Healthnotes Library

Chiropractic: Skepticism, Integration and Consumerism

By: Brian D. Justice, DC

Published and reviewed January 2009

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“The chiropractic profession is assuming its valuable and appropriate role in the health care system in this country and around the world. As this happens, the professional battles of the past will fade and the patients at last will be the true winners.”

Wayne Jonas, M.D., past director National Center for Complementary and Alternative Medicine, National Institute of Health(1)

History of skepticism and mistrust

From rather humble beginnings, chiropractic was founded in the Midwest in the 1890s with an early focus on treating the spine to optimize health without the use of drugs or surgery. Although the profession has produced some philosophically based splinter groups, the majority of chiropractors still focus on the diagnosis, treatment and prevention of spine related disorders. Of course, like any profession, there are subspecialties. Many chiropractors have additional training in sports injuries, muscle and joint disorders outside of the spine, radiology, nutrition, etc. A typical common thread amongst chiropractors is the use of manual techniques such as manipulation or joint adjustment (2). In fact, the word chiropractic comes from the Greek roots meaning “done by hand”.

Embedded within some older chiropractic philosophies is the word “subluxation”, a term with variable meanings in both chiropractic and medical literature(3), but which literally means a slight dislocation or bone out of place. An early concept that a bone out of place could push on a nerve and create almost any human ailment is still purported by some chiropractors, despite lack of supporting scientific evidence. This early simplistic approach to health care led to distrust and confusion by other health care professionals. Although the majority of the chiropractic profession has moved past this simplistic and inaccurate approach to health, bias and mistrust of chiropractors remains, despite a significant scientific research base demonstrating doctors of chiropractic validity and safety.(4)

Chiropractors are best known for treating back pain (approximately 60% of their practice) followed by other musculoskeletal pain such as neck pain, shoulder, extremities and arthritic conditions (20%). Headaches, including migraines, make up about 10% of a typical chiropractic practice. The remaining 10% is “a wide variety of conditions caused, aggravated or mimicked by neuromusculoskeletal disorders (e.g. cervical thoracic angina, dysmenorrheal, respiratory and digestive dysfunctions).”(5)

The evolution and survival of chiropractic has been based on:

• Improvement in education standards, now comparable to medical school in years of study as well as often sharing the same certification agencies, professors and textbooks. The curriculum differ in that chiropractic colleges focus more on musculoskeletal disease/injuries, exercise, nutrition and prevention and less on organic illness, pharmaceuticals and surgery.

• The incorporation into practice of quality research over the last 20 years demonstrating chiropractic's effectiveness and safety(6), the highest patient satisfaction of any health profession and faster recovery rates from back and neck injuries . Approaches gleaned from good research include using a biopsychosocial model, or whole person approach, that often incorporates manipulation (the single most researched approach to back pain), patient active exercise programs and general health advice/prevention.(8)

• A strong research base has, in turn, led to the inclusion of the main tools of chiropractic (manipulation, encouragement of activity and patient education) into the national clinical guidelines for the management of both chronic and acute back pain. These have been prepared by expert multidisciplinary panels and had been repeated locally in Rochester, across the US and in many nations worldwide.(9,10,11,12,13)

• Cost-effective care. There is compelling evidence from health economists that chiropractic management of the most common types of back pain, neck pain and headaches cost the same or less than typical medical care.(14,15,16,17)

• Lawsuits and lobbying. Unfortunately, years of significant bias against chiropractic needed to be overcome in the courts(18) and legislature to level the playing field, allowing chiropractors entrance into hospitals, insurance coverage and in to multidisciplinary practices.

• Most important to the survival of chiropractic profession has been the personal experience of chiropractic patients. Good clinical outcomes on an individual basis led to many years of word of mouth referrals as the only avenue to patients for chiropractors. In my near quarter-century of practice, I have seen an evolution of patient flow from patient to patient referral to now near 70% of our practice being through M.D. referral. 20 years ago, physicians were coming to see me as patients and asked to come in after hours so they would not have to be seen in the waiting room. Thankfully, this discomfort has passed as our practice became more accepted and integrated into the healthcare community.

An integrated healthcare team – what patients want

Slowly but consistently, trust and confidence is replacing the skepticism of the past. This is key to the evolution of a balanced consumer driven health care system. Patients want an integrated system where all their doctors communicate, where the right patient is directed to the right provider at the right time. To date there has been some integration of our practice and other select chiropractic practices in the community for the betterment of all concerned.

Integration minded chiropractors will routinely send reports to the primary care physician, will order appropriate diagnostic testing when needed and will refer for consult with other healthcare providers appropriately. By getting hospital privileges, giving grand or community rounds at local hospitals, attending grand rounds and multidisciplinary educational events and participating in multidisciplinary research, these chiropractors are creating opportunity for interdisciplinary dialogue….. a must for any true cohesive healthcare team.

At the international level, chiropractic is fully integrated into the national healthcare systems of many European countries. At a national level, examples of chiropractic services being included into existing healthcare include chiropractors being covered under Medicare some 30 years ago(19) and, more recently, the introduction of chiropractors into the Veterans Administration health delivery system. The inclusion of chiropractors into the NCQA back recognition program will prove to be another important step toward integration nationally. (Interestingly, there are more chiropractors recognized by NCQA in the Rochester region than anywhere in the country!) Locally, our practice has had the opportunity to work in a collaborative environment at Highland Hospital, Wegman's medical department and other occupation health departments, and, most recently, the new Spine Center at Unity Hospital. We also have both chiropractic and family practice residents regularly come to our practice as part of their training, encouraging future doctors to be collaborative in their decision-making.

Being a good consumer

Evolving acceptance of chiropractic into mainstream health systems only happens because the lives of individual patients have been positively impacted. When enough individuals voiced their desire for a certain approach to care and follow that up with feedback on the quality of care they received, doctors collaborate more, better outcomes are achieved, outdated beliefs fall by the wayside and, finally, systems change for the better.

Successful integrated models only work if quality doctors are included in the mix. One of the strengths of chiropractic, its ability to look at health issues from a fresh perspective, can, when taken to an extreme, also be a weakness. Being open to non-evidence-based approaches creates opinion-based healthcare decision-making, suboptimal outcomes and the inability to develop a consistent model of care, all preventing meaningful integrated care.

So whether you are a physician or a patient, be a good consumer before seeking the services of any other healthcare professional. Things to look for when shopping for a healthcare provider:

• Frequency of treatment: 2 – 3 visits per week for 2 – 3 weeks is certainly reasonable with the expectation of some measurable/noticeable improvement within that time frame. If not, a different treatment approach, either within that office setting or referral out, should be considered. If you are seeing improvement in a reasonable timeframe, continue with that care path. If not, discuss with your provider a different approach, or seek one yourself.

• Promotes patient independence: the treatment goals should always be based around trying to alleviate the complaint (cure) or learn self-care approaches to control (manage) the discomfort or disability. Understand that this is not always possible, and that ongoing provider care may occasionally be necessary. However, this is the exception more than the rule.

• Cost-effective care: you should feel as though you are getting good value (cost/quality) for your time and money put into treatment. Providers should have coverage with most of the major insurers. Beware of providers who want you to sign up for a set number of treatments ahead of time or want to collect for a case payment/lump sum for care for a condition.

• Have expertise in the area of your concern: while many chiropractors are well versed in spine pain syndromes, others purport expertise in a variety of subspecialties. Checked their credentials/background for making these claims. Along the same lines, most primary care providers do not have a very extensive background in spine or musculoskeletal disorders. Be a good consumer, seeks the care of a provider with the appropriate expertise.

• Trust your instincts: if the provider is using language you do not understand, or does not explain your condition in a way that makes sense to you, ask more questions. If these are not answered to your satisfaction, find another provider.

• Keep office records: your provider should create a record of every encounter you have in the office. They should also send periodic reports to your primary care provider.

• Diversity of care: the provider should have a variety of tools at their disposal to help you feel better/function better. This may include different hands-on approaches (manipulation, mobilization, muscle stretching techniques, etc.), machines or modalities, and educational approaches (flexibility, balance, posture and/or strengthening exercises, ergonomic suggestions, nutritional or dietary recommendations, stress management techniques, etc.).

• Embrace a biopsychosocial model: You should be looked at as a whole person, not addressed solely by your chief complaint. You are a complex organism with highly variable physical, psychological and social influences that are impacting your current state of health. Find a provider who understands and addresses the complexity of who you are.

• Choosing a healthcare provider: Trust referrals from your physician, family and close friends. Would you really pick your physician from the phone book?

• Beware of advertisements which seem gimmicky, offer free services or promise results.
• Beware of elaborate education/marketing schemes used to create dependence on your caregiver. You should not feel pressured to comply with your chiropractor's recommendations.

• Make sure you clearly understand the risks, benefits, and goals of treatment before undergoing any therapy. What would happen without treatment? What is the “natural history” of the condition?

• Your diagnosis should be a typical medical diagnosis which may also include “subluxation” as a finding.

• There are no “killer” subluxations. If you feel a health care provider is trying to confuse, intimidate or instill fear in you, walk away.

• If the provider says they are “the only provider that does that technique” or denigrates another provider, move on.

• Your first visit to a chiropractor's office should be, in many ways, similar to your experience in other physicians offices, including a thorough history, physical examination of the area of chief complaint and, likely, treatment on the first visit including self-care measures you can do to promote a more rapid recovery.

Conclusion

Worldwide, most major guidelines on back and neck pain suggests the use of manipulation, exercise, and education (i.e. staying active) and other approaches commonly used by chiropractors. These guidelines, based on the best available research, have expedited the integration of chiropractors into multidisciplinary centers around the world as well as locally. Whether you are a patient or a provider, given the near universal prevalence of back and neck pain, the time is now to find a doctor of chiropractic to be on your health care team.

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References
1. Jonas WB, Foreword to The Chiropractic Profession, Chapman-Smith D, NCMIC Group, West Des Moines, 2000.

2. World Federation of Chiropractic (2007) Facts on Chiropractic, WFC Pamphlet.

3. Terrett A (1987) The Search for the Subluxation: An Investigation of Medical Literature to 1985, Chiropractic History 7(1):29-33.

4. Haldeman, S, Carroll LJ, Cassidy JD, and the Scientific Secretariat (2008) A Best Evidence Synthesis on Neck Pain: Findings from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 33(4S): S1-S220.

5. Chapman-Smith, LLB, D, (September 2008) The Chiropractic Report, Vol 22, No. 5 1-8

6. Cassidy JD, Boyle, E, Cote et al (2008) Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study, Spine 33(4S):S176-183.

7. Sawyer CE and Kassak K (1993) Patient Satisfaction with Chiropractic Care, J Manipulative Physiol Ther, 16(1):25-32.

8. Cherkin DC and MacCormack FA (1989) Patient Evaluation of Low Back Pain Care from Family Physicians and Chiropractors, Western Journal of Medicine 150(3)351-355.

9. Manga P, Angus D et al. (1993) The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain, Pran Manga and Associates, University of Ottawa, Canada.

10. Bigos S, Bowyer O, Braen G et al. (1994) Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD; Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.

11. Rosen M, Breen A et al (1994), Management Guidelines for Back Pain Appendix B in Report of a Clinical Standards Advisory Group Committee on Back Pain, Her Majesty's Stationery Office (HMSO), London.

12. Available at www.backpaineurope.org.

13. Chou R, Qaseem A et al. (2007) Diagnosis and Treatment of Low-Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society, Annals Int Med 147 (7): 478-491.

14. Meade TW, Dyer S et al. (1990) Low-Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment, Br Med J 300:1431-37.

15. United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomised Trial: Effectiveness of Physical Treatments for Back Pain in Primary Care, BMJ Online First, Nov 19, 2004:1-8.

16. Wilk et al. v AMA et al. U.S. District Court Northern District of Illinois Eastern Division No. 76 C 3777, Getzendanner J, Judgement dated August 27, 1987.

17. Second Report (June 1986) Medicare Benefits Review Committee, C.J. Thompson, Commonwealth Government Printer, Canberra, Australia, Chapt. 10 (Chiropractic).

18. Stano M, Smith M. Chiropractic and Medical Costs for Low-Back Care. Med Care 1996;34:191-204.

19. Legorreta AP, Metz RD, Nelson CF et al. (2004) Comparative Analysis of Individuals with and Without Chiropractic Coverage, Patient Characteristics, Utilization and Costs, Arch Intern Med 164:1985-1992.

20. Metz RD, Nelson CF et al (2004) Chiropractic Care: Is it Substitution Care or Add-on Care in Corporate Medical Plans? JOED, 46:847-855.

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