Dear Editor:
I recently read "The 3-2-1 Syndrome" by Walter Markey, D.C., (Nov. 1, '89 "DC" I was appalled by some of his statements! He speaks about a patient of which little or no history is derived, who "needed only one treatment to normalize her sacro-iliac and lumbars and balance the related muscles." Did she have this condition for years? If so, then has hypertrophy/hypotrophy of the muscles occurred? How do you "balance" hypertrophied/hypotrophied muscles in one treatment? (I know of one case where this happened; however, supreme, instantaneous healing is not a chiropractic technique.)
If this was an acute condition, was there muscle/tendoligamentous damage? Wouldn't this indicate an instability that, although treatment might give some amount of normalization in the first several treatments, might need further care until healing in those tissues takes place?
It is apparent that Dr. Markey treats based on pain, not on correction of the problem. I understand chiropractic -- our job is to correct and prevent, not to relieve the pain only.
My clinical experience, along with experience from my forefathers in chiropractic and five family members who preceded me in chiropractic, has led me to corrective programs that are designed to correct problems, not only pain. I may see a patient initially three times, two times, or one time a week for a period of time. His "3-2-1 Syndrome" is not necessarily true throughout the profession, nor does his one to several treatments work for the majority of conditions commonly seen. I have had correction achieved in one to a few visits; however, this is only seen in infants, children, and well-trained athletes' bodies.
Due to American lifestyle and eating habits, we cannot hope to actually correct common problems in so few visits. This may be true in select parts of Russia, Africa, amongst the Amish people, etc. -- all due to the high quality, low stress environment and better dietary habits found in these locales. Dr. Markey's belief only gives power to the insurance companies to ultimately disrupt the doctor/patient relationship.
Stephen W Forbess, B.S., D.C.
Cooper City, Florida
Dear Editor:
Dr. Markey has an excellent point that patient treatment programs must not be based on standards set by practice builders or anyone else if those standards are based only on increasing income without delivering value to the patient. I certainly agree that "chiropractic has to raise its ethical standards if it is ever to receive the recognition it is striving to achieve." And, I agree, "We must strongly establish ourselves as a healing art and not as lineal descendants of the medicine man selling a cure-all."
My concern is this: Dr. Markey cites a case example of the patient who "----needed only one treatment to normalize her sacro-iliac and lumbars (sic)----" And, he cites another example to say, "----the patient required only a few treatments both to eliminate the pain and to normalize him anatomically."
So, I ask, is it ethical to use only symptoms as criteria to determine that a patient needs no more treatment? Is it proper patient service to deliver "----only a few treatments to normalize him anatomically?" If so, how do "a few treatments" do the job of "normalizing him anatomically?" And, how do you know?
Current research shows that histological changes occur immediately on injury to a joint. These changes create fixations in the joint and are the beginnings of spinal degeneration. And, the fixation introduces all aspects of the vertebral subluxation complex: altered motion patterns, muscle dysfunction, tissue inflammation and degeneration, neural dysfunction and degeneration, and organic dysfunction and pathology. Science says so.
Dr. Markey might read Immobilization Degeneration and the Fixation Hypothesis of Chiropractic Subluxation, by Charles A. Lantz, Ph.D., D.C., Chiropractic Research Journal, Volume 1, Number 1, Spring 1988. Or, Disc Regeneration: Reversibility Is Possible In Spinal Osteoarthritis, O.J. Ressel, ICA International Review of Chiropractic, March/April 1989.
He may notice the vast research that tells us that within one day of joint injury there are measurable changes in cartilage cell activity. On the second day biochemical changes of the cartilage are preset. On the third day there are changes in the structure of cartilage. On the fourth day there are changes in the physiology of ligaments. By the tenth day the articular capsule tissue has swollen and osteophyte formation can be detected. By the 15th day gross structural changes are seen in layered cartilage, and synovial fluid is being replaced by fibro-fatty connective tissue which forms adhesions. Within 45 days there is ulcer formation on the surface of the cartilage, and by 60 days there are cracks and fissures extending to and involving the underlying bone.
And, all of the above can occur without the victim of vertebral subluxation complex experiencing symptoms. Symptoms generally occur from recent traumatic injury or as a result of degeneration which continues as a sequela of the above. This, when it is later seen on radiographs, is then named osteoarthritis, degenerative joint disease, etc. Should we condemn our patients to that by using symptoms as our treatment plan criteria?
I agree with condemning treatment plans advocated by anyone based purely on profit rather than patient well-being. But, I equally condemn treatment plans which grossly short-change patients by substituting symptom relief, "aspirin" adjustments, for real, long-term corrective care programs to genuinely "normalize him anatomically."
Rationally based and scientifically justified treatment plans cannot be based on pain relief, ambulation, and the ability to work. That criteria of care is truly the non-scientific medicine man cure-all claptrap. That criteria will not allow us to "establish ourselves as a healing art." Indeed, it may even become malpractice. It should, based on the real facts.
Those who seek to confine and eliminate chiropractic love that criteria because it saves them money and guarantees them patients. But, we have the responsibility to base our standards, instead, on the best that science has to offer.
Doing that will promote the well-being of our patients. Doing that will establish us as ethical. Doing that will give us rational and justifiable standards of care. Doing that will assure our survival. Doing that will build us that "firm foundation." Because a scientific and ethical treatment plan requires long-term care at a high frequency, it will also make us rich.
Storm Gill, D.C.
Portland, Oregon
Dear Editor:
I would like to comment on Dr. Walter Markey's article in the November 1, 1989 issue of Dynamic Chiropractic. I feel that he is absolutely correct in his sentiments regarding the 3-2-1 Syndrome. The matter of over-treatment by our profession is one that has troubled me for a long time.
Dr. Markey mentions his concern with the practice consultants who encourage their DC clients to treat their patients for inordinate periods of time. I have heard consultants tell chiropractors that the average condition will take from 3 to 5 months to treat, or 30 to 40 office visits. I do not mind a researcher telling me how long to treat a certain condition, but when a practice consultant tells me this, it sounds very dubious.
I certainly realize that some injuries and conditions, such as disc syndromes, do require quite extensive care. However, the vast majority of injuries will probably heal much quicker.
I have also found, as Dr. Markey has, that some conditions can be corrected (objectively and subjectively) quite quickly, some in one or two treatments. Of course, the practice consultants would call us poor business people.
I strongly feel that our profession is undermining its credibility by these practices. It concerns me when a DC refuses to release a PI patient after a period of time, even though he is asymptomatic, both objectively and subjectively. This is done because PI cases are supposed to be a certain amount or because the attorney won't refer anyone back to him if the medical bills are not large enough. Our biggest problem is not proving that what we do is clinically sound or of value. The dysfunctional joint and all the clinical objective findings that are consistent with the subluxation complex are now being documented. And, of course today it is hardly even debatable whether or not corrective spinal manipulation is of value.
I feel the practice of over-treating will be the one obstacle that, if not addressed, could preclude us from being fully accepted into the health care mainstream.
This habit is often justified by well meaning DCs who state that all people need chiropractic care for life and thus their patients are literally never released. It is my contention that people do need periodic chiropractic care. When a person recovers from an injury, I feel they should be released. Tell the patients that they should have periodic care, but tell them that most insurance companies do not cover maintenance care and that they will have to be personally responsible for their bill. I feel this is far better than simply changing the diagnosis after a few months so the chiropractor can continue treating the patient.
I believe this issue is of critical importance and must be addressed by our profession. We must establish a standard of care for our profession or else the insurance companies will do it for us, as they have with medicare.
James D. Gustin, D.C.
Glendora, California
Dear Editor:
Dr. Markey's article "The 3-2-1 Syndrome," in the November 1, 1989 edition of Dynamic Chiropractic, was ludicrous to the point that it could not be ignored. Naturally, one would automatically concede that there are some of us that abuse the system by overutilization of care or providing non-medically necessary services. It is likewise a "given" that some "practice builders" advocate methods which may lead to the utilization of frequency guidelines and/or treatment procedures solely for the sake of increased income regardless of the patient's needs. However, this is certainly not the case when one considers the vast majority of our practitioners and the management companies that serve them. Having served over five years as the Indiana Peer Review chairman, I found that the true abusers were in the minority. Most cases of overutilization and/or unnecessary procedures were due to incompetence to some degree, not fraud.
I agree with Dr. Markey that a treatment plan should not be devised without a full revelation of the diagnostic evaluations. Also, he is right when he says that "----but money should not be the prime objective of chiropractic." My biggest argument with the content of his article is our apparent great difference in the philosophy of chiropractic care. His words have led me to assume his primary purpose is to diagnose only to the extent of a patient's subjective complaints and consider a case to be corrected when the symptomatology is absent. To me this is not what chiropractic is all about, and people who adhere to parameters such as these are apparently missing "the big idea."
It seems to me that our utmost goal is the correction of subluxations to allow for normal nerve transmissions so that the human organism can return to homeostasis and express health. It is my contention that many people can and do possess subluxations that are not symptomatically expressive; yet, these people need care. Must they wait until they feel pain? The example of the woman doubled over in pain that was mentioned in the article was cured in two visits. What caused her pain? If it just occurred for no reason, then maybe her subluxation was chronic, and if that be the case, with only two treatments, it would be hard for one to believe that anything other than symptomatic relief had occurred. If the subluxation was traumatic, it would be even more difficult to completely clear it in two visits.
To tell you the truth, I would rather see a modicum of overutilization than underutilization. I would rather have a body of homeostatic patients out there than those who have had a quick- fix for their pain. We are not pain doctors, we are physicians entrusted with responsibility of providing health care.
S.J. Kelman, D.C.
Fort Wayne, Indiana
Dear Editor:
At first glance, "The 3-2-1 Syndrome" appears like a well-meant and well-written article. However, it is ill-conceived and the generalities made in this article are incorrect. The author obviously does not understand the pathological processes involved with spinal degeneration as stated by Kirkaldy-Willis and many other well-published authors.
My practice is based on returning the spine to normal functioning. I utilize a motion palpation analysis procedure which enables me to know when the patient is free of spinal dysfunction. The heart of a dynamic practice (motion palpation based) is an understanding of biomechanics and the degenerative changes that take place in a spine endangered with spinal fixation (hypomobilities/restriction of joint play).
Treating a patient 2-3 times for spinal conditions is a disservice to that patient. As long as spinal dysfunction remains, degenerative changes will continue. This dysfunction can be resultant from actual problems in the spine (hyper/hypomobilities), various extremity fixations that result in spinal dysfunction, muscle weakness, imbalance, etc.
Treating a patient only through the painful stage is not chiropractic. Chiropractic has often stated it affects the cause, not the symptoms. Practices based on symptom relief failed to see what chiropractic has to offer. These patients, given only symptomatic care, will be allowed to degenerate and not live life to their fullest potential.
In our office, we have three categories of patients: acute, acute manifestation of chronic, and chronic. These patients deserve different treatment schedules based on the pathological nature of each spine. I defy any doctor to relieve a patient of chronic, unremittent back pain of 70 years duration, in 2-3 visits. These patients have chronic, pathological changes that take time to respond to gentle, effective manipulative procedures. Dr. Faye reports that often chronic patients, approximately 45-60 years of age, might need as much as 1-2 visits per week for up to 6-18 months. These are truly chronic patients.
For the young, healthy, athletic patient falling under the acute category, 3-10 visits will usually restore the spine to normal function.
The most difficult situation, I feel, is the category of acute manifestation of a chronic. These patients often have spinal conditions that tend to recur every year, with associated radiographic changes (osteoarthritic degeneration). As with most relatively healthy patients, 3-5 visits will usually relieve the symptoms. The problem lies in the fact that the symptom relief is only temporary, and if the spine is not returned to normal function, the problems will recur year after year. The true cause of the patients' symptoms will not be elucidated and, therefore, degeneration will continue.
I feel it is of the utmost importance to have ethical practices based on an understanding of biomechanical principles and an understanding of spinal pathomechanics. I agree with the author of "3-2-1" that there are many, many doctors who run practices based on dollars and not patient health. On the subject of practice management, many doctors need a greater understanding of management and marketing principles, myself included. There are several good and ethical management companies and there are those who are not! Chiropractic practices that fail tend to reinforce public opinion about our skills as primary care physicians. Good management skills must occasionally be purchased from ethical management firms.
One aspect of chiropractic practice that has not been mentioned yet is confidence. One of the most difficult decisions in practice is where to apply our most important tool -- the chiropractic adjustment. I feel that the Motion Palpation Institute provides the best courses available in the field of spinal analysis procedures. These seminars also provide some understanding of the pathomechanics of spinal degeneration. These procedures, complete with practice in the adjusting skills, will provide the confidence and competence to run a profitable but ethical chiropractic practice.
Terry M. Elder, D.C.
Winfield, Kansas
Dear Editor:
I would like to take exception to the 3-2-1 article written by Walter J. Markey, D.C., in the November 1st issue of your tabloid.
Unfortunately, Dr. Markey lumps all practice management consultants into one category, criticizing them as if they all taught the same information.
Nothing could be further from the truth. I have been a practice consultant for over 15 years, and I have never heard of the 3-2-1 system. For that matter I have never heard anyone else recommend the same.
Dr. Markey also states that "No where do we find any mention of their clients contributing anything to the field of healing." What nonsense! I guarantee that one of the primary leaders of honest, ethical practice management is Peter G. Fernandez, D.C., president of PMA. I know he has donated more to chiropractic colleges in the form of grants, to college students in the form of scholarships, and to our state associations, than any other living DC that I am aware of.
You infer that because a DC is interested in building his practice, he is dishonest. Your inference offends me and all other moral DCs who read your article.
W. N. Cannister, D.C.
Sewickley, Pennsylvania
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