Perspective


Why Self-Development is Crucial for the Entrepreneurial Chiropractor
Perspective
Written by Tom Owen III   
Sunday, 22 July 2012 23:11
C
hiropractors are often considered to be true entrepreneurs. This is because they often graduate from their educational program and immediately open and build their own businesses from the ground up, without a formalized support system. Furthermore, they do not have a business model that provides them immediate patient flow and income, unlike other healthcare professionals. More than ever, chiropractors need to spend time and money continuing their entrepreneurial education because they are working as entrepreneurs.

Continuing one's education offers many great benefits. The benefits of self-development include:

  • selfdevelopmentBetter care for patients. For chiropractors, patient care is the top priority. By continuing your learning through professional development opportunities, you are able to offer better care to your patients. Continuing education ensures that you are knowledgeable about the most recent research and techniques, which can be helpful to your patients and ensure they are receiving the best care available.
  • Opportunity to promote your business. By obtaining a certification in a new technique or even having knowledge in a new procedure, you are able to promote your business and yourself as an expert in this area. This will help you attract new customers and expand your business.
  • Growth as a professional. As a professional, continuous learning is important to ensure that you are constantly growing. This is what keeps you challenged and interested in the profession. For chiropractors, pursuing self-development opportunities is important to make sure you are learning new things and challenging yourself professionally.

While many chiropractors are turned away from professional development opportunities because of the cost, it is a cost that is well worth the price. It is important that continuing education opportunities are considered an investment, rather than an expense. This is because it is an investment in the chiropractor's future, in helping them develop the skills to further their ability as a professional. Furthermore, the IRS allows professionals to deduct learning opportunities on their taxes each year, which also includes professional development. Because of this, it's important that a chiropractor keeps a running tally of the courses that they take and the associated expenses to ensure they are reimbursed the proper amount from the IRS. This makes it even more affordable and appealing to chiropractors, especially those who practice on their own.

In addition, engaging in professional development opportunities helps chiropractors build reputation within the field. This is important for several reasons. For one, it gives chiropractors an opportunity to build a network, which will in turn help build their client base and provide support if he or she chooses to move to a different practice in the future. Engaging in conversations with other chiropractors is a good way to help develop as a professional, as it's easy to share best practices and other information casually. Furthermore, it opens doors to present at national conferences, which raises a chiropractor's profile among key vendors and companies that provide services. This is helpful because it allows them to build relationships with these vendors for product discounts. It may even provide an opportunity to chiropractors to try out new equipment or services because of their clout within the industry.

Overall, engaging in self-development opportunities as a chiropractor provides many personal and external benefits. It can help improve the chiropractor's overall ability to serve his or her patients, while building the business through networking and a higher profile within the industry. From the patient's point of view, engaging in continuing education is important because it will augment the services that can be provided and will ensure the chiropractor is focused on the newest techniques and understands the latest research that has been released.

 
Treating: Doctors Can Fight & Overturn Improper IME and Peer Reviews
Perspective
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Saturday, 02 June 2012 01:51

T
he IME, or independent medical examination, and peer review processes are necessary and integral steps in maintaining a system of checks and balances in health care billing in order to prevent unnecessary care. Over the last two decades, the system has evolved to where too many doctors who are hired by the carriers through an IME company (middle man) or directly by the carriers are not performing examinations that are remotely close to independent. Going back 20-30 years, you could historically find inaccuracies in how the insurance companies hired doctors that reported on the conditions of the patients. 

 
improperimeandpeerreviewsIn addition, rarely were retrospective audits or retrospective opinions from contemporary IMEs performed or rendered. Today, this has become vogue and a huge revenue source for private, public and governmental carriers alike. There is hardly a doctor in the nation that hasn't been affected by overwhelming negative IMEs that include inaccuracies, partial truths and a blatant disregard and/or misrepresentation of facts.  

Over the years, too many IME companies have handed doctors completed reports, mandated diagnoses, misquoted research and given strict orders regarding the scope of care permitted, all prior to the examination. In almost every instance I have encountered, the carrier or IME company has offered to send the doctor more cases if he/she works with them to reach a desired conclusion, whatever that may be.

Treating doctors currently have 2 choices. They can either ignore the opinions rendered which would tarnish or possibly damage their reputations as treating doctors or fight back with rebuttals. Unfortunately, most doctors choose to do nothing, leaving the final word of their clinical decision making and abilities up to the IME or peer review doctors. For the most part, based upon review of 100s of rebuttals, the doctors who do fight back with rebuttals are fraught with emotional statements and/or attempts to clarify the records.
 
Although this is a good first step, it comes down to a treating doctor's word vs. an IME or peer review doctor's opinion, and in the end the treating doctor rarely wins the argument. If you attempt to scrutinize the reasons why, it comes down to the fact that the IME and peer review processes are time-honored systems for which decades and countless resources have been spent defining templated language and research has often been supplied to the "insurance-hired" doctors. It's an area where treating doctors do not have access to the same type of technology or research teams that the carriers and the IME companies can afford...and...there is nothing wrong with that. 

They just play the game at a higher level than you in order to keep their money...and...it is always about the money. The problem arises when the IME and peer review doctors step over the line of integrity and report partial truths and/or half truths, making glaring omissions, or simply are dishonest in reporting their findings. This is what needs to be focused on in "weeding out the bad ones" and setting the record straight.

Treating doctors are not powerless, but need to understand how to get past the rhetoric of a well-constructed IME or peer review report in order to bring out the inaccuracies, partial truths and blatant disregard of facts when those circumstances arise. In the November, 2011 and February, 2012 issues of this journal, I chronicled actions that can be taken by the treating doctors and state organizations. In March and April of 2012, I outlined the perils facing the IME and peer review doctors. You must first understand every aspect of the process in order to prevent having negative IMEs and peer reviews and prevail in overturning improper reports.
 
In order to craft a proper rebuttal, it is necessary that you understand the licensure standards of the doctor-patient relationship between the insurance-hired doctor and the patient. You also must understand the regulatory requirements in that examination and the IME or peer review doctor's requirements to report the results. This is a state by state issue, as each state has independent rules on the required conduct of insurance-hired doctors.  You then must learn how to recognize when a partial truth or "untruth" is being documented by the examining doctor. It is that scenario which mandates that you protect both your reputation and your patient's interests by rendering evidence of how licensure and regulatory standards were not adhered to. 
 
The language typically written by IME doctors is, "The above captioned claimant is examined in accordance with the restrictive rules concerning an independent medical evaluation. Prior to the evaluation, it was explained to the examinee that this appointment was for the purpose of evaluation only and not for care, treatment or consultation, and, therefore, no doctor-patient relationship would result."  In many states, this statement alone is not consistent with court rulings and regulations and can be considered a licensure violation due to a misrepresentation of the facts. Rendering false reports, or misrepresenting material facts is also considered a licensure violation in many states. 

Massachusetts regulations state:
4.06: grounds for disciplinary action

The board may, by majority vote after a hearing conducted in accordance with M.G.L. C. 30a and 801 CMR 1.00 et seq., take disciplinary action against any registered chiropractor who holds a certificate of registration issued pursuant to M.G.L. c. 112, §§ 89 through 97 and 233 CMR 2.00. Grounds for such disciplinary action shall include, but shall not be limited to:

(11) engaging in, authorizing, or aiding or abetting, fraud, misrepresentation or deceit in connection with his or her practice of chiropractic, as defined in 233 CMR 4.10;

(12) making any false statement or misrepresentation of material fact in connection with any application or claim for payment of any health care benefit, as defined in 233 CMR 4.11;

Delaware's regulation's state: 
Title 24. Professions and occupations

Chapter 17. Medical practice act

Subchapter iv. Disciplinary regulation; proceedings of the board

§ 1731. Unprofessional conduct and inability to practice medicine
 
(a) A person to whom a certificate to practice medicine in this state has been issued may be disciplined by the board for unprofessional conduct, as defined in subsection (b) of this section, by means of levying a fine, or by the restriction, suspension, or revocation, either permanent or temporary, of that person's certificate to practice medicine, or by other appropriate action, which may include a requirement that a person who is disciplined must complete specified continuing education courses. The board shall permanently revoke the certificate to practice medicine in this state of a person who is convicted of a felony sexual offense.

(b) “unprofessional conduct” includes but is not limited to any of the following acts or omissions:

(1) the use of any false, fraudulent, or forged statement or document or the use of any fraudulent, deceitful, dishonest, or unethical practice in connection with a certification, registration, or licensing requirement of this chapter, or in connection with the practice of medicine or other profession or occupation regulated under this chapter...

Every state has its own rules that must be adhered to. However, some states have separate rules for IME and peer review doctors. 

This is one of many avenues that can be taken to overturn improper IME and peer review reports, but remember, the IME and peer review doctors are entitled to their opinions and you do not have to like them or agree with them.  For those honest insurance-hired doctors, the solution is for you to simply write a better, more thoroughly documented accounting of your patient's problems initially, and then rebut the IME doctor's opinion with your own documentation or request that your patient get an independent opinion from a doctor of his/her own choosing.

For those insurance-hired doctors who have crossed the line of integrity, the only solution is to use the rules and regulations, through documented proof, of how they violated state licensure standards and the best proof is the insurance company-hired doctor's own report. Don't let inaccuracies about your clinical opinions and abilities be the last word.  
 
Adjustment vs. Manipulation: Yes, Language Really Matters to the Future of Chiropractic
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Perspective
Written by Christopher Good DC, MA(Ed)   
Wednesday, 29 February 2012 16:44

W
hen I was first asked to write an article about the words adjustment and manipulation, a flurry of thoughts and emotions hit me…not the least of which was the question, “Aren’t we over this yet?”  But after thinking about it for a few weeks I’ve come to the realization that we will never really get beyond this quagmire any time soon.  Essentially this is because these words define us in a way that helps create our professional identity and distinguishes us (for better or worse) from the rest of the manipulative professions.  So, relative to the future of our profession, there is no question that language matters because in order to communicate with our patients, amongst ourselves, with other professions and the public at large, words are the basis for all understanding.  Personally I am convinced that given who we are as a profession, the words unique to our profession like adjustment and subluxation will not go away within the foreseeable future.  Given that, I think the more important questions are, “What do these words mean?” and “How can we use them to advance the profession?”

The Clarity of Definitions

languagemattersAs a teacher to new members to our profession, I firmly believe it’s necessary to learn our lexicon.  This is important not only for historical reasons, but also to understand the present and future debates regarding chiropractic and, more importantly, to add to and access the scientific literature and improve patient care. But in order to debate or utilize published evidence, we must be clear and consistent with the words we use. To my knowledge the most comprehensive work to date on establishing consensus in our profession regarding our terminology was done by Gatterman and Hansen in 1994 (1).  In the heroic attempt to bring some order to the chaos, they organized and reported on the work of an international Delphi panel, whereby these leaders offered their conclusions about the various words and definitions we commonly use.  I would suggest that as a profession we continue to use the definitions that were crafted at that time until a similar process is undertaken to update them.  As such, an adjustment is defined as “ANY (emphasis added) chiropractic therapeutic procedure that utilizes controlled force, leverage, direction, amplitude, and velocity which is directed at specific joints or anatomical regions.  Chiropractors commonly use such procedures to influence joint and neurophysiological function.”

As I see it, there are both strengths and weaknesses in this definition.  The strengths include the fact there was 87% agreement by the panel members to adopt this definition and that it is inclusive of the myriad of the subluxation/joint dysfunction interventions that we use, including high velocity, low amplitude (HVLA) manual thrust procedures, instrument-assisted thrust procedures, pelvic blocking, and even flexion-distraction procedures.  I personally like it because when someone tells me she had an adjustment, I immediately know she knows something about what we do and has probably visited a chiropractor.  I also like it because it implies that there is a high level of precision involved when giving an adjustment.  I believe this is an important distinction relative to other manipulative professions which can be used to our advantage when we explain our different types of adjustments.   Of course the major weakness is that it is so broad and vague that it is useless as a word when performing research investigations, having meaningful intraprofessional or interprofessional dialogue, or crafting legislative or public policies or practice guidelines. 

As for manipulation, the Gatterman and Hansen definition is “a manual procedure that involves a directed contact to move a joint past the physiological range of motion, without exceeding the anatomical limit.” The strength in this definition is that it had 91% agreement among panel members and is relatively specific.  For example, manipulation is distinguished from mobilization and other manual therapy procedures.  It is highly useful as the basis for a research investigation even though often there must be further refinement of the term; as a literature search term it is far more useful than the word adjustment.  Certainly as we integrate ourselves further into mainstream health care systems, it is the word that is best understood.  It is the word typically used to describe the commonly used hands-on HVLA thrust procedure and there is no particular benefit to not using it.  Indeed, we have used it to our great advantage when other professions have published favorable trials on neck pain, back pain or headaches (among other things) and used manipulation as one of the interventions.  As an example, the recently published UK Evidence Report was a review on randomized controlled trials on conditions which were treated by manipulation (not adjustment), many of which were performed by non-DCs (2).   This document is extremely useful in evidencing at least some of what we do to those outside of the profession and clearly advances our cause to support and increase the utilization of our services.

In conclusion, I will close with this thought regarding what words we use: follow the money.  As we better define ourselves and our procedures and truly determine which of those are most safe and effective, I am convinced we will separate ourselves from the pack and this will help us flourish.  This belief begins with the fact we are the most educated users of manipulation and other forms of adjustments in the US (and probably the world).  As one compares the curricula of competing professions, especially the hours of study, this becomes very clear (3, 4, 5).  If we were to do direct comparisons of DC, PT and DO manipulations and other procedures we could evidence this.  But where is the money to do such things?  The federal government is one source.  The National Institutes of Health now provide approximately 100 million dollars per year to fund such research through their National Center for Complementary and Alternative Medicine (6).  All we need to do is access this money by writing high-quality grant proposals. The good news is we already have had a number of projects funded, which suggests that the interest is there and the internal expertise exists.  We just need to take more advantage of our knowledge by being very clear and consistent with the words we choose.  Language matters, especially when money is involved!

 

References

  1. Gatterman, M.I. & Hansen, D.T. Development of chiropractic nomenclature through consensus. J Manipulative Physiol Ther 1994;17:302-9.
  2. Bronfort, G., Haas, M., Evans, R., Leiniger, B., & Triano, J. Effectiveness of Manual Therapies: The UK Evidence Report. Chiropractic & Osteopathy 2010, 18:3.
  3. University of Bridgeport College of Chiropractic website accessed on 09Oct2011 at http://www.bridgeport.edu/academics/graduate/chiro/curriculum/curriculumbreakdown
  4. Boissonnault, W., Bryan, J.M., & Fox, K.J. Joint manipulation curricula in physical therapist professional degree programs. J Orthop Sports Phys Ther. 2004, 34(4):171-8.
  5. H. Shubrook, Jr & Dooley, J. Effects of a structured curriculum in osteopathic manipulative treatment (OMT) on osteopathic structural examinations and use of OMT for hospitalized patients.  JAOA , 2000, 100(9): 554-558.
  6. National Center for Complementary and Alternative Medicine website accessed on 09Oct2011 at http://www.nccam.nih.gov/

 

Christopher Good, DC, MA(Ed) is a Professor of Clinical Sciences at the University of Bridgeport College of Chiropractic.  He teaches courses in clinical biomechanics and chiropractic technique, extremities technique, and chiropractic principles and practice. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Implementing a “Code of Ethics” Can Help Prevent IME and Peer Review Abuse
Perspective
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Wednesday, 29 February 2012 11:03

I
n 1847, the American Medical Association adopted the world's first national code of professional ethics in medicine. For the more than 160 years, the AMA's "Code of Medical Ethics" has been the authoritative ethics guide for practicing physicians. Currently, the AMA has 200 ethical opinions. The chiropractic profession needs to learn from the AMA and, in the end, further protect our patients and doctors from fraud and abuse. In this case, I make the argument in order to protect against IME and peer review abuse.

codeofethicsThe AMA's Code of Medical Ethics, Opinion 10.03, is titled "Patient-Physician Relationship in the Context of Work-Related and Independent Medical Examinations" and outlines a cogent relationship that should exist between both IMEs (independent medical examiners) and IEPs (industry employed physicians). The AMA writes:

Despite their ties to a third party, the responsibilities of IEPs and IMEs are in some basic respects very similar to those of other physicians. IEPs and IMEs have the same obligations as physicians in other contexts to:

(1) Evaluate objectively the patient’s health or disability. In order to maintain objectivity, IEPs and IMEs should not be influenced by the preferences of the patient-employee, employer, or insurance company when making a diagnosis during a work-related or independent medical examination.

(2) Maintain patient confidentiality as outlined by Opinion 5.09, "Industry Employed Physicians and Independent Medical Examiners."

(3) Disclose fully potential or perceived conflicts of interest. The physician should inform the patient about the terms of the agreement between himself or herself and the third party as well as the fact that he or she is acting as an agent of that entity. This should be done at the outset of the examination, before health information is gathered from the patient-employee. Before the physician proceeds with the exam, he or she should ensure to the extent possible that the patient understands the physician’s unaltered ethical obligations, as well as the differences that exist between the physician’s role in this context and the physician’s traditional fiduciary role. (http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1003.page)

Although the AMA worked hard to protect patients and doctors from improper IME and IEP examinations, they are a labor organization and neither a regulatory body, nor a court of law.

However, upon joining, members have to agree to abide by the Code of Ethics, which is a contractual obligation and has legal precedent in tort (trial) proceedings. In addition, many regulatory bodies seek counsel from state organizations to determine if a doctor is practicing within the current standard of care and ethics for his/her particular state.

It is here where every national and state chiropractic organization has the ability to level the playing field in protecting both patients and doctors by having a code of ethics outlined and agreed upon by all of their members. This creates a standard of practice in the state and should an improper IME, IEP or peer review be performed, then there are guidelines to justify recourse. Although some states have ruled that IME, IEP and peer review doctors are not subject to state licensure disciplinary boards as a result of their interpretation of "duty of care" or the legal obligation of the doctor to the patient because they believe no doctor-patient relationship exists, many states do hold the IME or IEP doctor to the same standard as the treating doctor. This dichotomy creates a problem in those states where a doctor can tell half-truths, report only snippets of research or do only a partial examination for a desired conclusion and not be subject to losing his/her license. Courts in New York, Maryland, The District of Columbia, Arizona, Michigan, West Virginia, Montana, and The United States Court of Appeals, Fifth Circuit, among others, have ruled that these doctors are responsible in a doctor-patient relationship.

symbolchiropracticShould an independent examining doctor do an improper or fraudulent examination in any of those states, the code of ethics will weigh heavily against them. In states  like Alaska, Missouri and Colorado where there is no "duty of care" and it has been determined there is no doctor-patient relationship for independent examining doctors, the Code of Ethics then helps litigators, to some degree, in creating justice for the injured. Furthermore, it can help give direction to creating legislation to overturn the court rulings that currently protect the licenses of IME, IEP and peer review abusers. We must never lose sight of the fact that independent examining doctors have a tremendous personal financial gain to render a desired diagnosis and conclusion and there have to be checks and balances in place to ensure an honest opinion is rendered.

I strongly suggest that every state and national organization adopt a version of the following language as a code of ethics standard for all of their members:

Chiropractic Code of Ethics:

A. Conduct of Independent Examiners

(1) Evaluate objectively the patient’s health or disability. In order to maintain objectivity, independent chiropractic/medical evaluations should not be influenced by the preferences of the patient-employee, employer, or insurance company when making a diagnosis during any type of independent chiropractic/medical examination, including, but not limited to, sequellae from auto accidents, on-the-job injuries and pre-employment physicals.

(2) Maintain patient confidentiality as outlined by the State of [add your state].

(3) Disclose fully potential or perceived conflicts of interest. The doctor of chiropractic should inform the patient about the relationship between himself or herself and the third party as well as the fact that he or she is acting as an agent of that entity. This should be done at the outset of the examination, before health information is gathered from the examinee. Before the doctor of chiropractic proceeds with the exam, he or she should ensure to the extent possible that the patient understands the doctor of chiropractic’s unaltered ethical obligations, as well as the differences that exist between the treating doctor's role and that of the independent examiner.

(4)The examining doctor shall:

  1. Include all pertinent and related diagnostic findings and test results in his/her report(s).
  2. Consider all pertinent and related diagnostic findings and test results when rendering a diagnostic conclusion.
  3. Include complete pertinent and related research, when applicable, in rendering a conclusion.
  4. Perform examinations to the same standard as he/she does for all other patients with similar diagnoses.
  5. Note in his/her report(s) the absence of any diagnostic or test findings when he/she is aware he/she does not have possession of said reports or results.

Adopting these standards is taking the first step towards leveling the playing field to help ensure that our patients get the care they need and that doctors receive the payments they are entitled to for rendering necessary services.

 

References:

  1. American Medical Association. (n.d.). History of AMA ethics.  AMA Code of Medical Ethics, Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/history-ama-ethics.page?
  2. American Medical Association. (1999). Opinion 10.03 - Patient-physician relationship in the context of work-related and independent medical examinations. AMA Code of Medical Ethics, Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1003.page
 
Adjustment vs. Manipulation: Does the language really matter to the future of chiropractic?
Perspective
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Saturday, 28 January 2012 07:26

M
y mantra for many years was "Chiropractors adjust and osteopaths and physical therapists manipulate." I had a dogmatic philosophical belief that anything else was blasphemy and that sentiment was and is shared erroneously by many. Over the years, I have felt that nomenclature was more of a philosophical issue that served to divide the profession and I was of the opinion "Who cares about words? Let's call it a left elbow to the spine and move on together." I was wrong!

adjustmentvsmanipulationThe nomenclature utilized in a healing, regulated profession cannot be based upon belief. It must be based upon standards taught in our teaching institutions and verified both by research and in the field daily as practiced by clinicians and evidenced by their results. Having spent the last few years researching chiropractic and related topics and having spoken to many in our teaching institutions, it has become "crystal clear" as to why we have gravitated towards the label "manipulation" as a descriptor of what we do rather than "adjusting." Until you "read between the lines" and see how we are being seen as a result of the lines being blurred, you will not understand the dilemma the dichotomy of language has created.

If we look at a Barnes, Bloom, and Nahin (2008), we see that 2002 findings revealed that chiropractic had a 7.5% utilization rate among Americans 18 years of age and over. In 2007, the results for chiropractic read "xxx," meaning the category was not applicable because there were no chiropractic statistics. Our utilization was placed under the banner of "manipulation" and lumped together with osteopaths. The formal heading is "chiropractic or osteopathy manipulation."  Some may see this as progress, as we are now being considered equals in the eyes of the government with doctors of osteopathy. However, based upon the facts we are no longer being quantified for utilization as a separate and distinct profession.

Cerritelli et al. (2011) published research findings revealing that "...among patients affected by cardiovascular disorders, osteopathic treatment is significantly associated to an improvement in intima-media and systolic blood pressure after one year" (p. 69). They went on to detail what osteopathic treatment or osteopathic manipulative technique (OMT) is. "OMT is characterized by different techniques, i.e. myofascial release, craniofacial, High Velocity Low Amplitude (HVLA) manipulation, Balanced Ligamentous Tension (BLT), Muscle Energy Technique, biodynamic, strain-counterstrain, etc. This wide range of techniques permits the operator to choose the more appropriate to apply on a patient in a given moment. During scientific studies, OMT can be used as an approach, as was done in this study, or as an isolated technique" (Cerritelli et al., 2011, p. 69). The published definition of an OMT is not close to a chiropractic manipulation, it is identical.

Chevan and Riddle reported in 2011 that "physical therapists and chiropractors are similar because both provide manipulative and corrective care. The conceptual and philosophical basis of care for physical therapists and chiropractors does differ, and 2 older studies conducted in the UK and Sweden indicate that chiropractors use more manipulation and physical therapists provide both manipulation and mobilization, as well as exercise, modality-based treatment, and education" (p. 467). The literature clearly reflects that both physical therapists and chiropractors do the same thing, manipulate, but physical therapists offer more by adding "mobilization, exercise, modality-based treatment, and education."

While everyone within the chiropractic world knows this to NOT be true, the scientific community has reported this and our regulators, payors and referrers (primary care physicians who treat 95% of the population and control 95% of the referrals in America) have accepted this. We, as a profession, have validated their arguments and research findings by exclusively using the tag "manipulation" for chiropractic in too many venues and publications. Conversely, Welsh and Boone reported in 2008 on the sympathetic and parasympathetic responses to specific adjustments to chiropractic vertebral subluxations. The metric that was being analyzed was blood pressure and pulse rate. They reported, "Diastolic pressure (indicating a sympathetic response) dropped significantly postadjustment among those receiving cervical adjustments, accompanied by a moderate clinical effect (0.50). Pulse pressure increased significantly among those receiving cervical adjustments, accompanied by a large effect size (0.82). Although the decrease in pulse pressure for those receiving thoracic adjustments was not statistically significant, the decrease was accompanied by a moderate effect size (0.66)...It is preliminarily suggested that cervical adjustments may result in parasympathetic responses, whereas thoracic adjustments result in sympathetic responses.

atlasadjustmentFurthermore, it appears that these responses may demonstrate the relationship of autonomic responses in association to the particular segment(s) adjusted" (Welsh & Boone, 2008, p. 86). The clear conclusion is that a specific chiropractic adjustment is the reason for the positive outcome.

Rochester reported in 2009 that "The data supports the alignment model’s predictive validity by suggesting that a threshold of altered atlas alignment toward the orthogonal configuration following the first adjustment was associated with a better outcome inc 2-weeks for disability from neck pain" (p. 173). Again, the conclusion is clear that a specific chiropractic adjustment is the reason for the positive outcome and cannot be used to validate physical therapy or osteopathy under the generic banner of manipulation. In addition, physical therapists and osteopaths do not perform adjustments, therefore precluding them from laying any claim to the successes of chiropractic.

Cifuentes, Willets and Wasiak (2011) compared the treatment of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15-day absence and return to disability. Anyone with less than a 15-day absence was excluded from the study. 

The study concluded that chiropractic care during the health maintenance care period resulted in:

  • 16% decrease in disability duration of first episode compared to physical therapy
  • 6.6% decrease in opioid (narcotic) use during maintenance care compared to physical therapy care
  • 32% decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

The study concluded that chiropractic care during the disability episode resulted in:

  • 24% decrease in disability duration of first episode compared to physical therapy
  • 5.9% decrease in opioid (narcotic) use during maintenance care compared to physical therapy care
  • 19% decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

In essence, Cifuentes, Willets and Wasiak (2011) verified through statistical outcomes that all manipulation is not alike because what chiropractic offers is a specific type of manipulation/adjustment or simply a chiropractic spinal adjustment that is not taught, performed or offered by either physical therapists or osteopathic doctors. These outcomes certify chiropractic to be a superior form of treatment for this specific type of condition and impairment, yet we leave open the ability for disparate professions to falsely lay claim to chiropractic successes by following the chiropractic treatment plan of manipulation. This has occurred because the chiropractic profession has not remained unique in the nomenclature in describing what we do.

The next challenge is billing. CPT codes 98940, 98941, 98942 and 98943 are labeled "chiropractic manipulative therapy," forcing all doctors of chiropractic to utilize the manipulation label to get paid. The primary difference in this "carve out" code is that the word "CHIROPRACTIC" comes first. If all chiropractic research and literature and arguments used "chiropractic manipulation" and not just "manipulation," it would be better. However, this is not the best solution that would ensure our separation and distinct position among other healthcare professionals because the words and lines still blur.

doctors5A literature search for "chiropractic adjustment" rendered 596 results without all of them being peer reviewed journals. However, all were specific to chiropractic and each is a building block to grow on. A literature search for "spinal manipulation" rendered 8,145 results, but only 3,518 had "chiropractic manipulation" in the text. There is so much overlap in what we do versus what others do that others often lay claim to chiropractic manipulation results to certify non-chiropractic care. We are empowering other professions that manipulate and the regulators, payors and referrers who utilize the research must get a clearer message for chiropractic to flourish. The results are: we get reimbursed at the lowest level or none at all (i.e. Medicaid), there is ongoing legislation further limiting chiropractic care, we are prevented from participating in too many local, state and Federal programs and we are bypassed in the referral process by well meaning but misinformed referral sources such as primary care physicians who rely on literature for verification of the best referral pathway.

Organized medicine controls the purse strings of everything related to healthcare in government, locally and nationally, and we do not have enough money to fight them because we have not centralized as a profession like physical therapists have with the American Physical Therapy Association. Who does organized medicine control? Physical therapy, osteopathy or chiropractic? The answer is obvious and armed with literature that erroneously states that DCs, PTs and DOs all do the same thing, individual outcomes will be overlooked for politics, power and money as they have been for the last 116 years by those that significantly control our destiny. It cannot be business as usual or we will keep being homogenized, as the US Census Bureau already has done, to the point where no one will recognize the power of a chiropractic adjustment. For proof, see the history of osteopathy, and if we take that pathway, realize that unfortunately today virtually no one says "I need to see my osteopath for a manipulation."

 

References:

  1. Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Reports, 12, 1-23.
  2. Cerritelli, F., Carinci F., Pizzolorusso, G., Turi, P., Renzetti C., Pizzolorusso, F.,...Barlafante, G. (2011). Osteopathic manipulation as a complementary treatment for the prevention of cardiac complications: 12-months follow-up of intima media and blood pressure on a cohort affected by hypertension. Journal of Bodywork & Movement Therapies, 15(1), 68-74.
  3. Chevan J., & Riddle, D. L. (2011). Factors associated with care seeking from physicians, physical therapists, or chiropractors by persons with spinal pain: A population-based study. Journal of Orthopaedic & Sports Physical Therapy, 41(7), 467-476.
  4. Welch, A., & Boone, R. (2008). Sympathetic and parasympathetic responses to specific diversified adjustments to chiropractic vertebral subluxations of the cervical and thoracic spine. Journal of Chiropractic Medicine, 7(3), 86–93.
  5. Rochester, R. P. (2009). Neck pain and disability outcomes following chiropractic upper cervical care: A retrospective case series. Journal of the Canadian Chiropractic Association, 53(3), 173-185.
  6. Cifuentes, M., Willetts, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
 
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