American Chiropractic Association Rehabilitation Board (ACRB) is currently completing a Delphi process on chiropractic rehabilitation. The Delphi process is designed to arrive at a consensus of experts after a review of literature and existing standards of practice. It is ideally suited for creating testing standards. The RAND Corporation utilized the Delphi approach when looking at the literature on spinal manipulation for back problems.
In 1994, John J. Triano urged that a Delphi process be employed to achieve a consensus on the educational requirements for the chiropractic rehabilitation specialty. On May 13, 1995 the first Delphi meeting on chiropractic rehabilitation took place in Dallas, Texas under Dr. Triano's supervision. This was a highly successful meeting with attendance of 11 chiropractors, from NWCC, CMCC, WSCC, LACC, Palmer, NYCC, Cleveland (KC), and Parker. Dr. Alan Adams of LACC, a participant in the RAND studies, outlined for the group the basics of a consensus process.
At this first Delphi meeting agreement on the following steps was reached:
- arrive at a core topic list through Delphi consensus process after study of course syllabi & outlines of the various colleges teaching rehabilitation, CARF guidelines, and scientific literature;
- contact subject matter experts (SMEs) for content information;
- create operational definitions of Delphi items establish knowledge, skills, and attitudes necessary to be a rehabilitation specialist in chiropractic;
- publish a candidates guide of the minimum competencies required for the diplomate status.
The second meeting took place on July 3, 1995 at the Chiropractic Centennial in Washington, D.C. This meeting was attended by representatives of NWCC, CMCC, WSCC, LACC, Palmer, and Cleveland (KC), and Parker. A matrix of core topics for a 300-hour rehabilitation diplomate course was agreed upon by consensus process. Agreement was also reached to invite SMEs to flush out definitions, references and a key outline for each Delphi topic.
The following are the core topics established for the first 100 hours. They were divided into separate sections: general, basic science, assessment, rehabilitation treatment, and management.
I. General
- Functional pathology of the motor system (the interrelation between dysfunction of the muscular, articular, and motor control systems)
- Functional restoration
- Biopsychosocial approach
- Case management (introduction to assessment/treatment protocols which integrate muscle/joint dysfunction)
- Facility development, practice management, legal issues
- Cost containment
II. Basic Science - Clinical biomechanics (stress/strain curve)
- Principles of human locomotion (arthrokinematic events, kinesiology)
- Exercise physiology
- Motor learning
- Behavior modification
III. Assessment
- Functional testing (physical performance isolated of muscles/joints)
- Objective measurement of soft tissue injury (outcomes management)
- Kinesiopathology
- Evaluation of muscle imbalance (identification of tight/weak muscles)
- Evaluation of cardiovascular system
- Activities of daily living and health habits
- Ergonomics
- Psychosocial factors
- Diagnosis: history, vitals, imaging
- Strength
- Endurance
- Flexibility
IV. Rehabilitation Treatment
- Stabilization exercise
- PNF (psychomotor skills development)
- Strength, endurance
- Propriosensory training
- McKenzie protocols
- Patient education
- Time limited passive modalities
- Urgent care (emergency procedures, emergency or urgent referral needs)
V. Management Topics - Cervical (soft tissue rehabilitation approach)
- Thoracic (soft tissue rehabilitation approach)
- Lumbar (soft tissue rehabilitation approach)
- Multidisciplinary (office composition, outside referral)
Following the July 3, 1995 meeting SMEs were invited to contribute to our Delphi process. SME material began flowing in throughout the rest of 1995 and early 1996. The Delphi topics arrived at on July 3, 1995 were forwarded to the newly established ACRB on December 13, 1995 to facilitate a speedy implementation of the new "Delphi" topics into the ACA rehabilitation council's testing process.
The third Delphi meeting will have just been completed (August 3 in Dallas) as this article is readied for publication. Representatives from each of the schools teaching at least 100-hour approved rehabilitation courses were invited: Cleveland (KC), LACC, NYCC, CMCC, NWCC, Palmer, Parker, TCC, and WSCC. Most importantly, this meeting will assign operational definitions, references and a key outline for each Delphi topic item. This will bring us a giant step closer to our goal of creating a document which outlines the core minimum competencies required for a chiropractic rehabilitation specialist. In particular, this will be an invaluable study guide for those preparing for certification/diplomate examinations.
All participants in ACRB approved chiropractic rehabilitation certification/diplomate programs will be able to benefit from the results of this Delphi process. Testing will be based on defined topics making teaching and study clearer. By establishing the core competencies in terms of knowledge, skills and attitudes a blueprint of the chiropractic rehabilitation specialist will be available. This should help our profession establish more thoroughly its expertise in all aspects of conservative care of musculoskeletal problems. Establishing expertise in active care is essential to our fight against being isolated into a corner as manipulative therapy specialists only. Active care and patient education are just as crucial parts of chiropractic practice as are any passive techniques.
In July, 1995 John Taylor and John Scaringe of the ACA's Chiropractic Specialty Council committee congratulated the rehabilitation council for choosing to use the Delphi process. We hope other specialty councils will also establish their core competencies through a similarly valid process. Ultimately, this is for the protection of our scope of practice. Active care has not always been associated with chiropractic. If you have read any of my columns you know that there is a great deal of literature support for active care. In fact, for treatment beyond four weeks active care is the primary care recognized as appropriate by the Mercy, AHCPR, CSAG, and Quebec guidelines. Using active care in our practices, and documenting it in our SOAP notes and reports can protect our control of a case in the event of review or deposition.
The Delphi is the best form of defense for the chiropractic practice of the future. Quality chiropractic will be better able to stand up under scrutiny in courtroom testimony, fee for service arrangements, and capitated contract negotiations. Chiropractic rehabilitation inclusive of active care, outcomes management, diagnostic triage, and early risk factor identification is at the cutting edge of quality assurance.
Craig Liebenson, DC
Los Angeles, California
