Commentary

Finding a Common Ground in Chiropractic: The Key to Progression

Jordan A. Gliedt, D.C.

 

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Topics in Integrative Health Care 2011, Vol. 2(4)   ID: 2.4002



Published on
December 30, 2011
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INTRODUCTION

The chiropractic profession has survived many challenges in its brief lifetime.  As a result of its many trials, the profession has a history filled with inner discord and external confusion, carrying over to the present.  Conflict among chiropractors with differing opinions in scope of practice, education and the chiropractor’s role has been embedded in the profession.  Chiropractors have traditionally vocalized passionately to each other and to each new generation of chiropractic students and patients their positions on these topics, creating an environment of intra-professional disorder and public uncertainty.  In order for chiropractic to mature to its highest potential, the profession must connect and present itself as a consistent and united group.  If chiropractors hope to unite, a bond must be created with some form of commonality in each area of dispute, overcoming the culture of internal friction.  This commentary, from a chiropractic student’s perspective, provides a historical look into how dispute in chiropractic has become so deeply rooted and presents a unifying principle in which chiropractors can relate to and overcome the profession’s divisions and public confusion while advancing chiropractic’s future.

BACKGROUND

It has been more than 110 years since Daniel David (D.D.) Palmer delivered his first “chiropractic adjustment” and subsequently founded the Palmer school.1 The chiropractic profession has grown to more than 49,000 practicing chiropractors in the United States2 and there are currently 19 accredited chiropractic colleges in the U.S.  Americans are increasingly embracing the Complementary and Alternative Medicine (CAM) industry, spending $33.9 billion of out of pocket expenses and $2.2 trillion dollars total for CAM services each year.14 Chiropractic is the largest CAM profession in America and is expected to continue to grow in the number of practitioners in the future.2  Doctors of Chiropractic have been included as part of the treatment regimen for many citizens including  professional athletes, Olympians, entertainers and politicians.  Despite the apparent success and growth, chiropractors are reported to typically treat approximately 7 percent of the overall population4-6 and the profession has been referred to as being at a “crossroads” with an uncertain identity and future.7-10  As mentioned, throughout the history of chiropractic there has been internal disagreement, provoking calls for reform.11-13 The discrepancies amongst practitioners’ ideology pertaining to scope, education and role have created a non-unified and often times segregated group.  Inherently, the inability to unite as a whole has disabled the profession from optimally progressing to its utmost ability.  Particularly at this time of precariousness in the health care world, it is imperative that chiropractors find a common ground to unite in order to maximize public acceptance and growth.

HISTORY

To fully understand the current rifts so commonplace to American chiropractors, a brief history of chiropractic in the areas of scope, education and role should be explored. 

Scope of Practice and Education



The scope of practice and education appropriate for a chiropractor are two interrelated topics that have been argued upon since chiropractic’s beginnings.  Soon after D.D. Palmer announced the arrival of the chiropractic profession, the Palmer School of Chiropractic began operation.  One of Palmer’s graduates by the name of Solon Langworthy soon thereafter opened the American School of Chiropractic and Nature Cure.  Langworthy introduced naturopathic, stretching and herbal remedies into the curriculum which Palmer vehemently disagreed with.15 Further arguments arose within the profession and most practitioners would eventually become labeled as “straight” chiropractors (practitioners relying exclusively on spinal manipulation) or “mixers” (practitioners incorporating a variety of therapies in addition to manipulation). This would lay a foundation for a debate concerning scope of practice which has divided chiropractors throughout the entirety of its history.  This argument has been highlighted by the two national chiropractic organizations representing the two sides (International Chiropractic Association representing the “straights” and the American Chiropractic Association representing the “mixers”). In addition to the chiropractor’s scope, the Palmers and their followers disagreed with other practitioners concerning suitable educational requirements.  B.J. Palmer (the son of D.D. Palmer and major chiropractic figure) was so fanatically opposed to revising traditional chiropractic education, when the head of the National Chiropractic Association’s (now the American Chiropractic Association) Council on Education pushed for a four year curriculum and upgrades in diagnostic and basic science instruction, Palmer called him the “Anti-Christ of Chiropractic”.15

As World War I ended, returning servicemen flooded the profession and chiropractic began to grow rapidly.15 New schools emerged every year, each offering a new opinion on best treatments and scope of practice.  However, as veterans’ benefits were exhausted, many schools were forced to close or merge with one another.15 Nevertheless, the diverse range of schools’ ideologies set the tone of incongruence amongst chiropractors, which has carried over to our present era.  As the varied scope of practice philosophies has remained amongst each institution, so has arguments concerning educational standards.  In the 1960’s and 1970’s the “straights”, represented by the Association of Chiropractic Colleges, were feuding with the “mixers”, represented by the National Chiropractic Association’s (NCA) Council on Chiropractic Education (CCE), over the recognition of the United States Office of Education (USOE) accrediting agency.  The two parties opposed each other to such an extent, the USOE established it would only recognize one party for the profession.  The NCA’s CCE would eventually have its application accepted and other opposing schools would ultimately conform to the requirements set to receive accreditation.15 The current length of chiropractic education and curriculum is still controversial today, with some calling for a Flexner type report and reform of some kind.10, 13, 18

Additionally the chiropractic health care system has fought long and hard for licensing across America.  Each state has been granted licensing laws independently of each other, resulting in a total of 61 years between licensing of the 50th state and the 1st.15 Consequently, this has contributed to the varying scope of practice laws between all 50 states and general confusion of a typical chiropractor’s scope of practice. 

Chiropractic’s Role in Health Care



During the early years of chiropractic, United States legislation considered chiropractors to be practicing a form of medicine.  It is estimated by 1931, there were approximately 15,000 chiropractors prosecuted for practicing medicine without a license.15, 16 In 1906 Palmer and his followers founded the Universal Chiropractic Association (later the International Chiropractic Association) to aid in the defense of chiropractors being prosecuted.  The first and most notable defense case was the Morikubo trial in La Crosse, Wisconsin.  The defense won based on the argument that chiropractic was “separate and distinct” from all other forms of health care, including medicine and osteopathy.15

The notion of “separate and distinct” has followed the profession both internally and externally throughout much of history.  This viewpoint has contributed toward opposition and competition with other health care fields, highlighted by the Wilk vs. AMA trial in which the chiropractic profession accused the medical profession of conspiracy to “contain and eliminate” chiropractic.15 The American Medical Association was eventually found guilty based upon Sherman Anti-Trust Violations, furthering the disconnect between the two professions. 

As health care in America has evolved, particularly with the emergence of strong chiropractic research, many within chiropractic have pressed for integration with other health care specialties.  This initiative however contradicts many chiropractors who desire to remain “separate and distinct”. 

Not only has the conversation of separate and distinct vs. integration remained a key conflict in chiropractic, so too has the debate of disorders which are most fitting for a chiropractor to treat.  There remains a strong segment that remains loyal to D.D. Palmer’s theory that manipulation of a subluxated spinal joint removes disruption of health to all body systems, even though this theory lacks current evidence.  Furthermore, a division of the field pushes for a focus on spinal and musculoskeletal ailments, which the majority of chiropractic visits are for.17, 25, 26 

FINDING COMMON GROUND

As mentioned previously, chiropractic has been labeled a profession at a crossroads with an uncertain future.  Fairly so, the profession will be judged in the future to a large extent on how it approaches issues during this time of ambiguity.  Keating et al state, “The way the profession ultimately addresses the inevitable conflicts between newly emerging evidence and traditional beliefs will undoubtedly shape its future”. Additionally, Keating et al identify a key question for chiropractic’s future is how to incorporate the profession into mainstream health care so that chiropractic services can be readily available to the mass public in need and how this can be achieved without diluting the uniqueness of chiropractic to the point of it being unrecognizable.15 Over time, chiropractic has deeply rooted itself in three major areas of dispute; scope, education and role.  Any unifying movement might therefore need to encompass each topic and allow for potential enhancement for each stance. The author suggests the chiropractic profession identify a common ground premise which chiropractors as a whole can agree upon and rally around, backed by the evidence based health care (EBHC) approach,.  EBHC is embodied by the following three tenets: 1. Best peer reviewed literature evidence.  2. Practitioners’ expertise. 3. Patients’ values and expectations.  A unifying theme supported by EBHC provides a foundation for mutual growth by enhancing the patients’, clinicians’ and researchers' integrated involvement.  A unifying chiropractic perspective will aid in the advancement of the profession10, assisted with the backing of EBHC acceptance. 

CONSERVATIVE TREATMENT OF SPINE RELATED DISORDERS

The author proposes that the chiropractic profession unify around the conservative treatment of spine related disorders (SRD), a concept supported by EBHC principles.  The author surmises that a shift to this paradigm will generate an increase in market impact for the chiropractic profession and increase public and inter-professional confidence.  If warranted, the profession could then use this positive impact as a catalyst to potentially strengthen other areas of chiropractic treatment and further expand the role of the chiropractor.  A paradigm shift to SRD treatment may also yield immediate benefits to the overall health care environment.

A spine related disorder is defined by Murphy et al as “the group of conditions that include back pain, neck pain, many types of headache, radiculopathy, and other symptoms directly related to the spine”12 For purposes of this article, the conservative treatment of SRD’s is defined as spinal manipulative therapy and other manual musculoskeletal therapies applied individually or in combination with rehabilitative exercise prescription, nutritional counseling and/or healthy lifestyle coaching.  Evidence indicates the efficacy of manual treatment and manipulation for SRD’s is strong.19-23  The public overwhelmingly relates chiropractic treatment with spine related disorders, evidenced by the vast majority of chiropractic visits that are for spine related complaints.17, 25, 26 Furthermore, the profession is already in a position that it could make a relatively horizontal transition to this paradigm and garner the rewards of cultural authority and increased market impact that may be associated.

An approving and cohesive group could only improve the profession.  According to Villanueva-Russell, an unclear presentation of chiropractic self identity ultimately increases the difficulty for the profession to compete at the macro level.27 A united campaign for the treatment of SRD’s would improve public awareness, cultural authority and gain confidence from other health care physicians by creating a platform for a consistent message and effective and accepted treatments.  One concern many medical physicians have impeding them from referring patients to chiropractors is a lack of knowledge of what chiropractors do.  The inconsistency in treatment paradigms increases the confusion and lack of a desire that many medical doctors hold concerning interacting with chiropractors.  An established consistency in the chiropractic field would decrease the present confusion and increase the volume of patients whom could benefit from chiropractic care.  Currently, chiropractors are only seeing around 7 percent of the population4-6 with an estimated adult low back pain point prevalence of 37.1 percent of the population.24 Regardless of the stance a chiropractor takes with regard to the chiropractic profession's disagreements, all chiropractors would benefit from the potential increase in patient volume and cultural authority.  Moreover, many chiropractors would argue that all patients can benefit from chiropractic treatment.  This scenario could provide an avenue for more patients to benefit from chiropractic care.

From a chiropractic perspective, the conservative treatment of SRD’s represents a commonality in each aforementioned question of internal dispute.  SRD’s and their management is a long-standing routine in a chiropractor’s office and a traditional emphasis in chiropractic education.  The chiropractic practitioners who argue that chiropractic treatment can benefit many more conditions than SRD’s and the role of chiropractors should not be limited to SRD treatment, wouldn’t the increased volume of patients begin to notice the extra-spinal benefits of chiropractic treatment and thus bolster the other tenets of EBHC currently lacking in that area of chiropractic treatment?  If so, this would allow for an added patient expectation and value for typical chiropractic care while permitting a launching pad for optimal peer reviewed evidence in this field.  Additionally, this concept could then spill over to an expanded typical and accepted chiropractic scope and education.  This scenario could evolve without compromising the immediate focus of care for the current typical spine related patient presentation.17, 25, 26 The chiropractors who advocate for being musculoskeletal/spine specialists, the increase in cultural authority would further stamp chiropractic excellence in this area of treatment.  Both sides of the profession’s interests could be potentially further propelled while maintaining the distinct nature of chiropractic. 

From a non-chiropractic perspective, a cohesive chiropractic group treating SRD’s has positive benefits to the health care world overall.  Chiropractic treatment offers an effective and safe option for the ever mounting number of individuals who suffer from SRD’s, particularly patients who are poor candidates for NSAID therapy.  As the chiropractic profession transitioned to a portal of entry primary care physician for SRD’s, benefits for both society and health care can be expected.  Murphy et al propose the notion that as the chiropractic profession takes this role patients would save on expense, recovery time, avoid disability and increase productivity among others benefits.  Murphy et al also highlight the health care arena benefits this transition would provide such as controlling costs, unburdening traditional PCP’s and allowing for new evidence/technology to emerge among other advantages.12 These positive results of this treatment paradigm would provide the chiropractic profession a higher authority and confidence from other health care professions and the public.

SUMMARY

Chiropractic has experienced a disjointed profession since the beginning of its existence.  Continued arguments concerning scope, education and the role in health care have debilitated the profession from developing into a mainstream health profession.  As the evidence and acceptance of typical chiropractic treatments continue to become acknowledged, it is vital that the profession can find a unifying factor to rally upon to assist in chiropractic progression.  The conservative treatment of spine related disorders is a paradigm the profession can easily connect with and provides a springboard for chiropractic advancement.  A chiropractic rally around this model would allow for growth and integration while maintaining the profession’s uniqueness.

DISCLOSURES

The author has no competing interests.
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References

1.   

Palmer College of Chiropractic. The Palmer Family. (Accessed 2011 Aug 12)

 [ Full-Text Link ]

2.   

US Department of Labor. Bureau of Labor Statistics.  (Accessed 2011 Aug 12)

 [ Full-Text Link ]

3.   

American Chiropractic Association. Chiropractic Colleges. (Accessed 2011 Aug 12)

 [ Full-Text Link ]

4.   

Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data May 27 2004(343):1-19.



5.   

Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by U.S. adults: 1997-2002. Altern Ther Health Med 2005 Jan-Feb;11(1):42-9.



6.   

Lawrence DJ, Meeker WC. Chiropractic and CAM utilization: a descriptive review. Chiropr Osteopat 2007 Jan 22;15:2.



7.   

Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002 Feb 5;136 (3):216-27.



8.   

Reggars JW. Chiropractic at the crossroads or are we just going around in circles? Chiropr Man Ther 2011 May 21;19:11.



9.   

Hawk C. Evidence of chiropractors' views on identitiy: Who do we think we are? Journal of the American Chiropractic Association. May 2004 2004;May 2004.



10.   

Institute for Alternative Futures. The Future of Chiropractic Revisited: 2005-2015. Alexandria, Virginia: the Institute for Alternative Futures, 2005. hhtp://www.altfutures.com. Used with permission.



11.   

Mootz RD. Chiropractic’s current state: impracts for the future. J Manipulative Physiol Ther 2007 Jan;30(1):1-3



12.   

Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ. The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropr Manual Ther 2011;19:17.



13.   

Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropr Osteopat 2008 Aug 29;16:10.



14.   

National Institutes of Health. National Center for Complementary and Alternative Medicine (NCCAM). (Accesssed 2011 Aug 16)

 [ Full-Text Link ]

15.   

Keating JC, Cleveland CS, Menke M. Chiropractic History: a Primer. Association for the History of Chiropractic, 2004.  (Accessed 2011 Oct 3)

 [ Full-Text Link ]

16.   

Turner C. The Rise of Chiropractic. Los Angeles: Powell Publishing Company, 1931.



17.   

Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients Using Chiroractors in North America: Who Are They, and Why Are They in Chiropractic Care? Spine (Phila Pa 1976) 2002 Feb 1;27(3):291-6; discussion 297-8.



18.   

Johnson C, Green B. 100 years after the flexner report: reflections on its influence on chiropractic education. J Chiropr Educ 2010 Fall;24(2):145-52



19.   

Walker BF, French SD, Grant W, Green S. A Cochrane review of combined chiropractic interventions for low-back pain. Spine (Phila Pa 1976) 2011 Feb 1;36(3):230-42.



20.   

Bronfort G, Haas M, Evans RL, Leninger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat 2010 Feb 25; 18:3.



21.   

Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007 Oct 2;147(7):478-91



22.   

Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache Pain. 2011 Apr;12(2):127-33. Epub 2011 Feb 5



23.   

Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, Haneline M, Micozzi M, Updyke W, Mootz R, Triano JJ, Hawk C. Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74.



24.   

Schmidt CO, Raspe H, Pfingsten M, Hasenbring M, Basler HD, Eich W, Kohlmann T. Back pain in the German adult population: prevalance, severity, and sociodemographic correlates in a multiregional survey. Spine (Phila Pa 1976). 2007 Aug 15;32(18):2005-11



25.   

Christensen M, Kollasch M., Hyland JK. Practice Analysis of Chiropractic. Greeley, CO: NBCE; 2010.



26.   

Waalen JK, Mior SA. Practice patterns of 692 Ontario chiropractors (200-2001). J Can Chiropr Assoc 2005 Mar;49(1):21-31



27.   

Villanueva-Russell Y. Caught in the crosshairs: Identity and cultural authority within chiropractic. Soc Sci Med (2011). Doi:10.1016/j.socscimed.2011.03.038