Rand S.Swenson and Scott Haldeman
Complementary Therapies in Neurology: An Evidence-Based Approach Edited by Barry S.Oken
ISBN 1-84214-200-3 Copyright © 2004 by The Parthenon Publishing Group, London
INTRODUCTION
Manual therapies have been practiced in virtually all societies and cultures throughout recorded history. In Western civilization, its practice is recorded in the works of Hippocrates as well as Galen and has survived to the present in various forms in different societies. In some countries, such as Japan, the majority of practitioners of spinal manipulation are lay practitioners, while in Europe a large percentage are medical physicians who have additional training in the practice. In North America, some medical and osteopathic physicians offer spinal manipulation. There is also a growing (but still small) group of physical therapists practicing spinal manipulation. Although the osteopathic profession was the first in the USA to organize a body of knowledge in the practice, the great majority of osteopaths today do not practice manipulation. At this point in time chiropractors provide the vast majority of these services in North America as well as in many other parts of the world, and are equated in the public perception with the practice of spinal manipulation. Currently, well in excess of 90% of spinal manipulations in the USA are delivered by chiropractors1. They also provide a growing percentage of these treatments in Japan, Australia, New Zealand, South Africa and many parts of Europe. This chapter concerns itself with the current state of chiropractic, focusing on its place in the health-care system in the USA.
Chiropractic traces its roots to Daniel David Palmer, a magnetic healer and sometime school-teacher in the Midwest. He was exposed to the ideas of various practitioners who employed manual therapies (bone-setters, lay practitioners and maverick medical physicians) and organized these skills into the profession of chiropractic. The first official chiropractic treatment, described by Palmer as a spinal adjustment, was performed in 1895 in Davenport, Iowa. This first treatment was described by Palmer as the reduction of a prominence in the upper thoracic spinal region of a janitor named Harvey Lillard.
This man, who had been profoundly deaf, claimed return of hearing following treatment.
Palmer eventually opened his first chiropractic school in Davenport, where it exists to this day. Flamboyant and excessive claims by early chiropractic leaders led to serious conflicts with mainstream medical practitioners that persisted throughout the first 80 years of chiropractic history.
Several milestones have been important in understanding the relationship between the chiropractic profession and medicine. These include a conference that was organized
under the auspices of the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) at the instruction of the US Congress in 1975. This conference, entitled The Research Status of Spinal Manipulative Therapy2, brought together many experts from the medical, chiropractic and scientific communities to examine the state of research into spinal manipulation and to chart directions for future study. Much of the progress in the validation of spinal manipulation can be traced to this conference. Another noteworthy milestone included changes to the American Medical Association code of ethics that had previously proscribed interactions between chiropractors and medical doctors. This change only occurred after a lengthy and rather bitterly fought lawsuit, but has been followed by an era of unprecedented growth in professional relationships between chiropractors and medical professionals. Recent recognition of the large number of Americans utilizing complementary and alternative therapies3,4 hasmotivated significant interest on the part of policy makers as well as physicians. This interest prompted the development of the Office of Complementary and Alternative Medicine within the National Institutes of Health. This office has grown into the National Center for Complementary and Alternative Medicine. These and other developments have led to greater interaction and increasing co-operation between medical physicians and chiropractors, as well as increased curiosity regarding the training, theories and practices of these practitioners.
UTILIZATION
The growth of chiropractic services pre-dates the recent explosion of interest in complementary and alternative approaches to healing and health maintenance. However, its recent growth must be viewed in the context of the expanded use of all forms of complementary and alternative medicine (CAM) therapies in the USA. This was clearly illustrated by systematic surveys in 1990 and repeated in 1997 by Eisenberg and colleagues3,4. Theseresearchers were the first systematically to demonstrate the high levels of use of CAM therapies by the public at large and they also illustrated a significant growth over this relatively short period. In 1990, 33.8% of the adult population in the USA reported using one or more CAM therapy, while by 1997, this figure had grown to 42.1%. Not only was use of CAM therapies increasing, but the probability of visiting a CAM provider increased (from 36.3% in 1990 to 46.3% in 1997).
Their findings indicate a 47.3% increase in the number of visits to alternative medicine practitioners over this brief interval of 7 years. Expenditures on these therapies also increased (by 45.2%, according to their estimates). It is somewhat astounding to realize that a conservative estimate of these expenditures amounted to $27 billion in 1997, a figure that is comparable to the projected out-of-pocket expenditures for all US physician services.
In the survey by Eisenberg and co-workers, the single most popular CAM intervention was relaxation therapy. However, chiropractic followed close behind and represented by far the largest group of alternative providers frequented by the general population4. It is clear that both the number of patients frequenting chiropractors and the number of chiropractic visits per capita have markedly increased in the past 15–20 years. In 1980, the US Department of Health, Education and Welfare reported that about 3.6% of the
population received a chiropractic treatment each year, and that the number of individual treatments amounted to 62 visits per 100 person-years5. A survey in 1990 reported that 10.1% of the population consulted a chiropractor within the preceding year3, and this number had grown to 11.0% by 19974. Estimates based on data collected from the late 1980s to 1991 determined that there were about 100 visits to chiropractors per 100 person-years6.
Medical practitioners, including neurologists, can anticipate that many of their patients have recently been treated by, or are likely to seek the services of, a chiropractor during the course of their care. It is therefore of growing importance to have some knowledge of chiropractic, including the training and background of its practitioners, its theoretical basis and the research relative to its use, in order to advise patients appropriately.
THE STATUS OF THE PROFESSION
Chiropractic enjoys greater recognition, utilization and integration into the health-care system than any other CAM profession. Over the past 100 years, chiropractic has become an organized profession with licensure to practice as a primary contact health-care profession in every state in the USA and all Canadian provinces as well as many other countries around the world. Chiropractic colleges and universities now have accredited educational programs of study, described in the following section. The National Board of Chiropractic Examiners administers the basic science, clinical science, case management and practical examinations that are required by all states in order to obtain a license to practice. A similar licensing board exists in Canada, and licensing agencies exist in countries such as the UK, the Scandinavian countries, Australia, New Zealand, South Africa and many others.
More than anything, however, the growing integration of chiropractic into the mainline health-care system is due to the dual effects of increased numbers of patients seeking such care and the growing number of studies, both clinical and basic science, supporting a positive effect of spinal manipulation. The emerging emphasis on ‘evidence-based’ health care and on patient satisfaction and cost containment has further advanced interest in chiropractic as an alternative treatment for a number of conditions, some of which respond poorly to conventional medical care. The growing body of evidence of effectiveness of spinal manipulation for several indications has culminated in the inclusion of manipulation among a very short list of recommended therapies in evidence-based guidelines published in the USA7, Canada8, and the UK9. These have resulted in an increase in the integration of chiropractic and spinal manipulation into pain clinics, spine centers and managed care systems.
Along with an increasing use of manipulative therapy has come a dramatic increase in the number of chiropractors. From an estimated 13000 practitioners in 1970, the number had grown to around 50000 by 1994. This represents approximately one chiropractor for every 5000 residents in the USA. A recent study anticipated that the number of chiropractors will double again by the year 2010 to over 10000010. These numbers become all the more remarkable when contrasted with the projection that the number of medical physicians will grow only by an estimated 16% over the same period. This
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indicates that chiropractors will constitute a growing segment of the health-care system in the near future.
The development of chiropractic has not been confined to North America. The World Federation of Chiropractic (WFC) has representatives from 80 countries and is recognized as a Non-Governmental Organization within the World Health Organization (WHO). Since 1993, the WHO has co-sponsored the academic program at the biannual congress of the WFC. The WFC is also a member of the Council of International Organizations of Medical Sciences of the WHO. There are now colleges of chiropractic in Canada, Australia, New Zealand, several European countries, South Africa, Japan, Mexico and Brazil. Most of the colleges outside North America are components of government-sponsored universities and colleges.
EDUCATION
Over the past century, chiropractic education evolved from a limited, 8-week course of study at the turn of the century to a full-fledged course of study lasting 4–5 academic years, preceded by 3–4 years of undergraduate education. It would not be an exaggeration to say that success in the development of chiropractic education has played a large part in the growing acceptance of chiropractic as a profession.
There have been several important milestones in the development of chiropractic education. None was more important than the recognition of the Council on Chiropractic Education (CCE) as the accrediting agency for chiropractic education by what was then the US Office of Education (now the US Department of Education) in 1974. The CCE established a minimum standard for admission and pre-professional requirements as well as prescribing minimum standards for facilities and the course of study in accredited chiropractic teaching institutions. Current standards require that all prospective students have a minimum of 2 years of pre-professional education, with specific requirements in the sciences and a minimum grade point average (GPA). Increasingly, individual colleges require a bachelor’s degree for admission. The course of study in chiropractic schools is 4–5 academic years, with much of the final year being devoted to training in a supervised clinical setting (with defined standards for this clinical experience). The first 3–4 years of the program is evenly divided between the basic medical sciences and the clinical sciences.
Currently, there are 14 accredited chiropractic colleges in the USA. An accreditation process, under the direction of the CCE, with periodic reaccreditation, ensures that colleges continue to meet these standards. Many chiropractic schools have also received accreditation from their regional post-secondary accreditation body, permitting them to grant undergraduate degrees based on their course of basic science instruction. The CCE has also been instrumental, through involvement with the Councils on Chiropractic Education International, in helping to establish minimum education standards in other parts of the world.
Under the guidance of the CCE, the great majority of the basic sciences are taught by professors with advanced degrees in the particular area of study. Most of the clinical sciences are taught by chiropractors, although there is a growing educational involvement of medical physicians and individuals with dual degrees. Additionally, an increasing
number of chiropractic students are receiving part of their clinical experience in medical facilities.
The great majority of chiropractic students take a national board examination that is administered under the auspices of the National Board of Chiropractic Examiners (NBCE), which was established in 1963. This examination consists of a basic science part, a clinical part, a problem-solving portion and a practical examination. Most states currently require passage of this examination prior to licensure.
LICENSURE
Chiropractic licensure is the responsibility of each state, subject to its own chiropractic practice act and the interpretations of that law. Therefore, there is some variability between states in the licensure requirements. Although the great majority of states require graduation from a chiropractic school accredited by the CCE, the role of the National Board examination in licensure varies. Many states require their own examination, often in addition to the National Board, prior to licensure. Furthermore, the requirements for postgraduate continuing education vary from state to state.
All states permit direct access of patients to chiropractors as portal-of-entry providers.
In the great majority of states, chiropractors are permitted to employ diagnostic measures necessary to ensure the suitability of patients for treatment. This includes the performance of physical examination procedures and the interpretation of laboratory tests. Most states also permit chiropractors to maintain and use radiological facilities. To a large extent this is the result of a long-standing boycott of chiropractors by radiologists who would not perform radiological tests at their request. The more recent co-operation between these professions has led to a decrease in the number of chiropractic offices maintaining their own radiographical facilities. Chiropractic schools have historically devoted a significant amount of training to the study of radiology, and studies have shown that the ability to interpret X-rays for pathological red flags by chiropractors is at least as good as that of family physicians and orthopedic residents and specialists11.
Despite the relative uniformity of chiropractic laws, there remain a few states where chiropractors are permitted to recommend or prescribe medications and perform minor surgical procedures, and other states where they are not even permitted to perform such procedures as a prostrate physical examination. Most of these practice variations fly in the face of education, which has become increasingly uniform as the result of national accreditation.
SPECIALTIES
The chiropractic profession has several established specialty councils, most of which have a diplomate or certification process. These councils are established under the auspices of the American Chiropractic Association (ACA) and/ or the International Chiropractic Association (ICA) to recognize and encourage greater expertise in particular disciplines. At the present time, recognized programs include radiology, orthopedics, sports medicine, rehabilitation, industrial medicine and nutrition.
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With the exception of the diplomate program in radiology, which has an established 2year residency, most of these programs consist of postgraduate courses of at least 300 h (diplomate programs) or 100 h (certification programs) of study in the field. There are qualification examinations required at the end of these programs.
SCOPE OF PRACTICE
State law and the legal interpretations of the law define the scope of chiropractic practice.
As described above, there is some variability in the diagnostic and therapeutic interventions that are permitted from state to state, but in most locations these include the diagnostic procedures that are required to determine the appropriateness of patients for chiropractic care. In all states, chiropractors are allowed to see patients without referral from other physicians and to treat them within the scope of the law.
Most state laws do not restrict the type of patients that can be seen and treated by chiropractors. On a practical level, however, the vast majority of patients seen by chiropractors are treated for musculoskeletal conditions, with only a very small percentage seen primarily for conditions that would commonly be consid ered to be internal disorders6,12. Historically, exaggerated claims of therapeutic efficacy on the part of some chiropractors, particularly regarding treatment of various non-musculoskeletal conditions and diseases, has been a major impediment to good relations between chiropractors and medical physicians. There are many anecdotal descriptions of successful chiropractic treatment of various internal disorders scattered within the chiropractic (and, indeed, osteopathic and medical) literature. The few attempts at systematically evaluating these claims (particularly with regard to the treatment of asthma and colic) have not provided any dramatic support for spinal manipulation in these conditions (see below).
Surveys and reviews of records of chiropractic offices6,12 havefound that the majority of chiropractic patients are seen for complaints of low back pain. Neck pain is the next most common presenting complaint, with headache (cervicogenic and otherwise) following. Many of these patients presenting with these conditions have additional diagnoses and a wide variety of general symptoms. Improvement in these additional symptoms during the course of chiropractic treatment has provided much of the impetus for anecdotal claims of benefit in the treatment of other conditions, including internal disorders. The three most frequently diagnosed non-musculoskeletal complaints treated by chiropractors are asthma, otitis media and migraine headaches. These conditions, however, accounted for only one in 200 patients. Only a very small percentage (1–10%) of patients seeking chiropractic care do so for non-musculoskeletal symptoms. Given these statistics, it is somewhat ironic that overzealous claims made by some chiropractors concerning the treatment of a tiny fraction of chiropractic patients produce the greatest amount of friction between chiropractors and the medical community.
The strongly musculoskeletal bias of the conditions presenting to chiropractic offices probably results from the fact that patients are most likely to view chiropractors as being particularly effective in the treatment of these conditions. This distribution of patients may also result from the fact that conditions such as back and neck pain are often refractory to conventional medical care. It is not surprising, then, that the greatest amount
of evidence for a beneficial effect of chiropractic and spinal manipulation is in the treatment of back pain, neck pain and headache (see below and Chapter 15.
Historically, most chiropractic patients saw medical physicians first, and only sought chiropractic care when all else failed. Increasingly, this is now not the case. Therefore, the quality of chiropractic education in the primary analysis and diagnosis of patients has become of greater importance.
REIMBURSEMENT
The nature of reimbursement for chiropractic services has changed, along with the maturation of the chiropractic profession and the fact that the general population has increasingly viewed chiropractic as a viable alternative or adjunctive method of treatment. To some extent, changes in reimbursement patterns have also been driven by trends in medicine as well as social and reimbursement policy in general.
Up to the 1960s, the vast majority of chiropractic treatments were provided on a fee-for-service basis. One milestone in the movement away from this was the inclusion of chiropractic in the original Medicare law. This inclusion was legislated in a rather narrow fashion and with tight restrictions on issues ranging from the types of conditions to be treated and the reimbursements provided. Nonetheless, it provided some impetus towards incorporation of chiropractic services in other third-party payer systems. However, through the 1970s and early 1980s transition to third-party payment proceeded at a slow pace with inclusion of chiropractic services in worker’s compensation programs and many private insurance programs. Since chiropractors were often involved in treating patients with neck and back injuries, there was also involvement in the personal injury arena.
With the more recent growth of health maintenance organizations (HMOs), there has been slowly evolving inclusion of chiropractors in many of these plans. Some have restricted access strictly on the basis of referral from primary care providers, while a growing number of plans permit self-referral, usually under a system of strict guidelines for numbers of treatments.
Integration of chiropractic into the US armed services is proceeding after the conclusion of a pilot program exploring the feasibility of such involvement. Additionally, the US Veterans Administration health-care system will be incorporating chiropractors, although the precise nature of this involvement is still being established.
In the early 1990s the primary sources of payment for chiropractic services included private insurance and direct payments from the patient6. Together these were estimated to comprise 60% of chiropractic payments. Worker’s Compensation and automobile accident insurance accounted for an additional 10–15% each, and Medicare represented another 8%. Other forms of payment, including Medicaid and managed care, contributed the remaining 10%. However, with the growing integration of chiropractic services into managed care, the portion related to HMOs is expected to grow significantly10.
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ALTERNATIVE, COMPLEMENTARY OR MAINSTREAM?
There has been considerable debate, both inside and outside the profession, regarding the role(s) chiropractors should play in the health-care delivery system. The most common way in which chiropractors practice is as limited musculoskeletal specialists, dealing primarily with painful conditions either independently or, increasingly, as part of an interdisciplinary team. There are those within the profession who advocate chiropractors as primary health-care gatekeepers with a particular emphasis on ambulatory musculoskeletal conditions. There are some chiropractors still advocating a broad practice as general primary (alternative/complementary) health-care providers not limited to musculoskeletal conditions13,14. Although all three of the sepractice models can be found within the chiropractic profession, all studies have shown that chiropractors treat a limited array of conditions, with up to two-thirds of patients presenting with low back pain6,12,15.
Chiropractic has become so commonly utilized and tightly woven into the fabric of health care in the USA that some have argued that it has entered the health-care mainstream14,16–18. Indeed, there are a growing number of examples of integration of chiropractic services into medical clinics and HMOs. Chiropractors are permitted membership in all major spine societies including the North American Spine Society, the American Back Society and the International Society for the Study of the Lumbar Spine, and there is a recently formed society specifically to encourage co-operation between chiropractors and neurosurgeons.
Even when chiropractic services are not performed as an integrated part of medical care for their condition, most patients utilize chiropractic services in combination with traditional medical care. Therefore, it has become increasingly common to refer to chiropractic as ‘complementary’, rather than ‘alternative’19–21. It is important to note that many patients with common neurological illnesses suffer from conditions for which they seek relief from multiple practitioners in the community. For example, Schwartz and colleagues found that 12% of patients with multiple sclerosis had utilized the services of a chiropractor in the previous 6 months. These patients tended to report fewer emotional problems and express less confidence in their medical health-care plan22.
Despite the movement towards acceptance of a role in treatment of musculoskeletal conditions, there remains substantial controversy regarding the treatment of other conditions. There are chiropractors who continue to treat patients with a variety of non-musculoskeletal complaints and advertise themselves as providing such services to the general public. This has been a major barrier to integration between chiropractic and main-line health care and has kept it in the realm of alternative medicine, despite the fact that only a small number of chiropractic office visits are for non-musculoskeletal conditions.
At the present time, there are chiropractors practicing in all three capacities—as limited musculoskeletal specialists, as primary providers with musculoskeletal emphasis and as primary alternative health-care providers. In the treatment of spinal disorders and when functioning in inter-professional clinics, chiropractors practice as part of the mainstream healthcare system. Frequently, chiropractors provide treatments that are