Unanswered Questions About Patient Care

The chiropractic profession has faced some daunting challenges through the years, and by and large has come through admirably, though often scarred and bruised. We have many new challenges facing us, and our hope is that this letter will serve to open intraprofessional dialogue and that the chiropractic profession, as a whole, will be motivated to address some fundamental issues relative to patient care. Let's discuss a few of these issues that we as a profession have failed to adequately define.

Clinical Issues: A Lack of Meaningful Criteria

There are five clinical issues that lack definition: 1. a meaningful (testable) definition of subluxation; 2. meaningful (valid and reliable) criteria to determine the presence or absence of a subluxation; 3. meaningful criteria to determine which treatment technique is appropriate for a specific clinical presentation; 4. meaningful criteria to determine appropriate treatment frequency and duration; and 5. meaningful outcome assessment criteria to determine response to treatment. There are two caveats relative to answering these five clinical issues: Are they evidence-based (influenced)? Are they patient-centered?

First, the profession must come up with a testable model for the subluxation, avoiding political rhetoric and quasi-religious verbiage. The current definitions fail the testable model rule.¹ The political definitions use scientific terminology, but are generally illogical and certainly untestable. The quasi-religious definitions relegate the subluxation to the ineffable [incapable of being expressed in words], and one can never define the ineffable. Efforts at a meaningful way of determining the location of these spinal lesions have not shown inter- and intra-examiner reliability.^2-4 Validity is impossible to test without a meaningful definition of subluxation.

There is also a need to determine the efficacy of different chiropractic techniques. The profession must make decisions on what defines a successful technique. There are many issues that must be addressed: the effective velocity of the adjustment, the amount of force required for achieving an efficacious adjustment, the dosage of treatment, and what specific rehabilitative procedures should accompany treatment.^5-6

The profession must then determine which conditions will be amenable to specific types of treatment methods. While some recent data suggests we may be able to determine which patients might benefit from spinal manipulation in general,^7-8 we have no reliable data to date that enables the practicing doctor to determine what specific chiropractic technique will be most efficacious for a specific patient's condition. There is compelling data to date on the value of spinal manipulation combined with a type of exercise program, yet no definitive data on what type of exercise is most appropriate for specific conditions.^9-11

Who Should Determine Chiropractic Standards of Care?

There is a need to develop a consensus within chiropractic in regards to standards of care, particularly with reference to treatment dosage (frequency and duration.) Attempts at developing these standards has met with mixed responses, with some having embraced them and others having ignored them, even creating their own guidelines.

It has been recommended that a valid guideline must objectively address the absence of rigorous scientific validation of the subluxation and its clinical significance, so chiropractors, patients and third parties might have information with which to evaluate the necessity and risk/benefit of chiropractic treatment of the condition. It is also appropriate for guidelines to address issues such as the natural history and prevalence of disorders such as the subluxation, sensitivity and specificity of associated tests, and efficacy of various treatment procedures.^12-13

It is imperative that the profession determine who will provide these guidelines. Should they come from academic groups, such as the CCGPP, government agencies, practice management groups or insurance carriers? And how do we achieve "buy-in" from the majority of practicing chiropractors?

Most of our academic institutions in chiropractic have failed to adequately teach a consistent model of chiropractic standards of care. Those institutions that have attempted to do so generally fail to follow the caveats of evidence-based and patient-centered case management. Our students are graduating owing in the upwards of $100,000 in student loans and lacking consistent guidelines for making appropriate clinical decisions. They all too often flounder in practice, self-conscious and lacking in confidence, searching for some type of guidance toward success.

There are too many gaps in the clinical training of our chiropractic interns, and the practice management groups are all too happy to fill in these gaps with their own version of a chiropractic standards of care. With the lack of a profession-wide standard of care, it is no wonder we have so many practice management organizations within the chiropractic profession, and they all seem to be thriving. If our colleges start teaching a consistent practice model that includes the five fundamental clinical parameters of care noted above, more new graduates will succeed and the role of the practice management group will change. Let the colleges teach students how to make sound decisions regarding patient care, and let the practice management groups teach office procedure and policy, not clinical decision-making.

Regardless of who determines the guidelines (and who doesn't), they must be "patient centered", not "doctor centered." They must put the best interest of the patient ahead of the financial interests of the treating doctor.¹⁴ Perhaps it is time for the chiropractic profession to look to the reformation efforts that were thrust upon medicine after the Institute of Medicine report on quality of health care was released in 1999. A key component of those recommendations is that patient care should be safe, effective, patient centered, timely, efficient and equitable. It may be time for the chiropractic profession to look at each of these recommendations and determine how we can do a better job.¹⁵

References

1. Keating JC Jr. To hunt the subluxation: clinical research considerations. J Manipulative Physiol Ther, 1996 Nov-Dec;19(9):613-9.
2. Keating JC Jr. Inter-examiner reliability of motion palpation of the lumbar spine: a review of quantitative literature. Am J Chiro Med;2(3):107.
3. Boline P, et al. Interexaminer reliability of palpatory evaluations of the lumbar spine. Am J Chiro Med;1(1):5.
4. Breen A. The reliability of palpation and other diagnostic methods. J Manipul Physiol Ther, 1992;15:54.
5. Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic technique procedures for specific low back conditions: characterizing the literature. J Manipulative Physiol Ther, 2001 Jul-Aug;24(6):407-24. Review.
6. Haas M, Groupp E, Kraemer DF. Dose-response for chiropractic care of chronic low back pain. Spine J, 2004 Sep-Oct;4(5):574-83.
7. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med, 2004 Dec. 21;141(12):920-8.
8. Leboeuf-Yde C, et al. The Nordic Back Pain Subpopulation Program: demographic and clinical predictors for outcome in patients receiving chiropractic treatment for persistent lower back pain. J Manipul Physiol Ther, 2004;27(8):493- 502.
9. United Kingdom Back Pain Exercise and Manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ, 2004 Dec. 11;329(7479):1377. Epub 2004 Nov. 19.
10. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G. Cervical Overview Group. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine, 2004 Jul 15;29(14):1541-8. Review.
11. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J, 2004 May-Jun;4(3):335-56. Review.
12. Villanueva-Russell Y. Evidence-based medicine and its implications for the profession of chiropractic. Soc Sci Med, 2005 Feb;60(3):545-61.
13. Cates JR, Young DN, Guerriero DJ, Jahn WT, Armine JP, Korbett AB, Bowerman DS, Porter RC, Sandman T, King RA. An independent assessment of chiropractic practice guidelines. J Manipulative Physiol Ther, 2003 Jun;26(5):282-6.
14. Jamison JR. Reflections on chiropractic's patient-centered care. J Manipulative Physiol Ther, 2001 Sep;24(7):483-6.
15. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press. 2001.