Chiropractic, One Big Unhappy Family: Better Together or Apart?

The Chiro.Org Blog

SOURCE:   Chiropractic & Manual Therapies 2019 (Feb 21); 27: 4

Charlotte Leboeuf-Yde, Stanley I. Innes, Kenneth J. Young, Gregory Neil Kawchuk and Jan Hartvigsen

Institute for Regional Health Research,
University of Southern Denmark, DK-5000
Odense C, Denmark.

Editorial Comment:

It’s with heavy heart that I realize that it’s all come down to this: chiropractic depicted as a bad soap-opera marriage.

What is more upsetting is that this article is penned by some of the best, brightest and most-published of our chiropractic researchers. I love these folks!

That said, I’d like to challenge some of their assumptions. Chiropractic is not a marriage between chiropractors. At best, it’s a Family.

And families interact. I just might marry your sister, for example.

Now you may not like me, or you may not like our marriage. But that’s a personal problem.

The word Evidence has taken on a sacred-cow glow lately, and is only eclipsed by the adoption of the word skeptic by every Tom, Dick and Harry blog-opinionist/critic on the planet. So, let’s set the stage for the conversation.

This article dishes up several reasons why (as they call themselves) the ‘evidence-friendly’ faction are opposed to the ‘traditional’ group.

Here’s a short list of the infractions that are practiced by the ‘traditionalists’

  1. They ‘believe’ in “subluxations”

  2. Some of them ‘believe’ that you can find “subluxations” on x-rays

  3. Some of them ‘believe’ that correcting “subluxations” leads to improved health

So let’s address these concerns, one at a time.

  1. The Medicare and Medicaid definition of “subluxations” is:

    There are more articles like this @ our:

    What is the Chiropractic Subluxation? Page

    “Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine, are altered, although contact between joint surfaces remains intact.” [1] (page 3)

    Naturally, we can argue all we want about the accuracy of this term, until we turn blue in the face… BUT this is the definition adopted by the Government of the United States of America.

    Then, to bill Medicare for that spinal manipulation, I must use one of the 3 CPT codes that describe
    Chiropractic Manipulative Therapy
    (CPT codes 98940–98942)

    AND

    I must use an ICD-10 code to describe WHAT I adjusted:

    M99.01   Segmental and somatic dysfunction of cervical region

    Medicare enjoys being exclusive, and has always been the allopathic boy’s club, so they don’t permit us to use the mildly more accurate ICD-10 codes:

    M99.11     Subluxation complex (vertebral) of cervical region

    M99.12   Subluxation complex (vertebral) of thoracic region

    M99.13   Subluxation complex (vertebral) of lumbar region

    M99.14   Subluxation complex (vertebral) of sacral region

    M99.15   Subluxation complex (vertebral) of pelvic region

    As an aside, the AAPC states that

    “The International Classification of Diseases (ICD-10) is the standard international diagnostic classification system for documenting all general epidemiological conditions.” [2]

    Houston, we have a problem. (LOL)

    Our ‘evidence-friendly’ pals have a real problem on their hands. It’s not just the U.S. they have to contend with, it’s the whole international community, which has adopted the ICD-10 mechanism to describe the subluxation.  My recommendation:   Pack a lunch.

    Who gets to decide that we need a NEW word to describe WATER?

    Hell, with all the pollutants in our water supply, what if we simply RENAME water? That will solve the dilemma, right? Really? Oh yeah, the skeptics will finally embrace us if we just call it something else. LOL

    Subluxation (as a term) is the word that was adopted way-back-when to describe “that-thing-we-adjust”.

    I have yet to hear another term that was more pleasing to the ear, and didn’t smell like an over-anxious submission to organized medicine.

    While we’re on the subject, some folks prefer to use the term “manipulate” rather than “adjust”.

    I had the pleasure of listening to Virgil Strang, DC’s opinion on that topic. Back in the day, before television became digital, when we changed the channel, we often had to adjust the antenna or the tuner, to get the bext picture. So the term adjust became associated with the concept of fine-tuning.

    Now answer me this:   If your woman looks you in the eye, and says: “Don’t manipulate me”, you KNOW you are NOT going to have a nice day. That term carries some unpleasant baggage.

    I guess my point is that some terms (manipulate, subluxation etc.) may have developed a bad connotation, particularly after spending enough time reading skeptic blogs. The words themselves are not to blame. Accept it, we’ve been conditioned by the culture and the language in which we are submerged. But, I digress.

    1. Finding “subluxations” on x-rays

    I guess that partly depends on what you describe as a subluxation (or that-thing-we-adjust, if you prefer). If it is loss of normal end-feel, or limitations in normal range of motion, or things like that, then yes, the normal AP and lateral film can’t portray that loss of function.

    However, a careful videofloroscopic study of the cervical spine reveals a lot of what we feel with palpation.

    It’s easy to see facets that fail to slide up or downhill during flexion and extension.

    It’s easy to see IVFs failing to open, or to close down during flexion and extension. That should also be correlated with whether the spinous processes fans out, or move closer together, during flexion and extension.

    When I say *easy* I mean that when you look at enough of these studies, those things jump out at you.

    I had the good fortune to watch Dr. Verne Pierce do VFs on 100+ patients each semester for 7 semesters in a row, and we had access to those studies in our research department at Palmer (Davenport). I started a VF Analysis Club in my 5th tri, and 20-30 interested students popped in each week to view the studies and to talk about what we saw.

    1. Does anyone ‘believe’ that correcting “subluxations” leads to improved health?

    LOL! What does belief have to do with it?

    Like any other applied scientist, we observe what changes when we adjust a patient. That’s Care 101. You don’t need to believe anything. Just ask your patient IF they feel better, AND does that improvement sustain for longer and longer periods of time?

    I like using the RAND SF-36, because it documents 8 different ways that being subluxated impacts their work day, their joy and sense of well-being.

    That is the definition of rational care.

    All those other distinctions are political, an unpleasant “I’m-cooler-than-you” rap, and it is simply unprofessional. (Well, I do believe you folks ARE cool… just not cooler than me.)

    We have national standards, we have State Professional Associations, so if you think someone is doing something unprofessional, then file a complaint, and let the Board do their job.

    All this jabbering in Chiropractic & Manual Therapies, which is famous for it’s “we’re-more-evidence-based-than-you-are” rants, demeans our profession, and slows our progress.

    References:

    1. Department of Health and Human Services
      Centers for Medicare & Medicaid Services
      Overview of Medicare Policy Regarding Chiropractic Services

    2. What is ICD-10?

BACKGROUND:   The chiropractic profession has a long history of internal conflict. Today, the division is between the ‘evidence-friendly’ faction that focuses on musculoskeletal problems based on a contemporary and evidence-based paradigm, and the ‘traditional’ group that subscribes to concepts such as ‘subluxation’ and the spine as the centre of good health. This difference is becoming increasingly obvious and problematic from both within and outside of the profession in light of the general acceptance of evidence-based practice as the basis for health care.Because this is an issue with many factors to consider, we decided to illustrate it with an analogy. We aimed to examine the chiropractic profession from the perspective of an unhappy marriage by defining key elements in happy and unhappy marriages and by identifying factors that may determine why couples stay together or spilt up.

MAIN BODY:   We argue here that the situation within the chiropractic profession corresponds very much to that of an unhappy couple that stays together for reasons that are unconnected with love or even mutual respect. We also contend that the profession could be conceptualised as existing on a spectrum with the ‘evidence-friendly’ and the ‘traditional’ groups inhabiting the end points, with the majority of chiropractors in the middle. This middle group does not appear to be greatly concerned with either faction and seems comfortable taking an approach of ‘you never know who and what will respond to spinal manipulation’. We believe that this ‘silent majority’ makes it possible for groups of chiropractors to practice outside the logical framework of today’s scientific concepts.

CONCLUSION:   There is a need to pause and consider if the many reasons for disharmony within the chiropractic profession are, in fact, irreconcilable. It is time to openly debate the issue of a professional split by engaging in formal and courageous discussions. This item should be prioritised on the agendas of national associations, conferences, teaching institutions, and licensing/registration as well as accreditation bodies. However, for this to happen, the middle group of chiropractors will have to become engaged and consider the benefits and risks of respectively staying together or breaking up.

KEYWORDS:   Allied health; Attitude of health Personnel; Chiropractic; Professionalisation; Social perception; Trends

From the FULL TEXT Article:

Background

Health care is becoming increasingly evidence-based

Over the past decades, governments, society and patients have an increasing expectation of an evidence-based approach to health care and as the knowlege base has become larger and more widely accepted, the space available for alternative modalities has become smaller. [1–4] This has resulted in a greater contrast between mainstream and fringe medicine. Also, in the musculoskeletal area there are now different demands on indications for treatment and positive outcomes than what was seen only a few decades ago. [5] Increasingly legislation is being bought to bear to enforce such approaches. Chiropractors have for many years balanced at the crossroads between mainstream and alternative medicine, so this development poses particular challenges for chiropractic organisations, who have tried to cater for both. [6–8] Although chiropractors, officially, are part of the evidence-based movement in relation to musculoskeletal problems, we were late adopters, and some are not prepared to adopt this approach at all.

      The consequences for chiropractors

To the public, chiropractors are known to be ‘back pain clinicians’. [9–12] This is potentially a good niche, because back pain is one of the lagest public health problems, negatively affecting hundreds of millions of people. The number of years people live with disability has increased globally by 52% since 1990. [13, 14] The recent Lancet Low Back Pain Series pointed to the gap between what is known and what is being practiced, and called for a de-medicalisation of back pain and promotion of public health approaches in order to reverse this trajectory. [15, 16] Chiropractors appear to be well placed to respond to this call and become relevant in mainstream healthcare globally.

      Divisions within the chiropractic profession

As is the case with professions generally, chiropractic has always had subgroups, some further toward the fringe and others closer to mainstream healthcare. Chiropractic arose out of a vitalistic tradition. D.D. Palmer, the founder of chiropractic, declared that 95% of all disease was caused by subluxated vertebrae and that the remaining 5% was caused by slight displacements of bones other than those in the spine. [17] An early split developed between the vitalists and those who developed towards a more scientific approach, and divisions remain. It is estimated that approximately 20% of the profession in Canada still adheres to a vitalistic explanation for how they practice. [18, 19] Despite the presence of these factions, chiropractic has gradually become a global healthcare profession [20], and in some jurisdictions chiropractors are regarded as mainstream healthcare providers, as part of national health systems or reimbursed with public or private insurance funds. In places where chiropractors have adopted modern evidence-based principles, external stakeholders have determined that chiropractic practice accords with modern healthcare principles and should be included among legitimate healthcare practitioners. [21, 22] Nevertheless, there is a continuing divide between ‘evidence-friendly’ and ‘traditional’ chiropractors, which has become more visible in recent years, as the focus on back pain and musculoskeletal health has increased and a wealth of new evidence in the area has emerged. Unfortunately, these disparate voices reflecting different approaches confuse external stakeholders and threaten the credibility of the chiropractic profession.

Read the rest of this Full Text article now!