Chiropractic: A Glorious Future

In an article in the Journal of the American Medical Association, Kilo and Larson¹ describe the real issues surrounding our current health care crisis.  It is not purely an economic problem to be solved by altering the way health care goods and services are paid for. It is acknowledging that applying the same clinical strategies that got us into this predicament, but tinkering with finance and distribution, will not solve the problem. According to the authors: "On balance, the data remain imprecise, and the benefits that U.S. health care currently deliver[s] may not outweigh the aggregate health harm it imparts ... it is time to address possibility of net health harm by elucidating more fully aggregate health benefits and harms of current health care."

Not only have the authors acknowledged that the current system may be doing as much or more harm than good, they cite the observations of Schroeder² that"Determinants of well-being transcend health care ... since health care contributes only about 10% toward reducing premature death, even a perfectly designed delivery system would prevent only a modest proportion of premature death. Lifestyle choices, not medical and surgical treatments, are the determinants of longevity over which we have control."

According to Uwe E. Reinhardt, the James Madison Professor of Political Economy at Princeton, government accounts for about two-thirds of health care spending.³ State Medicaid expenditures exceed those for education, while U.S. health care spending in 2008 totaled approximately $2.5 trillion; nearly 17 percent of the gross domestic profit. In a previous article, I discussed how the broad application of chiropractic care could result in spectacular cost savings.⁴ Now let's discuss the specifics of a strategy for the future of chiropractic that would operationalize that vision.

Our Identity

The chiropractic profession needs a solid identity that differentiates it from other health care professions. An amorphous identity, such as that proposed by the World Federation of Chiropractic (WFC), as "The spinal health care experts in the health care system,"⁵ places chiropractic in direct competition with physical therapy, manual medicine, orthopedics, physical medicine and rehabilitation, osteopathy, naprapathy, and others. Particularly disturbing is the absence of any explicit reference to the vertebral subluxation - arguably the one unique feature of chiropractic practice. Rosner has articulated some of the potentially devastating consequences of the WFC identity, and I encourage readers to carefully ponder his remarks.⁶
 The WFC identity stands in sharp contrast to the findings of a survey of North American chiropractors completed by the Institute for Social Research at Ohio Northern University and published in 2003, in which the following was reported:

• 88.1 percent of chiropractors stated that the term vertebral subluxation complex should be retained.
• 89.8 percent stated the adjustment should not be limited to musculoskeletal conditions.
• 93.6 percent said they recommend maintenance/wellness care.

The study noted, "For all practical purposes, there is no debate on the vertebral subluxation complex. Nearly 90% want to retain the VSC as a term. Similarly, almost 90% do not want the adjustment limited to musculoskeletal conditions. The profession - as a whole - presents a united front regarding the subluxation and the adjustment."⁷ With that said, to realize its potential, the chiropractic profession needs to embrace an identity focused on vertebral subluxation, whole-body health and wellness.

Politics and Health Policy

Political strategies must be congruent with the identity and core values of a profession. As noted above, there is already a high level of consensus among North American chiropractors. Regretfully, some of our organizations and political leaders have failed to acknowledge this. The result has been a predictable disconnect with the field, with only a minority of DCs belonging to a national professional association. Is this any wonder when they focus on third-party reimbursement for the diagnosis and treatment of a narrow array of musculoskeletal pain syndromes, when the majority of North American chiropractors do not want the adjustment limited to musculoskeletal disorders, and when 93.6 percent recommend maintenance/wellness care?

It is imperative that chiropractors implement strategies that go beyond short-term political fixes focused on third-party pay. Long-term strategies addressing health policy are needed if we are to realize our rightful place in American health care.

Research Priorities

Purchasers of health care services, be they cash-paying patients, insurers, managed care organizations, or government agencies, are demanding evidence that the services they are buying have a beneficial clinical effect. We must conduct research that establishes the clinical meaningfulness of the vertebral subluxation and the objectively demonstrable health benefits of the chiropractic adjustment. I am not suggesting randomized controlled trials of every known chiropractic technique for every condition in the Merck Manual. Rather, I am encouraging research that addresses function, quality of life, and cost-benefit analysis of chiropractic care. Our experimental designs must be epistemologically sound and congruent with our clinical objectives.

Clinical Assessment

Many chiropractors continue to place a primary emphasis on examination procedures, such as orthopedic tests, which have not been shown to be reliable or valid.⁸ Furthermore, these orthopedic tests are generally not relevant to the clinical objective of identifying or characterizing vertebral subluxations.  Fortunately, there are reliable and valid metrics for neurospinal function available to chiropractors, which are relevant to subluxation evaluation.⁹ Here are a few examples:

• Algometry assesses pressure point sensitivity. Tender areas discovered by palpation may now be quantified and progress can be graphically displayed throughout a course of care. 
• Inclinometry measures spinal ranges of motion. The reliability, responsiveness to adjustment or manipulation, and relationship of ROM to health and disability have been reviewed in the literature. 
• Surface Electromyography (sEMG) evaluates patterns of electrical activity in the muscles surrounding the spine. Static scans reveal tonic postural patterns, while dynamic scans are used to assess muscle activity through phasic (voluntary) motion.
• Thermal Scans assess autonomic function by measuring skin temperature differentials. Displays support both pattern and segmental analysis.
• Heart Rate Variability (HRV) measures the variations in heart rate of a patient in a resting state. Under resting conditions, healthy individuals exhibit periodic variation in the interbeat intervals. Chiropractors use HRV to get a window into how the autonomic nervous system modulates heart rate in the baseline or resting state.

A Glorious Future

The chiropractic profession has the ability to assume a leadership role in the reformation of a sick-care system into a comprehensive integral approach to address wellness, quality of life and human potential. The realization of this vision requires an identity firmly rooted in the principles of vitalism, as well as a clinical focus on vertebral subluxation and its relationship to nervous system function and general health.

References

1. Kilo CM, Larson EB. "Exploring the Harmful Effects of Health Care."  JAMA, 2009;302(1):89.
2. Schroeder SA. "We Can Do Better - Improving the Health of the American People."  N Engl J Med, 2007;357(12):1221.
3. McCoy M. "We Already Have National Health Care." Research Update. http://researchupdate.mccoypress.net/
4. Kent C. "A Strategy for Health Care Reform." Dynamic Chiropractic, Sept. 92008;26(19).
5. WFC Consultation on the Identity of the Chiropractic Profession.  Available at www.wfc.org.
6. Rosner A. "Chiropractic Identity: The Morning After."  Dynamic Chiropractic, Sept. 1, 2005;23(18).
7. McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice. Institute for Social Research, Ohio Northern University; Ada, OH, 2003. www.chiropracticsurvey.com
8. Kent C. "Examining Exams - Are They Reliable?"  Dynamic Chiropractic, Aug. 12, 2008;26(17).
9. Council on Chiropractic Practice. Vertebral Subluxation in Chiropractic Practice. Revised 2008. www.ccp-guidelines.org/guideline-2008.pdf. Summary available at:  National Guideline Clearinghouse (www.ngc.gov).