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Why Maintenance Care?

Dear Editor:

The graph on the front page of the June 12 issue of Dynamic Chiropractic asked a salient question, although for a different reason than I am asking it: why maintenance care? This question has never been satisfactorily answered. The study by Rupert¹ reported in the graph examined chiropractors' views on maintenance care. It is interesting that 78.7% of chiropractic patients were offered maintenance care, but only 34.4% received it. This suggests that the majority of chiropractors feel that maintenance care is valuable, but the majority of patients do not.

When are we going to wake up and stop trying to turn healthy people into dependant patients? The insistence on trying to push maintenance care on patients without any evidence that it benefits them is a major reason for the continuing negative view that much of society has toward chiropractors: the view that "they try to make you keeping coming back forever." This is also the primary reason more MDs do not refer patients to chiropractors.

I think that if more chiropractors started practicing in a patient-centered way - focusing on what the patient needs rather than trying to satisfy an unfounded chiropractic tradition, or worse, putting economics first - we will find our offices so busy that we will not have time for "maintenance" adjustments.

Again, I ask the question: why maintenance care?

Reference

1. Rupert RL. A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors. Maintenance care: part 1. J Manipulative Physiol Ther 00;23(1):1-9.

Donald R. Murphy,DC,DACAN
Providence, Rhode Island
rispine@aol.com

Dear Editor:

When is enough enough? The continued blatant discrimination from third-party payers has now extended to the "Blues" (Blue Cross/Blue Shield) and Medicare. The Blues are using the CPT codes (originally intended as guidelines, not law) through bundling to maximally decrease payments to providers. Hiding behind their interpretation and utilizing "designed incompetence" to the max, their intent is to put the squeeze on chiropractors.

First, our Maryland Blues bundled manipulation and myotherapy into one small fee. Now, they've reasoned that a certain amount of examination occurs with each treatment, so they are bundling in (and not paying) for any re-exams. I even have a couple of initial examinations that they are refusing to pay based on this rationale.

When you try to call them, their computerized response is that "due to the extreme high volume of calls (because they're not paying what they should), please call back," which further delays any payments. It's no secret why the Blues have developed this tactic, and it is not because of chiropractic overutilization (many of my claims are for under 10 treatments). It's because they want to show Wall Street that they can be very successful as a profiteering entity.

Let's not forget the usual blatant discrimination against chiropractors. What shall we do? If you agree with any of my assertsions or even care to disagree, please write, fax or e-mail me.

Paul Conway,DC
Ocean City, Maryland
Fax: (410) 524-1544
drpauljconway@beachin.net

(Editor's note: the following three letters were written in response to Dr. James Winterstein's article "Chiropractors and Chiropractic Physicians" which appeared in the May 29th issue of Dynamic Chiropractic.)

"I do not want chiropractic prostituted by chiropractic physicians"

Dear Editor:

Dr. Winterstein's article "Chiropractors and Chiropractic Physicians' is the most vile thing I have read in a long time. He should not only be ashamed but should ask forgiveness from the universal intelligence.

Let me make myself perfectly clear. I am a chiropractor. I do not want chiropractic prostituted by chiropractic physicians. Chiropractors and physicians are not compatible in words and definition. They do not go together, now or ever.

This letter is written to point out Dr. Winterstein's total denial and misjudgement of the chiropractic principles and practice. His vaingloriousness and egoisticalness is unsurpressed. A man in his position, an abecedarian and academician, should not with such a rabid attack on B.J. Palmer exhibit such egocentricity.

How dare he try to defame B.J. Palmer in any way! Only in a nightmare could he compare B.J. Palmer to John Fitz Alan Howard. How dare he!

I have remained a lady throughout this letter, but in person, I would have some well-chosen Texas words to describe him.

Mary Ann Pruit,DC,FICA
Fort Worth, Texas

Dear Editor:

A recent article in Dynamic Chiropractic by Dr. James Winterstein in the May 29th issue, "Chiropractors and Chiropractic Physicians," warrants a response. I can only surmise that his outlook on chiropractic history is somewhat biased.

Around 1908, the formulation of what chiropractic was and was not had been agreed upon. This was clearly evident in the litigation and acquittal of Shegataro Morikubo,DC in 1907: chiropractic had standards differentiating itself from other healing arts.

John Fitz Alan Howard,DC left PSC in 1906 and started the National School of Chiropractic with C.J. Jordan,OD,DC as secretary and Frew A. Tucker,MD,DO as treasurer in Davenport, Iowa. They apparently had little or no success, as Howard moved the school to Chicago in 1908. At that time, he went back into the chiropractic school business with William Charles Schulze,MD.

During this time, the National School of Chiropractic offered complete home study and practical course in the Howard system of chiropractic (physiological adjustment), including diploma, for $100.00. The National School of Chiropractic and National College of Drugless Physicians were operated by the same group.

More MDs were brought on staff to the National School of Chiropractic, and in 1914, Howard sold out to Schulze. Howard tried to open two more chiropractic schools with no success. In 1906, when Howard left PSC, it had around 20 students; by 1910, well over 400 students were in attendance at PSC. In The Chiropractor's Adjuster of 1910, D.D. Palmer shared his views on the Howard system of chiropractic on page 557. At what point in history does Dr. Winterstein feel Howard is qualified to be the one to define what is chiropractic?

The B.J. Palmer Chiropractic Clinic (BJPCC) in Davenport, Iowa did an extraordinary amount of research and produced volumes of medical, scientific and chiropractic case studies that showed that diagnosis was unnecessary.

The medical side of the BJPCC, with the staff of medical doctors using laboratories and diagnostic equipment, made the diagnosis of the patient's condition. On the chiropractic side, spinographs, neurocalometer (NCM) and neurocalograph readings of patients were analyzed to determine the presence or absence of a vertebral subluxation. The BJPCC also used the electroencephaloneuromentimograph before and after the adjustment on all patients to determine if there was an increase or decrease of energy flow above or below the subluxation.

The interesting aspect was that patients showed clinical improvement for a vast assortment of conditions that the medical side had diagnosed. They noted increased function in an array of medical tests. The patients were being analyzed and adjusted using only the HIO protocol. The fascinating part is that the chiropractic side did not have to perform prostate, gynecological, breast, eyes, or ear examinations, nor listen to the heart and lungs, to find the subluxation!

A detailed study of chiropractic history reveals that many of the early individuals that received DC degrees were from other professions and used chiropractic as an adjunct to their previous training. They started schools incorporating learning from the other professions, "mixing" the healing arts.

Dr. D.D. Palmer named and defined this great profession. As a profession, should we interpret chiropractic to mean whatever we want? Let's add acupuncture this year, and massage therapy next year, and magnets are big ... why not them? Or do we want to define ourselves by our specialty, the bedrock which our pioneers went to jail for, a separate and distinct healing art which detects and corrects vertebral subluxations!

The general public is confused about "choiropraktik," so why should we amplify this by making two different professions with the same name (Dr. Winterstein's chiropractors and chiropractic physicians)? Maybe Dr. Winterstein needs to formulate another name to suit his version of alternative health incorporating all that is outside of chiropractic and let chiropractic be chiropractic. Perhaps naturopath or allopathic drugless healer would be appropriate.

Norris A. Erickson,DC
Aurora, Illinois

Dear Editor:

I just finished reading Dr. Winterstein's letter regarding "chiropractors" and "chiropractic physicians." I am in complete agreement with Dr. Winterstein! I think the "physicians" should have a separate and distinct title. However, they better not attach the word "chiropractic" to it!

What Dr. Winterstein is proposing is specifically not related to chiropractors or chiropractic. I have listened to hundreds of hours of B.J. Palmer lectures on tape and read thousands of pages out of the Green Books. What he is proposing is not chiropractic. This tactic will merely confuse the public. At a time when people are reaching out for chiropractors and the chiropractic principle now more than ever, it is not the time to let them down!

For chiropractors that are afraid to speak the truth, now is the time to stop whining and face the facts. I run a subluxation-based practice (without any staff), and I see more patients in the average day than most chiropractors see in an average week! I practice pure, unadulterated chiropractic, as this is what my patients demand. I am the primary health care provider for virtually all of my patients! I don't look up any body cavities, nor do I try to be a "bastard physician." If my patients have a condition that warrants medical attention, I make the necessary referral. (Isn't that what being a primary care doctor is all about?)

Allen J. Harrison,DC
Newnan, Georgia

Dear Editor:

I have just finished reading the unfortunate saga of Dr. Wieben ("One Chiropractor's Nightmare," March 20, 2000). We all owe Dr. Wieben acknowledgment and gratitude for his personal sacrifice on behalf of the integrity of chiropractic. He is not alone, of course. However, too often our brethren look away from unethical and greedy practices of their colleagues.

Speaking out requires strength of character and the will to withstand slings and arrows. The cost may be financial, as in Dr. Wieben's (and others) case, or it may include the fear from having the health and welfare of one's family and life threatened. I have even seen the profits of the greedy used to hire private investigators in an effort to discredit the reputation and efforts of those unwilling to tolerate the continued denigration of the profession by the self-centered few.

My hat is off to Dr. Wieben and several other colleagues who have had the fortitude, grace and ethics to stand firm.

John J. Triano,DC,PhD
Texas Back Institute
Southlake, Texas

Dear Editor:

As a member of ACA and an enthusiastic reader of Dynamic Chiropractic, I must tell you I was greatly offended at the headline, "Al Gore Supports Chiropractic," in the March 6, 2000 issue.

I do not feel a professional publication such as Dynamic Chiropractic should be used by Jim Mertz or any other supporter of Democratic candidates as a means to further their own personal agenda. If Mr. Mertz wants members of the profession to support his choice for president of the United States, let him buy an ad in your publication, but do not use widely read and trusted publications such as Dynamic Chiropractic in this rather sinister way.

As a final note, if Al Gore is such a great supporter of chiropractic, why is it that the 1993 attempt to nationalize health care that was recommended by Mrs. Clinton and Ira Magaziner contained no inclusion of chiropractic? It seems that on this and any other issue, Mr. Gore will say whatever it takes to secure a vote.

Jack Doblin,DC
Pottsville, Pennsylvania

Dear Editor:

I saw your misleading letter, "Al Gore Supports Chiropractic," and the generic letter "he" wrote to a questionnaire. If you really want to know if someone supports chiropractic, the question is: Who do you and your family see for your regular chiropractic care? The answer to that question will tell the truth about a legislator's opinion of our profession.

Among other things, Al Gore supports social medicine. I worked too hard for my education and building my practice to work for the government. I also don't care to work for insurance companies which our so-called professional organizations have courted all these years. Had our profession spent the money we did on candidates, trying to buy legislation on first-class, educational, prime-time advertising, we would be better blessed.

Dennis Tidwell,DC
Miami, Florida
drdennistidwell@email.msn.com

Dear Editor:

I am writing regarding Dr. Thomas Griner's article, "The Purpose of Myofascia in the Distribution of Circulation and Innervation," in your February 7 issue. Though I can understand his concepts well, Dr. Griner should note that Dr. Homewood's research and hypothesis miss the major discovery printed in 1978 in Adverse Mechanical Tension in the Central Nervous System. The brain stem-cord (pons cord tract) and meninges together act structurally as an elastic stabilizer of the spinal column and distribute tension throughout the cord when it is stretched. The data were summarized in several articles quite some time ago: "Proof of the Subluxation Complex" (DC, September 1991), "More on the Case for Full Spine Radiography" (DC, September 1994), and "The Biomechanical Basis for Spinal Correction in Treatment of Tennis Elbow and Various Wrist Dysfunctions" (DC, Aug. 1993), as well as several letters to the editor.

This data completely answers and changes the viewpoint held by Dr. Homewood and others that a bone out of position is the hallmark of subluxation. The fact is that a subluxation in any one area of the column or body changes the mechanical tension on the cord. It can and does produce distant effects more often than local effects. Further, the effects of one subluxation are not significant unless taken in the context of what else is occurring in the entire spine.

Measuring the position of a bone relative to those immediately surrounding it is not a valid indicator of change of structure. As the neurosurgeon Breig notes, to validly measure the effects of any mechanical changes in the column of neural tissues, films of the entire spine are required in more than one position. Using sectional or single position films to measure the position of any one vertebra - or even a section of the column - was outdated even in its time, though chiropractors seem to have missed the research and continue to refuse to do full spine multiposition biomechanical research, though radiography is so low-dose today.

Dr. Homewood, well-meaning as he was, was mistaken in his search to justify chiropractic. Dr. Palmer, though entirely correct in predicting the effects of neural involvement with structure and what could be done with correction of structure, was mistaken in his analysis of the mechanism of neural involvement and in the subluxation mechanism. That is why chiropractic has had difficulty in researching the effects of structure on neurological function; his data was too limited.

Since the meninges and cord act as elastic stabilizers of the column, attached only at the foramen magnum and coccyx, mechanical stress on any one area of the cord is transmitted throughout the cord. (It is not commonly known that in the live person, the dentate ligaments are like loose bungee cords preventing the spinal cord from moving too far off center. They are relatively long and do not hold the cord against the column except at the foramen magnum and coccyx.) This is why in testing by MRI, more than two-thirds of randomly chosen people have significant disc lesions (herniations, protrusions and degeneration) with no history of symptoms or current symptoms in their back.

As Breig demonstrated in his studies of fresh cadavers and live subjects, the key factors in these types of syndromes involve hypertonicity in the meninges. involve hypertonicity in the meninges. Nerve roots caused by distant mechanical lesions cause tension on the entire cord, making it drag over the herniations or whatever that is responsible for the local symptoms. This is why meningeal releases immediately result in dramatic relief of these symptoms. One doctor, Rod Helgeson of Kentucky, noted he was "spoiled" since learning the meningeal release techniques, saying that "now, low back patients are cake to handle in a day."

Using the above information, you can consistently and predictably get the miraculous results chiropractic always promised but only sporadically obtained. You can use the objective data on the directions of muscle pull to see for yourself that though these pull vertebrae in most directions, with erector muscles pulling the vertebrae into flexion and extension, none are pulling directly posterior. (To pull a vertebra directly posterior, you would need a muscle attached to a vertebra and something stable behind the vertebra.)

With all due respect to Gonstead, he was wrong on the "vertebra can't go anterior" statement. However, Dr. Palmer was right; nerve interferences are caused by structural pathologies in the column and elsewhere in the body, and miraculously disappear when corrected. This phenomenon completely explains how his correction of a thoracic vertebra relieved the nerve pressure (more correctly tension or stretch over some hard structure) from which Harvey Lillard (the first "modern" patient of chiropractic) was suffering after displacing the vertebra enough to create the tension in the pons-cord tract.

This is found in a book by Alf Breig, using dissection to prove his theory. In his third book, Skull Traction and Cervical Cord Injury (a failed experiment), published in 1989 after a further decade of research, the Swedish doctor noted that despite the focus on enzymatic (genetic) or allergenic (autoimmune) factors, diseases such as multiple sclerosis and ALS were mechanical in nature and can be remedied with mechanical treatment. Unlike other approaches, every patient on which the procedure was used improved, and no failures were omitted from publication.

These are not suppositional or derived data. Breig did the physical experiments and demonstrated these facts.

Chiropractic consistently and predictably works exactly as it is supposed to work when these mechanical factors are taken into account within the technology applied to correct subluxations. The original theory was correct: bones go out of place, and the muscles are secondary. Two points were missed, however; only measuring the entire spinal column as a single unit with synchronized actions will account for the difficulties; and the only subluxations to correct are the ones in which the bones go out of position in directions the body cannot correct (because there are no muscles pulling in the direction the bone needs to be pulled).

References

1. Jutkowitz J. The biomechanical basis for spinal correction in treatment of tennis elbow various wrist dysfunctions. Dynamic Chiropractic 1993;11(17).
   
2. Jutkowitz J. Proof of the subluxation complex. Dynamic Chiropractic 1991;09(19);10,40.
3. Jutkowitz J. More on the case for full radiography. Dynamic Chiropractic 1994;12(22).

Dear Editor:

Thanks to Dr. Mark King for an excellent article ("Plantar Fascitis," DC, March 6, 2000). I have a couple of comments on his methods.

Counter-strain, or positional release, is exceptionally helpful for the tender points at the anterior-inferior surface of the calcaneus where the plantar fascia attaches. If the tenderness in this area is not changing from your adjustments, try "folding and holding" the foot, slacking the plantar fascia into a position that immediately releases and relaxes the tender spots. Try different positions until you find one that diminishes the tenderness by 70%. Hold for 90 seconds, then slowly let the foot out of that position. Recheck your previously tender spot: it should now be much less tender. Positional release is one of the few manipulative techniques that one can actually learn from a book. George Roth and Kerry D'Ambrosio's text, Positional Release Therapy, is excellent and well-organized. You can think of this method as either an adjustment or as a soft tissue technique.

Dr. King outlines several home care tips. In our experience, the key is to get the patient to never be without a fairly high-heeled shoe, at least an inch of height of the heel greater than the toe. This is critical at night. If the patient gets out of bed to use the bathroom, or gets up in the morning without getting into a clog or slipper, they can reirritate the whole area. This slacks or relaxes the calf, which reflexively relaxes the plantar fascia. Yes, they need to stretch the plantar fascia within tolerance, but they need to avoid suddenly stretching, thus irritating the fascia when they begin to bear weight after rest.

The second key home tool is tape. The purpose of the tape is to take the strain off the plantar fascia. Any nonelastic tape works. Show the patient a basic lo-dye taping. Tape around the heel horizontally and vertically up each side, directly under the front of the calcaneus. Two pieces of tape (1-2 inch width) in each direction are sufficient. Patients can easily learn to apply this themselves. If the patient keep the foot taped during the daytime for several days in a row, the irritation and inflammation will settle quickly. If you prefer, you can apply this yourself, and have the patient return two times per week to retape it. The tape is usually only needed for the first couple of weeks.

Now, a brief comment on orthotics. In plantar fascitis, the goal of the orthotic is to fill the space under the arch, so the plantar fascia is not constantly being stretched and irritated. For many patients, an over-the-counter orthotic will be adequate, depending on the anatomy of the foot and how sensitive the area has become.

I hope this helps more of your patients. I have seen many patients who suffered for months with this condition, despite seeing their family doctor and their podiatrist. Most recovered quickly once we gave them the proper home care and correct adjustments.

Marc Heller, DC
Ashland, Oregon
mheller@mind.net