Medicine and chiropractic are partners in Ontario office
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* Lynne Swanson

FIGURE Hart Bressler is a family physician and chiropractor who uses his dual skills not only to help patients but also to help create bonds between professions that are often at loggerheads. As one of the few Canadians to hold both degrees, Bressler says he avoids the wars and name calling. "I look at the situation as ignorance and misunderstanding of the nature and capacity of these 2 different professions. The combination of the 2 educations gives me a third angle towards a better understanding of the complexities of medicine." 

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Figure. Dr. Hart Bressler and UBC medical student Anne Kim meet with patient Troy Shepherd

Bressler draws this analogy. He compares medicine and chiropractic with scientists and artists who are asked to describe a single plant specimen distinctly. The scientists would likely label the species, genus and cultivar, and reach agreement among themselves. The artists would draw, paint or sculpt the same plant, each with a different perspective.

"This is where the art and science of medicine and chiropractic comes in," says Bressler. Physicians and chiropractors are trained differently when they assess the source of the pathophysiological disease process. "Myofascial pain syndromes can be an enigma," says Bressler. "With no high-tech diagnostic imaging or simple lab test to indicate that the source of the pain is indeed myofascial, it tends to be ignored and easily dismissed."

When they manage chronic pain, says Bressler, many physicians depend more on history taking than the actual musculoskeletal exam, and therefore end up relying heavily on drug therapy. Bressler, on the other hand, attempts to discover whether the pain can be reproduced. "Many chronic pain problems are myofascial in origin and can be located and reproduced with pinpoint accuracy."

Bressler said patients who have been in chronic pain for years are surprised when simple palpation of several myofascial trigger points at the appropriate anatomic location will duplicate the quality of pain. "Many physicians and patients have trouble grasping the concept of referred pain. The idea that a patient's area of pain is asymptomatic while palpation of a remote site replicates the pain seems inconsistent."

Bressler uses a structured, step-wise approach involving precise manual palpation of joint play, myofascial tissues and trigger points as part of his patient assessments. Although he has many years' experience, he acknowledges that "this can be subjective, difficult to quantify and have poor inter- and intra-examiner agreement if not done properly." However, the reliability of assessments improves when examiners are trained and understand what to look for, he adds.

Bressler implements one or a combination of various pain modalities to target specifically not only trigger points but all areas of myofascial pain. "Patients are not walking into the office and asking specifically for a medical versus a chiropractic treatment - they are asking for both. This has given me an array of possible approaches and the flexibility to address each individual as a unique individual."

Bressler's driving force is his aspiration "to go beyond pain management or control and achieve total pain resolution." With chiropractic training and 6 years' private practice as a "scientific underpinning," Bressler entered McMaster's medical school in 1990 in order to realize his goals of providing comprehensive medical care, health promotion and injury prevention. He says this combination gave him "additional armamentaria for a more diversified and innovative approach to patient care, as well as a broader scope of diagnostic and therapeutic regimens."

Bressler insists that "the concept of complementary medicine should be just that - complementary and complimentary - and respectful of each other."

With his special interest in musculoskeletal problems and chronic pain management, he knows there is no single panacea for every pain problem. However, his "cross-management" tools and skills often provide an effective approach. Bressler is particularly interested in research on chronic myofascial pain as well as in general disability issues affecting Canadians.

He works in a Pickering, Ont., family practice that combines his 2 professions. One of his primary focuses is to create an environment of interdisciplinary cooperation, with less fragmentation of the various health disciplines. He also promotes sound management philosophies that emphasize quality, evidence-based and cost-effective health care and ultimately have a positive effect on patients' lives.

Bressler is encouraged that other physicians refer patients for pain consultations and that some seek his treatment themselves. He takes this as a sign that interprofessional tussles are finally being put to rest.