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  • Dr. Richard McIlmoyle BSc, DC, PgCPain

Oh the places we'll go!! (From Vitalism to biomechanics complexity)

The narratives that exist in my profession contain tales from etherial energy to effects on molecular mechanisms.


Why do these ideas persist?

“Hey Doc… after you adjusted me, my hearing seemed to get better. My cousin told me the same thing happened after his chiropractor treated him.”

"Oh yes, after you treated me it felt like my glute was firing so much better, I was able to run that 20K with no pain"

WTF???

Many chiropractors have had an experience whereby a patient recounts the resolution of health related situations that are not related to musculoskeletal complaints. Sometimes they are not even issues, but enhanced function of their senses or perceived better function of systems, (“my digestion improved”)

Are these patients lying to have some sort of secondary gain in an enhanced relationship with a person they hold in high regard? Maybe?

OR

Did they have a suggestion planted that lead to attention bias? (This adjustment should help with your heart burn, that muscle is activating properly now) Possible?

OR

Perhaps they experienced non-specific effects of treatment that enhanced their overall well-being?

I have long thought that the spectrum of practitioners we find in the profession of chiropractic that fall at the tails of a bell curve of thoughts and ideas regarding vitalism vs biomechanics are both mired in their own bias.


Chiropractors at both ends tend to hold tightly to their beliefs and seek out research that supports their belief system rather than seek out research that challenges it. I’m not sure those in the middle are any better at that, but the beliefs seem slightly less rigid in the centre of this imaginary thoughts/beliefs bell curve.

Chiropractors all along the spectrum have patients with wonderful responses to treatments, and they are all likely having a beneficial effect for the similar reasons, and not the reasons the chiropractor thinks.

Let’s list the things that are having an effect in the therapeutic encounter. (partial list)

Patient beliefs

· Success of practitioner

· Value of treatment

· What is causing their problem

· What needs to happen to solve the problem

Practitioner beliefs

· Value of treatment

· What is causing the problem

· What needs to happen to solve the problem

Practitioner confidence

· The right treatment for the patient

· Confidence in ability to deliver the treatment with skill

· Low clinical equipoise (ie false confidence in one treatment over another)

Environment

Ritual of the visit

Payment for treatment

Technology utilized

Treatment delivery

Specific treatment (ie. Adjustment)

You may note that there is a lot of stuff going on that is NOT the actual treatment. We have a large body of evidence that all of these 👆🏽 things are having an effect on treatment outcomes, both positively and negatively. What we actually do TO the patients as the treatment has a very small effect.

The disconnect lies in the cause/effect belief of the practitioners. The reasons the practitioners believe they are having their effect are not supported by research.

Putting a vertebra back in place, or restoring its “normal motion”, allowing the free flow of nerves, restoring nervous system function, enhancing neuromuscular control, activating muscles, breaking down fascial adhesions, restoring ideal centration of joints or optimizing vertebral function are all ideas that are not supported by the body of research.

In school we are taught how important many of the aspects of the delivery of a thrust are, to the success of the treatment. Then we hear about a practitioner who uses activator methods having success providing patients with relief…WAIT!!!! If I need to generate a certain amount of force with specific vectors and load dynamics in order for me to deliver a “safe and effective” manipulation, how can a tiny spring loaded device do the same thing ?!?!?!

Why does Reiki work for some people? How about craniosacral therapy(sacro-occipital technique)?

All these different techniques are all just different rituals which the practitioner and patient have bought into. They may have small direct effects, but all the other contextual factors around the treatment are having a greater effect.

NOW…lets add in some mental priming, attention bias, lifestyle changes and an understanding that we (humans) are an ecosystem of effects that include thoughts, beliefs and ideas that integrate with physiology and motor systems and VIOLA!!!

A patient could very likely report a change in symptoms that is not a musculoskeletal complaint that they attribute to “the adjustment”.

The problem is that the attribution is inaccurate, based on what we know of human physiology/neurology/biology. A more likely scenario is…the confidence of the chiropractor to have a positive effect on the patient’s experience and the explanation provided, along with some advice to get better sleep, eat healthy, or move in a way that you are unaccustomed to led to a change in symptoms and reduced worry.

There is better support in the literature that the patient’s thoughts and beliefs had a significant physiologic effect on their condition than did jostling a vertebra.

My challenge to you, is to seek out research that challenges what narrative you have for why your treatment works. Learn how to critically evaluate the research and use those skills to evaluate the research both for and against what you believe.






References

Rossettini, G., Carlino, E., & Testa, M. (2018). Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskeletal Disorders, 19(1), 27. https://doi.org/10.1186/s12891-018-1943-8


Meynen, G., & Widdershoven, G. (2015, October 3). Dealing With Placebo Effects: A Plea to Take Into Account Contextual Factors. American Journal of Bioethics. Routledge. https://doi.org/10.1080/15265161.2015.1074308


Tousignant-Laflamme, Y., Martel, M. O., Joshi, A. B., & Cook, C. E. (2017). Rehabilitation management of low back pain - it’s time to pull it all together! Journal of Pain Research, 10, 2373–2385. https://doi.org/10.2147/JPR.S146485


Wells, R. E., & Kaptchuk, T. J. (2012). To Tell the Truth, the Whole Truth, May Do Patients Harm: The Problem of the Nocebo Effect for Informed Consent. American Journal of Bioethics, 12(3), 22–29. https://doi.org/10.1080/15265161.2011.652798


Enck, P., Daniali, H., & Flaten, M. A. (2019). A Qualitative Systematic Review of Effects of Provider Characteristics and Nonverbal Behavior on Pain, and Placebo and Nocebo Effects, 10. https://doi.org/10.3389/fpsyt.2019.00242


O ’sullivan, P. B., O ’keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O ’sullivan, K. (2018). Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Physical Therapy, 98(5). https://doi.org/10.1093/ptj/pzy022


Coleshill, M. J., Sharpe, L., Colloca, L., Zachariae, R., & Colagiuri, B. (2018). Placebo and Active Treatment Additivity in Placebo Analgesia: Research to Date and Future Directions. International Review of Neurobiology, 139, 407–441. https://doi.org/10.1016/bs.irn.2018.07.021


Murphy, D. R., & Hurwitz, E. L. (2011). THE USEFULNESS OF CLINICAL MEASURES OF PSYCHOLOGIC FACTORS IN PATIENTS WITH SPINAL PAIN. Journal of Manipulative and Physiological Therapeutics, 34, 609–613. https://doi.org/10.1016/j.jmpt.2011.09.009

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