addiction, mental disorders, and infertility.

            When I went on-line to investigate if there were any acupuncturists nearby, I was amazed to find over 40 sites in the Cleveland area.  That seems to be a lot of needles being stuck in people!  Apparently, acupuncture has caught on in a big way.  Before we get too far in this new endeavor, let me come clean… I must admit that this whole concept of “chi” sounds wacky to me.  I don’t remember coming across these meridians when I was dissecting my cadaver in anatomy class.  Despite my skepticism of “chi,” my perception is that acupuncture must work for some people.  I have heard enough testimonials of major surgeries being done using only acupuncture, rather than general anesthesia, that it seems to clearly do something for some people.  The question I have is: will it do anything for me?

            I have an appointment scheduled for this afternoon, and I must admit that I am a bit nervous about this one.  Despite being a doctor, I am not a fan of needles, knives, or anything sharp which can cause pain.  My wife, Beth, can attest to this.  She loves Quentin Tarantino movies, including “Kill Bill.”  During this particularly gruesome movie which insists on following the entire path of every blade, I cringed during every swing of the sword and the accompanying severing of appendages.  Eventually, I had to stop watching due to nausea.  On top of my squeamishness of needles and knives, I don’t like anything touching my feet.  My kids know this all too well and are always sneaking up on me and grabbing my feet when I am lying flat.  I am mortified that the acupuncturist might actually stick a needle somewhere in my foot.  From my research, this seems to be an all too likely possibility!  According to a drawing in my reference book of the >1,000 acupoints, the feet have more than their fair share!

            Despite my fears, I decided that if I am going to try acupuncture, I will do it right. Rather than see a granola-eating, hippie, Asian wannabe, I will try the real deal.  It seems that if acupuncture comes from China, than I should go to a practitioner from China.  I find a Dr. Z Lin (name changed for my protection-nobody wants a mad Asian woman with needles coming after them!) who received her training at the Academy of Traditional Medicine in Beijing, China.  She reportedly comes from a long lineage of traditional Chinese medical doctors and began to learn her trade as a teenager under the tutelage of her mother.  Her website (yes, she has a website) has a long list of maladies which she treats including gastrointestinal disorders, gynecologic disorders (here is one I don’t have!), respiratory disorders, headaches, back pain, allergies, addictions, anxiety, and shingles.  This seems like the right place for me.  I decided I will ask her to focus on my headaches and back pains which amazingly are still nagging me despite my visits to a naturopath and a chiropractor.  I gave Dr. Z Lin a call, and I am able to make an appointment within a week.  A week has passed and today is the day!

[Next week: The initial visit.]

The Chiropracter: My final analysis.

Two weeks have passed since I wrenched my lower back, and just two days since my final visit to the chiropractor.  I must admit that my back pain is considerably better!  I still have some slight discomfort and tightness, but it is almost back to baseline.  The last time I strained my back, I was an invalid for over 6 weeks.  I am not sure to what I should attribute my rapid improvement.  Was it due to Dr. D?  Was my back strain less severe this time?  I am not sure.  I do know that it is great to be feeling better.  This seems to be a good time to examine the evidence behind some of the techniques and claims asserted at my chiropractor’s office.

         First, let’s analyze the advertisement for Estronex which is posted throughout the chiropractor’s office.  Now I know this is not, strictly speaking, related to “chiropractic” care, but I do think the things a practioner chooses to promote reflect on the type of medicine he or she practices.  This test claims to help determine a women’s risk for breast cancer by measuring the levels of various “good” and “bad” estrogen metabolites in her urine.  The web site for this test suggests that certain imbalances in these levels are associated with an increased cancer risk.  It goes further by saying that through dietary changes, these imbalances can be corrected.  It references two studies to support these claims.  I found both of these articles.  The first thing that struck me was that both articles are authored by employees of the company which makes Estronex.  This is a major conflict of interest, and in my mind means that any conclusion by the authors needs to be taken with a big grain of salt.  The articles themselves are merely reviews rather than research articles.  The larger review article espouses the urine estrogen metabolite test to “determine one’s 2/16a ratio [for] . . . determination of cancer risk…”  The same article, however, admits that “no conclusive data has yet to be published showing cancer incidence falls when individuals are treated with interventions that raise the ratio…”   The Estronex test appears to be a waste of money, and it makes me question the professionalism of the chiropractors who willingly advertise and provides such a baseless test to their female patients.

            The second claim I felt compelled to investigate was the “before” and “after” MRI pictures for spinal decompression therapy.  I found these claims difficult to stomach.  If such a miraculously effective non-invasive procedure existed, why was this previously unknown to me?  If this simple procedure could really resolve a herniated disc, I would be shouting it from the mountaintops and leading the millions of people who suffer from sciatica to the Promised Land.  I suppose you detect my cynicism.  One theory regarding the possible mechanism by which decompression works is that traction on the spine lowers intradiscal pressure thereby allowing a herniated disc to return to its normal position.  On the internet, I quickly found a scathing repudiation of spinal decompression.  One doctor documented (with references) 10 pages of anti-decompression evidence.  He points to a study in the 1980’s that showed intradiscal pressure actually increased with traction as the back muscles contracted to resist the traction.  It appears that traction might decrease back pain, although there is no evidence that it is superior to any other intervention. A recent review published in the journal Chiropractic and Osteopathy by Dr. Daniel in 2007 concluded, “Only limited evidence is available to warrant the routine use of non-surgical spinal decompression, particularly when many other well investigated, less expensive alternatives are available.”  I could find no well-done studies that substantiated its use.  This all jibes with my conclusion that although spinal decompression feels good and intuitively makes some sense, in the end, it has no clear benefit.

            Despite not agreeing with some of the claims and techniques which my chiropractor used, I must admit that I still found some merit in my visits.  In general, he and his staff provided a lot of “hands-on” attention.  Second, I liked the fact that adjustments, spinal decompression, and the prescribed physical therapy are all pro-active attempts at getting me better, unlike an internist’s technique of prescribing medicines to alleviate the symptoms.  I must admit I am not sure if the chiropractor made a difference, but I am feeling better and I do feel that chiropractors remain a reasonable option for the treatment of back pain.  I suspect that much like traditional physicians, there are good and bad chiropractors.  Mine was just okay.

[Next week, Acupunture]

Chiropractic care: A visit to his physical therapist

     Only 3 days have passed since my most recent chiropractic adjustment.  Today, I have an appointment with the physical therapist.  My back feels no better.  I wonder whether it might be a little too early to begin physical therapy.  I threw my back out only 10 days ago; my lower back is as stiff as ever; and, I still have to lie on my office floor between patients.  I am reassured by the fact that I don’t have radiating pain into my legs.  I suppose this means my discs are in place, and my spinal cord is not being pinched.  I decide it is better for me to not think like a doctor and instead, put my faith in the chiropractor.  I remind myself that the purpose of this endeavor is to give alternative therapies a real shot, even when they run contrary to my own preconceived beliefs.

            I meet with Sam the physical therapist.  I am prepared for a grueling work-out. Despite arriving in my work clothes, I have brought shorts and running shoes to change into.  Sam tells me there is no need to change.  I am disappointed.  I came ready to work this back problem away.  It appears my expectations for this visit were a bit misguided.

            Sam reviews my history and does a basic exam.  Primarily, he observes me bend over and attempt to touch my toes, and he watches me walk.  Surprisingly, he comes to the same conclusion as Dr. D.  My left pelvis is higher than my right.  I have never had so many people interested in the alignment of my pelvis!  Rather than suggest a heel raise, he thinks the imbalance is due to tightened hip flexor muscles which he believes he can improve with a few maneuvers and some exercises/stretches done by me in my spare time.  He takes me through multiple maneuvers, not unlike those performed by the chiropractor.  He pushes deeply in my left groin to the point of moderate discomfort.  In the end, he seems satisfied that my pelvis is less tilted (somehow he has managed to lengthen my left leg by over an inch, or so it seems).  He thinks that if I follow his prescribed exercises and stretches, I should do well.  He completes the visit with a 10 minute ultrasound treatment on my lower back.  The ultrasound generates a penetrating heat which helps my back muscles relax.  I leave with a regimen of 5 different exercises that I should perform several times a day.  I vow to comply (hopefully, more faithfully than I did the exercises recommended by the naturopath).

            Over the next 4 days, my family and I take a long relaxing weekend at a condo on the shore of Lake Erie.  I take it easy, avoid heavy lifting, and do the recommended exercises.  I seem to be improving incrementally, but not dramatically.  On return, I have one more visit with Dr. D, the chiropractor.  This last visit is the most business-like of any of the visits so far.  After a short wait, Dr. D. comes in and does a quick exam.  He spends about 10 minutes with me.  He does some non-aggressive adjustments.  This time, he does not vigorously crack my neck.  When he steps out of the room, I snoop around and I come across a poster for applied kinesiology.  Included on the poster are what appear to be pressure points on the body which correspond with various body organs.  Also, there is a list of therapeutic extracts which include the previously mentioned spleen, thyroid extracts, liver, lung, etc.  Here is a whole field of medicine practiced by Dr. D which he appears not to have brought into play.  I wonder why.  Perhaps his knowledge that I am a physician has caused him to stay in the mainstream, or maybe this is an area explored more commonly by his associates (or maybe these extracts are aerosolized and pumped into the ventilation systems of the exam rooms!).  I feel like my experimentation with chiropractic care is coming to an end.  I have seen the doctor for treatment of both my chronic lower back pain, and also during an acute flare up.

[Next week, I review the results and conclusions drawn from my visits to the Chiropractor.]

Visit to the Chiropracter: Acute back pain.

     For the next few days after my initial visit to the chiropractor, my neck remains sore.  My lower back pain is little changed despite the addition of daily stretching.  As my second visit looms, I experience trepidation regarding the upcoming adjustment of my neck.  I again contemplate canceling.  At the second visit, I am taken directly to the exam room.  Dr. D places the x-rays taken at the prior visit on the light box for viewing. He points out that my left pelvis is higher than my right.  He suggests that I might eventually require a heel raise, but for now, he wants to see how I respond to spinal adjustments.  He again instructs his assistant to “loosen me up.”  She keys in on the same tender spot along the mid-lower left side of my back.  Fortunately, this time she is less aggressive in her torture.  Dr. D returns and performs a series of adjustments similar to the first visit.  I tolerate the cracking of my neck a bit better despite experiencing the same creeping feeling as he lurks around the room with me face down on the table.  I again am sent to the decompression machine which is set this time for 12 minutes with 55 lbs. of tension.  He says he would like me back in one week.  I state my agreement, but in reality, I want to see how much of a bill I have been racking up before scheduling my return.

            My insurance covers chiropractic care at a second-tier level, unlike primary care visits to my regular doctor for which I only have to pay a small co-pay.  For the chiropractor, I have a co-pay, and I must cover my ~$1000 deductible before the insurance kicks in.  When I finally get the bill 2 weeks later, I owe a total of $252.39 for the two visits.  My insurance company has negotiated the price down from an original $510 total - kind of pricey, but not too bad.

            As the weeks pass, I am unable to appreciate any improvement in my chronic lower back stiffness.  I am underwhelmed.  I finally schedule a return visit a few months later, but little changes.  My friends tell me not to lose faith.  My brother-in-law relates his personal experience with shoulder pain which miraculously resolved with a single adjustment.  A commenter on my blog says he achieves the most benefit from the chiropractor when he is seen for acute disabling back pain rather than for non-urgent adjustments.  He relates an instance when a single adjustment helped him go from severe pain to rock climbing within a week’s time.  I am left to wonder.  Coincidentally, I do not have to wait long to put the acute back pain theory to the test.  In a particularly vigorous day, as I attempt to reclaim my youth, I play pick-up basketball in the park followed by ice hockey with my two older sons (indoor rink).  By the evening, I can feel my back stiffening up.  By the next morning, I am in a crisis.  My back pain is markedly worse and I find myself walking stooped over.  I feel myself aging rapidly!  At this rate, I will be an old man before the end of the week.  I find myself lying on the floor of my office between patients.  Now is the time to get back to the chiropractor.  Despite my skepticism, I must admit I am eager for some immediate relief.  I give Dr. D’s office a call, and I am happy to find out that I can be seen in just a couple of days.  By the time the appointment rolls around, I am in need of a savior.

            At my visit, I tell Dr. D about my worsened condition.  He gives me a nod of understanding, observes my desperate attempt to touch my toes, and then he steps out while the assistant tries to relax my tightened back with massage and some warm blankets. When Dr. D returns, he is all business.  He has me lie face down on the exam table.  He presses on the back of my pelvis bone and asks me to lift my left leg towards the sky while he pushes down.  He does a few adjustments and then again tests my leg strength.  After a few rounds of this, it appears that I am able to offer more resistance. Am I actually stronger?  Am I just trying harder?  He explains that in response to the strain of bending over while playing hockey my “glutes had given out.”  He seems quite confident that the adjustments performed should make a difference.  I choose this time to ask him for some exercises I might perform to assist with my recovery.  I would like to play a more active role in my recovery.  He blows off this question, but prescribes a visit to the physical therapist located in his office.

            I am walking more upright immediately after my visit, but as the day progresses I deteriorate to my pre-visit condition.  I hold out hope for my upcoming visit to the physical therapist and a few more adjustments with Dr. D.

Visit to the Chiropractor : Cracking my back.

As I wait for the chiropractor, I examine the walls for interesting tidbits.  The room is unremarkable except for a large exam table with many detachable parts and a complicated system of foot pedals.  On the wall directly opposite the door is a foam board with multiple cubbies containing roughly a hundred glass vials.  Arranged in alphabetical order are various pills and powders.  Most of the names are foreign to me.  I recognize one labeled “thymus” and another “spleen”.  Apparently, these are some of the herbs and homeopathic remedies that are advertised in the center’s brochure.  On the long wall to the right of the door is a bulletin board with various postings.  One is a picture which shows MRI images of a person’s lower spine.  The images are labeled “before” and “after” decompression.  The “before” shot shows a vertebral disc impinging on the spinal cord while the “after” shot looks entirely normal.  I also see an advertisement for “estronex”, a urine test that measures estrogen metabolites to determine a woman’s risk for breast cancer.  This is a bold claim, one which I sincerely doubt.  I will have to research its veracity later.

            After a short while, Dr. D enters the room.  He observes me standing, stepping forward, and perched on one leg.  He remarks that my pelvis is tilted.  One side rides higher than the other.  He then instructs me to lay face down on the exam table, and he calls for the assistant.  He instructs her to “loosen me up”.  She spends about 10 minutes attempting to relax the muscles which run along my spine.  Believe me, this is not an easy task.  She presses with her palms, her forearms, and even her elbows.  The sensation alternates between soothing and excruciating depending on where and how firmly she applies pressure.  On completion, she places some warm towels on my back and calls the doctor.  He has me remain lying face down.  He places a few lifts under my hips and then begins to do some “adjustments”.  He asks me to breathe in, presses over my mid-spine, and cracks my back.  Next, he sits at the foot of the table and pulls my legs.  Then, he begins to circle.  His circling reminds me of a vulture sizing up his prey.  I remember my friend John’s comments, and I reflexively tense up despite my best efforts to remain relaxed!  He moves in for the kill.  He presses on my head and the side of my neck and sends a ripple of cracking up my neck.  He then repeats this from the other side (not my favorite feeling).  I cautiously wiggle my hands and feet.  I am relieved to find that I am not paralyzed.  Next, he pushes down on various portions of my spine and when he does, the table collapses and makes a loud clunking sound.  He does a few further adjustments while I lie on my side and to my legs.  He is done after about 15 minutes.  It seems like a decent amount of hands-on care and face time with the doctor.

            Doctor D then recommends that we do an x-ray which we will review at the next visit.  He also prescribes a session on the decompression machine.  He inquires whether I drink soda.  When I answer in the affirmative, he gives a knowing nod of his head as if he has found the cause of all my ills.  He recommends I cut out soda, but aside from this, he doesn’t stress any other dietary restrictions.  I am struck that he does not suggest any particular exercises or lifestyle changes.  He doesn’t even make a plug for the seat rests that are littered throughout his office. 

            I am next taken to a separate room and an upright x-ray of my spine is taken.  The x-ray machine appears ancient, and the staff seems somewhat blasé about the risk of radiation exposure.  The assistant then takes me to the decompression machine which I am eager to experience after seeing the aforementioned “before” and “after” pictures.  I imagine a medieval torture device, but in fact, the machine appears benign.  I lie face down on a padded table, and a soft Velcro belt is placed around my waist.  The belt is attached to an ancient appearing machine which basically provides traction on one’s spine.  The theory is that it opens the spaces between your vertebrae.  I spend the next 10 minutes lying in a quiet room as the machine applies moderate traction to my spine. It actually feels pretty good.  After awhile, I am unhooked and led to the check out counter. I arrange a follow up visit for the following Monday.

            As I exit the building, I reflect on my visit.  Similarly to my visit with the Naturopath, I am impressed by the amount of time that was spent with me by both the doctor and his staff.  I appreciate all the hands-on time with the exception of the neck cracking.  I can see why people would prefer to see a chiropractor over an internist for their back pain.  Here, it at least seems that something is being done to get you better rather than just covering up the discomfort with pain killers.  I am surprised that I wasn’t given instruction regarding things to avoid and exercises to perform.  With the chiropractor, as opposed to the Naturopath, I seem to play little role in getting my back to feel better.  Last, my neck is sore!  Perhaps this will distract me from my lower back discomfort.

[Next week: Visit to the Chiropractor-part III]