One day before Independence Day in the U.S., I am gazing out of my office window in Brookline at more than a few flagpoles that are preparing to fly the standard, in celebration of America declaring its identity as a distinct and separate state some 229 years ago. And so a similar phenomenon would seem to be happening with chiropractic, following the adoption of numerous identity statements on June 15, 2005 by the World Federation of Chiropractic (WFC) Assembly in Sydney, Australia - with, regrettably, less than 10 minutes of discussion from the floor.
This event was the culmination of two years of workshops hosted on the Life West campus, under the direction of the WFC and driven in part by a survey conducted by Manifest Communications that emphasized the disparity between what the public and chiropractors commonly perceive as treated by chiropractic. Far and away, the survey and various studies have suggested that chiropractors are considered to be managing primarily musculoskeletal problems, with emphasis upon back pain.1-4 The end-product of the Final Report of the Identity Consultation Task Force was the conclusion that a leading statement of identity must be made clear, concise, and immediately relevant to both the public and profession alike, and that this statement should be designated as the "pole." Numerous supporting statements, called brand pillars, were to be considered as the "ground."
The "pole," as presented, suggested that chiropractors should be regarded as "the spinal health care experts in the health care system." Numerous "ground" statements emphasized the following: 1. a patient-centered approach to health care; 2. wellness; 3. the self-healing powers of the individual; 4. avoidance of the use of drugs and surgery whenever possible; 5. examination, diagnosis and treatment based upon available research; and, in my opinion, the most critical element of all: 6. the relationship between the spine and the nervous system.
It is here where I begin to get queasy and express my concerns. In the rush to identity, an element without which most perceptions of chiropractic would wither away, as argued at the presentation of these statements for adoption in Sydney, the Task Force leadership landed upon the spine as chiropractic's hallmark. It seemed to be something that the profession could never give up - not for all the tea in China, or for that matter, all the car bombs in Baghdad. Admittedly, there is no doubt that there has been historical emphasis upon the spine in the profession in its 110 years of existence, and that the profession needs to secure some identity to prevent its abuse with unfounded claims, its distortion in the media, and the risk of its disappearance by encroachments from other health care professions.
The problem is what the public walks away with. If it perceives spinal health as specialist care and fails to perceive the spine as a dynamic entity - hard-wired into the nervous system, which at the end of the day, represents the actual heart of chiropractic theory, potential, and practice - then all is lost. If the public is denied exposure to the "ground" elements stated above and thus fails to utilize chiropractic as a vital portal of entry into the health care system - especially in view of the fact that a profusion of studies have indicated that the medical profession has been shown to be deficient in understanding and especially diagnosing enough musculoskeletal issues to qualify for a subscription,5-8 - then all is lost once again.
Indeed, as Joseph Brimhall, president of the Council on Chiropractic Education and director of the Council on Chiropractic Education International, has pointed out, there is nothing in the accreditation standards of the CCE, the Model Standards of the CCEI, or several jurisdictional definitions which restricts the chiropractic profession anatomically or regionally to "the spine."9
In the attempt to streamline the identity message, the Task Force has led our thinking away from the chiropractor's ability to manipulate the extremities in addition to the spine, justified by an encouraging body of literature that demonstrates effective outcomes in managing repetitive motion disorders.10-13 What about effleurage of the sternocleidomastoid muscles, shown to be an effective part of the chiropractic management of otitis media?14 Furthermore, the identity statements seem to have neglected the roles of nutrition, supplements, nutraceuticals, herbs and minerals, often recommended by chiropractors. According to Dr. Brimhall, many of these could be conceived to be "drugs." And what about manipulation under anesthesia, sometimes codified as "surgery"?9
These are but a few of the critical elements that could be lost upon the public if the spine is elevated to iconic status at the expense of its integration into the nervous system as a whole. Consider, for example, the care of the pediatric or elderly patient in the real world. As we ponder the message that goes out to the public for mass consumption, would you think for a moment that the infant, child, adolescent, parent, or senior citizen really gives a stuff as to whether they acquire a healthy spine by seeing a chiropractor? I think not.
If we are to follow the tenets of holism, wellness and preventive care in which the chiropractic profession is so fortuitously and advantageously grounded, are we harvesting enough of this message from the pole statement regarding spinal health? As I have pointed out previously,15 both the Institute of Medicine and the director of the National Institutes of Health have made it clear that both wellness and maintenance within a patient-centered framework are the concepts around which our medical system must revolve if health care is to be effective 20 years from now.
With these identity statements having now been ratified by the delegates present at the WFC Assembly in Sydney, I have the same feeling that one has just after checking one's bags at the airport, facing perhaps one or two connecting flights. One hopes that the identity statements - both pole and ground - are handled intelligently, with ample flexibility for accommodating new observations gleaned from future research. If chiropractic identity is allowed to degenerate into a specialist spine care role with referral only, it would be like having that checked luggage fail to reach its intended destination and wind up somewhere that no one expected - think Timbuktu. If something like the Canadian physical therapy model of treatment becomes the norm in chiropractic, the identity exercise will have become a tragic mistake with all eyes directed to the spine only.
Under those circumstances, to paraphrase a classic Las Vegas expression, "What happens in the spine will be thought of as staying in the spine." If that becomes the case, I would hope that what happened in Sydney stays in Sydney.
References/Resources
- Consultation on Identity: Quantitative Research Findings. World Federation of Chiropractic, Dec. 7, 2004: www.wfc.org.
- Ebrall P. A descriptive report of the case-mix within Australian chiropractic practice. Chiropractic Journal of Australia 1992;23:92-97.
- Prevalence of nonmusculoskeletal complaints in chiropractic practice: report from a practice-based research program. Journal of Manipulative and Physiological Therapeutics 2001;24:157-169.
- Hartvigsen J, Boding-Jensen O, Hviid H, Grunnet-Nilsson N. Danish chiropractic patients then and now: a comparison between 1962 and 1999. Journal of Manipulative and Physiological Therapeutics 2003;26:65-69.
- Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. Journal of Bone and Joint Surgery 2002;84-A(4):604-608.
- Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. Journal of Bone and Joint Surgery 1998;80-A(10):1421-1427.
- Matzkin E, Smith EL, Frccero D, Richardson AB. Adequacy of education in musculoskeletal medicine. Journal of Bone and Joint Surgery 2005;87-A(2):310-314.
- Vlahos K, Broadhurst NA, Bond MJ. Knowledge of musculoskeletal medicine at undergraduate and postgraduate levels. Australasian Musculoskeletal Medicine, May 2002:28-32.
- Brimhall JC. Memo to David Chapman-Smith, secretary-general of the World Federation of Chiropractic, June 7, 2005.
- Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1998;21(5):317-326.
- Winters JC, Sobel JS, Groenier KH, et al. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study. British Medical Journal 1997;314:1320-1325.
- Strait BW, Kuchera ML. Osteopathic manipulation for patients with confirmed mild, modest, and moderate carpal tunnel syndrome. Journal of the American Osteopathic Association 1994;94(8):673.
- Bergman GJD, Winters JC, Gronier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain. Annals of Internal Medicine 2004;141(6):432-439.
- Fallon JM. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. Journal of Clinical Chiropractic Pediatrics 1997;2(2):167-183.
- Rosner A. Identity crisis: a profession at the crossroads. Dynamic Chiropractic, June 4, 2005: www.chiroweb.com/archives/23/12/30.html.
- Chassin MR, Galvin RW, National Roundtable on Health Care Quality: The urgent need to improve healthcare. Journal of the American Medical Association 1998;280(11):1000-1005.
- Zerhouni E. April 14, 2005, quoted in the Boston Globe, April 19, 2005, pp. D1, D4.
Anthony Rosner, PhD
Brookline, Massachusetts
rosnerfcer@aol.com
