Two Legs to Stand On (Editor’s Message, September 2001)

September 19, 2001

I recently read your editor’s message in the September 2001 issue and would like to respond to some of your comments and observations. As someone who graduated from both schools of physical therapy and chiropractic, perhaps I could share the viewpoint of a practicing PT/DC on the issue of spinal manipulation.

For years the physical therapy profession stood side by side with the medical profession and embraced the position that spinal subluxations treated by chiropractic physicians did not exist.

However, now that numerous studies support the efficacy of spinal joint dysfunction with manipulation, PTs are claiming to diagnose and treat spinal subluxations. Let me suggest that PTs have not in the past nor are currently being trained to differentially diagnose in the same manner as a physician. The most challenging aspect of treatment with manipulation is knowing when and when not to treat. This requires a physician level of knowledge and skill. Physical therapists are not physicians!

I believe it is the responsibility of the chiropractic profession to safeguard consumers from unsuspectingly believing that any health care provider can safely render spinal manipulation. The 1998 government regulation chose to substitute chiropractic care with other providers in the correction of a subluxation; thus the great need for the ACA to file a lawsuit. I do not believe this is "demonizing one’s opponent" or "running to the courts."

It is much more than an issue of turf war or a battle for economic monopoly. No health care professional—DC, PT, MD, RN, or ATC—should be allowed to provide specific diagnostic/treatment services until they can demonstrate academic and clinical proficiency. For example, the physical therapy profession has been unwilling to establish entry-level baseline competency in spinal manipulation. The answer is obvious—it takes the equivalence of a doctorate in chiropractic to have the knowledge and proficiency of a chiropractor.

Sincerely,
Glenn D. Manceaux, DC, PT
Chiropractic & Physical Therapy Clinic Inc
Houma, La

In her editor’s message of September 2001, Miwon Seo seems to lack an appreciation of the historical battle that doctors of chiropractic have had to wage against blatant discrimination by the traditional medical establishment and the government.

ACA is neither demonizing its opponent nor "running to the courts" unjustifiably in its lawsuit against the Department of Health and Human Services (HHS). She seems to suggest that the "dignified course of action" for the chiropractic profession would be to go to the back of the bus and behave in a way that is acceptable to the medical monopoly. The ACA has chosen the only dignified course of action that it finds acceptable—fighting back against injustice.

While it is certainly nice to think that "healthy competition will increase the quality of service and can define and shape the future of chiropractic," it is woefully naïve to believe it. Unfortunately, everyone does not play fair, as history has proven. Seo need only look to the court documents in ACA’s lawsuit to see how the medical establishment and HHS worked to secure manipulation for MDs, DOs, and PTs, while essentially shutting DCs out of the marketplace.

A report released last year by the HHS Office of Inspector General (OIG) on the utilization of chiropractic care in Medicare managed care plans revealed a startlingly inexplicable reduction in chiropractic services available to beneficiaries—especially to patients enrolled in Medicare HMOs that required a physician referral to a chiropractor. In 1996, more than 1 million Medicare beneficiaries participated in Medicare managed care organizations with a physician referral requirement. According to the OIG report, only 6,200 (0.61%) of those beneficiaries were referred for chiropractic services. Although that number increased to 0.96% in 1997 and 1.08% in 1998, utilization of chiropractic services in Medicare fee-for-service ranged much higher during the same time period— between 4.15% and 4.42%. For comparison purposes, the utilization of chiropractic services among the American public as a whole is approximately 6.5%.

This report [demonstrates] that Medicare managed care patients are systematically being denied access to doctors of chiropractic. It is foolhardy to suggest that "healthy competition" will ensure that doctors of chiropractic are treated fairly, and even more foolish to allow PTs to claim as their own a form of treatment that is uniquely chiropractic.

ACA’s goal with its lawsuit against HHS is not to allow the courts to "interpret what is chiropractic and what is not," but to level the playing field to ensure that patients who have a right to chiropractic care are not being unfairly denied those services.

Sincerely,
Daryl D. Wills, DC
ACA President
Arlington, Va

September 18, 2001

You presented an interesting argument in your editorial. It seems that as chiropractors, we have been at odds when attempting to define who we are, what our purpose is, and why we do what we do. We may differ in vocabulary or technique, but we continue to produce amazing results in spite of ourselves.

It is essential to recognize that the traditional emphasis on correcting or reducing subluxation, and the components of the vertebral subluxation complex (VSC) distinguish chiropractic as a separate and distinct healing profession. The Association of Chiropractic Colleges (ACC) emphasized this point in its first position paper: "Chiropractic is concerned with the preservation and restoration of health, and focuses on the subluxation—a complex of functional, structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available and rational empirical evidence" (Position paper #1, ACC, July 1996).

The basic precepts defined by the ACC are found throughout the Council on Chiropractic Practice’s Clinical Practice Guideline, "Vertebral Subluxation in Chiropractic Practice" (No 1, 1998), which emphasizes evidence-based practice guidelines for the subluxation-based chiropractic practitioner, and in the Journal of Vertebral Subluxation Research (www.jvsr.com), which dedicates itself to peer-reviewed, subluxation-based chiropractic research.

The concepts explored in these venues clearly distinguish chiropractic as a separate healing art although some chiropractic approaches or methods may overlap those of the allied health care professions.

One of the most current revisions of the chiropractic model of the VSC, proposed by Lantz, identifies nine components, which every practicing chiropractor encounters: kinesiology, neurology, myology, connective tissue pathology, angiology, inflammatory response, anatomy, physiology, and biochemistry.

[According to] Lantz, "The VSC allows for every aspect of chiropractic clinical management to be integrated into a single conceptual model—a ‘unified field theory’ of chiropractic... Each component can, in turn, be described in terms of precise details of anatomic, physiologic, and biochemical alterations inherent in subluxation degeneration and parallel changes involved in normalization of structure and function through adjustive procedures" (Kent C. Models of vertebral subluxation: a review. Journal of Vertebral Subluxation Research. 1996; 1(1):1. Available at: www. jvsr.com/abstracts/1197-0061_models.htm. Accessed October 3, 2001).

It is also worth noting one commentator’s observations: "The field of functional pathology of the neuromusculoskeletal system, including its optimal diagnosis and management, is...a complex specialty in its relative infancy. No one profession has mastered the field, but one will become recognized as having a leading presence and expertise in the next millenium...Learning from and incorporating the best of others is what the founders of chiropractic did...If chiropractors wish to remain preemiment in manual care they must continue to investigate it in all its forms" (Chapman-Smith D, ed. Low-force and Soft-tissue techniques. The Chiropractic Report. 1998;12(4):8).

Chiropractic practice, therefore, is a complex, multifaceted, evolving healing art, which continues to revise its conceptual models of clinical efficacy as new evidence-based data is discovered.

Sincerely,
Gerald A. Anzalone, DC
Cortlandt Manor, NY

Editor’s Reponse:

I also strongly believe that increasing awareness about chiropractic will be more beneficial. As Gap created a "need" for khakis with its brilliant advertising campaign, chiropractic should do the same—chiropractic care is not a luxury but a necessity. This is one way to force Washington to listen.