We Get Letters & E-Mail

Adventures in Chiropractic Education

Dear Editor,

The response from the field to my article on South Africa for fulfillment of the vacated position at the Technikon Natal in Durban, was totally unexpected.

(See "South Africa's Technikon Natal -- An Adventure for Chiropractic Educators," in Internat'l Forum 7-3-95, or 8-15-95 North American issue).

The chiropractic concern has been overwhelming and continues even now. The correspondence has been of such magnitude that there remains culled 26 worthy applicants. Dr. Till has conveyed to me by phone that his fax is smoking and the position has not been finalized.

I personally have received no less than 50 communications by phone, fax, and letter, wanting more information of living conditions, tenure of work, remuneration and lifestyle of the area. In my article, I tried to convey every aspect of campus life and life in Durban. Be assured if they do not go with preconceived ideas, few problems will arise. Durban is not third-world; certainly not what you hear and read in the media. The person chosen for this position is surely a most privileged person.

Thanks again for your contribution to chiropractic in printing my article. Thanks will never pay for the kindness you have shown Dr. Till and the Technikon Natal of Durban, South Africa.

Lee Arnold, DC
St. Petersburg, Florida

"Pseudodiplomates"?

Dear Editor,

Dr. John Hofmann's article, "Who Are We?", for the most part seems to be an anti-intellectual diatribe against those of us who dare to value education, science and research. He seems to say that once one has a DC degree, no further learning is possible, hence all postgraduate credentialing is "phony," and the doctors who have spent their precious time and money devoting their attention to learning how to better serve their patients are "pseudodiplomates."

Dr. Hofmann seems to feel that if we all do more "caring and serving," then we wouldn't need different specialties. Apparently he feels that good intentions can make up for inadequate clinical skill and knowledge.

Fred Kourmadas, DC, CCSP
Manassas, Virginia

Student Column

Dear Editor,

I'd like to compliment you on your newspaper, "DC." I look forward to and enjoy receiving each issue. I think the articles and columns are interesting and well written. I'm a first year student at the Univ. of Bridgeport College of Chiropractic, and can remember receiving my first issue of "DC" a few months ago. It gave me my first sense of belonging and acceptance into the chiropractic profession. Because I have just begun my chiropractic education, I find many of the articles to be "over my head," however I know that someday I will be able to read it with more understanding and comprehension.

We here at UBCC are taught from the beginning that we should strive for excellence. We are taught that a doctor must continually attempt to educate himself and keep abreast of new information -- a never ending learning process. While I continue to read every article in "DC", even though I do not yet understand much of what is said, I believe that there may be many other students who find the same to be true. Therefore I think that a small column devoted to chiropractic students would be greatly appreciated.

I would like to be involved in such a column, and already have many ideas and suggestions. These article would be refreshing to both students and doctors.

Chad Rappaport
University of Brideport College of Chiropractic

Editor's note: While we do feature college news in our regional forums, we don't receive many article submissions from students. We would encourage more students to submit articles or items of interest. If we receive enough material, we'd be happy to start a regular student column.

The Path Less Traveled

Dear Editor:

I just returned from a spectacular eight day white water rafting trip through the Grand Canyon. We descended nearly five thousand feet on a 10 mile blazing hot hike from hell just to get to the river rafts in the Gorge. By the third day on the rapids, most of the people on the trip were sunburned, sore, bruised, fatigued, and having the time of their lives in nature's awesome grandeur. It was clear that this was a path less traveled.

The unspoiled, raw beauty and the adrenaline rush drenched me deeper than all the violent water that engulfed and at the same time propelled us.

I realized on that trip that the road less traveled offers danger, obstacles and uncertainty. Yet by realizing and truly accepting this, danger becomes excitement, obstacles become challenges, and uncertainty, adventure.

The people on this trip came from all corners of the globe and were different in more ways than they were alike. Yet, as our adventure unfolded we became closer, a strong camaraderie bound us together.

When we chose to become chiropractors we all chose the path less traveled. I firmly believe we are all the better for having made that choice if we realize and truly accept that choice.

The awesome beauty of the natural forces we work with each day within ourselves and our patients is no less spectacular than the natural forces that shaped the Grand Canyon. We all share common aspirations and fundamental beliefs about the benefits of chiropractic. Let's agree to unity without uniformity in our profession. Let's rejoice in the big idea that we all share and agree to disagree on the insignificant details.

Turbulent water is all about us: you chose the path less traveled so jump in and enjoy the adventure.

Robert Martines, DC
Pres., Santa Clara County Chiro. Society

At Odds with Luke Bucci Interview

Dear Editor:

In the September 12 issue of Dynamic Chiropractic, you ran an interview with Luke Bucci, PhD, conducted by Dr. G. Douglas Andersen. While the interview was very informative there were some technical errors.

As Bucci's former employer, we would like to clarify some misrepresentations presented in this interview. Bucci stated, "... if you have too much SOD you end up with Down's syndrome ..." He also insinuates that he conducted research on SOD for six years. This information was misleading to say the least.

SOD is a natural, potent antioxidant that has been used effectively by both humans and animals for over 20 years. It has wide usage among chiropractors, medical doctors, veterinarians, and other health professionals. Research is on-going on the effects and positive impacts of the usage of SOD. It is unfortunate that Luke Bucci used your magazine to make damaging and misleading statements.

Dynamic Chiropractic has been a useful and viable source of information for the chiropractic industry, therefore we are very disappointed that you printed such misinformation from a former employee without taking steps to determine the validity of the statements.

If there are any users of SOD, or our products, who are concerned about the comments made in this article, we welcome their calls and letters.

Denis DeLuca
Pres., Biotics Research Corp.
(713) 240-8010

A Wonderful Life

Dear Editor:

I want to thank you for your efforts and the generally excellent news I am finding in your publication over the last several years. It has moved me to action on a number of occasions, the last being your article including the fax number of the sponsors of the "20/20" rerun.

And by the way, the Dr. Krieger's letter in the October 9 issue was just perfect to my way of thinking. I disagree totally with Dr. Lynn's comments on philosophy, but the sad truth about loan repayment must be handled. It took me 10 years to pay mine off, and it was "only" $7,500! I can't imagine having a nut 10 times as large. My small rural practice is perhaps not the goal of many, and I have yet to gross even $9,000 in a month, yet I feel successful. In my 17th year, I am treating the children and grandchildren of many of my original patients, I have nearly paid off my second office building, and I have a wonderful life.

Your articles on AHCPR and "A Language of Our Own" are wonderful.

J. Pedersen, DC
Sweet Home, Oregon

Dissenting View of Motion Palpation

Dear Editor,

A recent misleading article in the October 9, 1995 issue of Dynamic Chiropractic by Dr. Mark King¹ purported to "set the record straight" on misconceptions regarding the "myths" of motion palpation.

He chose my two literature reviews published in the Activator Update as an example to base his arguments about motion palpation, although I made no mention of MP in my writings. My review in the Update is based on fact taken from the articles reviewed, not my opinions, but the expressions of the authors. Dr. King focused his argument from my review of an article on zygapophyseal joint crack sounds in the cervical spine.² Dr. King attempted to address zygapophyseal joint biomechanics with an anecdotal description of what he believes happened in this study that causes the audible to come from ipsilateral side of head rotation based upon an a priori assumption of a MP set-up.

Of perhaps greater interest was Dr. King's rationalization of MP to research methodology. I found it humorous that King desires to abstain his technique from the scientific method in inter and intra-examiner reliability because he believes that MP initiates reflexogenic changes which would "change the spine" making the study invalid. This is a poor rationalization for failure to do good research. If examiner #1 determines that no fixation is present at a given level, and then examiner #2 determines that there is a fixation present, did examiner #1 cause a subluxation through MP analysis?

Dr. King states: "We re-examine the joint after the adjustment to see if joint function has improved and if so this is an indicator of a successful adjustment." If merely MP analysis of the spine will reduce or remove fixation to be identified by another examiner, how can this reasoning be used to determine if the adjustment was successful? Was it the adjustment or the MP analysis that "changed the spine." Do MPI instructors believe that merely mobilization of the spine through MP analysis will break up fixations or cause fixations for that matter?

Dr. King was dismayed at the discussion of members of the profession questioning the reliability and validity of MP. This is consistent of Dr. Innes' recent emotional comments in the DC.³ Haas and Panzer4 state in Gatterman's 1995 text: "Fifteen studies report original data on the reliability of motion palpation in various regions of the spine and pelvis. The interexaminer reliability of identifying motion or end-feel restriction at specific segmental levels was poor, averaging 0.00 to 0.15. Raters agree little more than would be expected by chance." In further review of these papers, while intraexaminer reliability was found to be better, "the findings must be viewed with caution. ... If two examiners are self-consistent but cannot agree, then at least one rater must be consistently in error."⁴

Incidentally, Dr. King's "idea" of a model to assess motion (removing the reflexogenic components of the human spine) has already been done numerous times. Jensen et al.⁵ investigated the ability of 30 student interns and 15 experienced chiropractors to detect the presence or absence of a single and multiple intersegmental motion restrictions in the lumbar spine using a spinal model equipped with artificial segmental fixators. The students were found to detect the fixations more readily than the DCs. The DCs kappa was 0.297 or fair.

The validity of MP was also discussed at the 2nd World Chiropractic Congress. The study concluded: "The best results came from the first year chiropractic students who had never been taught lumbar spine motion palpation."⁶ Thiel concludes: "Clinical experience does not seem to be of any benefit for correct palpatory identification of fixed segments in a spinal model. This would suggest that the concepts of a fixed joint as a clinical entity and of motion palpation as a diagnostic procedure need to be critically re-evaluated and assessed."⁶ I am providing other references for the examination of MP by use of a mechanical model to assist Dr. King.^7,8

Dr. King justifies that the reason students do not choose MP is because, "They do not want to take the time or put in the effort to learn and master them."¹ What he has failed to realize is that students and DCs may not choose MP, not because they don't want to put into the time, but because they have been shown so unreliable that many question their value and utility. Many, like I, adhere to the same philosophy of the great Nikolai Bogduk: "In God we trust; all others bring data."⁹

I am disappointed in Dr. King's appointment of me as an example for his inconsistent rationalizations for his emotional attachment to his technique. It seems that the overwhelming majority of negative opinions regarding the value of MP analysis could be easily addressed through proper research investigation. Until MP participates in such studies, large numbers of the profession will continue to question its value.

References

1. King M. Myths about Motion Palpation. Dynamic Chiropractic, 1995; 13(21):18-9.

2. Colloca CJ. Literature Update. Update: A Bi-Monthly Publication From Activator Methods, Inc., 1995; 10(4):25,29.

3. Innes K. What if... Take Your Best Shot, Please. Dynamic Chiropractic, 1995; 13(19):25.

4. Haas M, Panzer DM. Palpatory diagnosis of subluxation. In Gatterman MI, ed. Foundations of Chiropractic Subluxation. St. Louis: Mosby, 1995:57-67.

5. Jensen KJ, Gemmell H, Thiel H. Motion palpation accuracy using a mechanical spinal model. Eur J Chir 1993; 41:67-73.

6. Thiel H. Reliability and validity of motion palpation procedures assessed on a mechanical spinal model. Bournemouth, UK: Anglo-European College of Chiropractic. Abstract in: J Manipulative Physiol Ther 1994; 17:290.

7. Harvey D, Byfield D. Preliminary study with a mechanical model for evaluation of spinal motion palpation. Clinical Biomechanics, 1991; 6:79-82.

8. Nunn NR. A Study to investigate the reliability of detecting single and multiple motion restriction in the lumbar spine using a mechanical model. Bsc Project, Anglo-European College of Chiropractic, Bournemouth.

9. Bogduk N. Letters. Spine 1995; 20:2173.

Christopher J. Colloca, BS, DC
Marietta, Georgia

"Chicken Little" Dares to Respond

This letter is responding to the Sept. 12th "What if..." column.¹ One issue I'd like to respond to is your misrepresentation of an article by Dr. Troyanovich.² This article was not an attack on motion palpation, but rather an interesting insight into the politics of the Mercy panel. Following an incomplete and selective review of the literature, the Mercy panel concluded: "There are a few validity studies of joint palpation, although the existing literature on reliability is disappointing."³ Then in direct conflict with its own guidelines, MP was rated as "equivocal to promising." The appropriate rating for motion palpation would be, "doubtful to investigational," given the definitions provided in the Mercy document.

The next issue relates directly to your challenge to those of us who dare question the doctrine of MPI. My education and experience has led me be become increasingly skeptical of the claims of chiropractic gurus, especially when large seminar machines are directly linked to their message. The 33 references to MP that you cited are merely an interesting survey of popular opinions and an appeal to authority. They do not in any way constitute scientific evidence of validity or reliability.

Keating⁴ reviewed seven studies on the interexaminer reliability of MP and found they demonstrated marginal to no reliability. Haas⁵ concluded that research did not support the claims of examiner reliability of palpation procedures commonly used by chiropractors. Breen⁶, on the reliability of palpation, states: "The ability to locate an anatomical point, let alone detect what it does in motion, is by no means secure." Jensen⁷, reviewing 15 articles on the reliability of MP, concluded: "The literature reviewed indicated that the claims of objectivity of motion palpation of any part of the spine are not valid and that motion palpation is not an acceptable predictor of vertebral joint dysfunction, and therefore, not valid as a diagnostic tool."

White and Panjabi, among others, have described six degrees of freedom of motion between vertebral segments with rotations and translations in all three axes (x,y,z), occurring to some degree simultaneously.^8,9 Describing the change in position of a vertebra requires the use of three dimensional positional analysis, e.g., screw axis analysis. To provide motion analysis, angular velocity and acceleration would also have to be considered. These factors would have to be recalculated continuously throughout the input motion to describe the three dimensional behavior. The complexities of dynamic analysis have proven prohibitive and no quantitative data on three dimensional dynamics exists. Static three dimensional analysis has also proven to be extremely complex. Limited data in the contemporary literature has recently described only the rotational components of motion.⁹ When the complex biomechanics are considered along with the various etiologies of joint fixation, it is surprising that anyone would seriously consider that palpation through multiple layers of tissues could provide an accurate analysis of joint dysfunction. The extrapolation of end play analysis from phalangeal models in an attempt to describe spinal joint motion is extremely crude at best. The failure of MP to scientifically establish its usefulness is hardly surprising.

Gary Robertson, DC

References

Innes K. Take your best shot, please. "DC", Sept. 12, 1995;13(19).
Troyanovich SJ. Guideline for chiropractic quality assurance? or Contraindications, inconsistency and politics? Amer J Clin Chiro, 1995;5(2):1,4.
Haldeman S. Guidelines for Chiropractic Quality Assurance and Practice Parameters. Aspen Pub., Gaithersburg, MD, 1993;Ch.10:148-149,152.
Keating JC. Interexaminer reliability of motion palpation of the lumbar spine: review of the literature. Amer J Chiro Med, 1989;2:107-110.
Haas M. Interexaminer reliability for multiple diagnostic test regimens. JMPT, 1991;14.
Breen A. The reliability of palpation and other diagnostic methods. JMPT, 1992;15.
Jensen KJ. Motion palpation accuracy using a mechanical spinal model. Euro J Chiro, 1993;41:67-73.
Panjabi MM, White AA. Clinical Biomechanics of the Spine. JB Lippencott, Philadelphia.
Panjabi MM. How does posture affect coupling in the lumbar spine? Spine, 1989;14:1002-1011.

Restrictive Policies by Some Boards
Dear Editor,
In recent issues of Dynamic Chiropractic there have been a variety of interesting articles addressing the topic of student loan defaults in our profession. One article addressed the question of whether state boards are really doing their job, i.e., assuring public safety and professional competence. It is possible that these two seemingly divergent areas of inquiry are intimately related.
Student loans have a grace period after graduation, typically six months, curing which interest is not compounded, and the new graduate need not start repayment. This grace period is intended to give the graduate some time to find gainful employment, or build a private practice to a level of success which can support repayment. To do this requires a license to practice. An unlicensed graduate in today's environment finds few employment opportunities within the profession; those that exist frequently offer inadequate financial compensation.
A number of state boards have policies which make it impossible for many graduates to become licensed until after the grace period has expired, effectively nullifying the loan grace period. My own state of California requires that a candidate for licensure must have graduated at least one month prior to administration of the examination, and results are not released until 10 weeks after the exam. With the interaction of exam and graduation schedules, June and December graduates who successfully pass on the first attempt will receive licensure nine to 10 months after graduation. Policies like these greatly increase the likelihood of financial failure and default, and apply tremendous pressure to the new doctor to do anything, however unethical, to generate income.
Many states allow candidates to sit for the exam during their internship, and withhold the license until the candidate has graduated. This approach allows new doctors to fully utilize their grace periods, is equally effective in ensuring competence and public safety, and helps to reduce predation by established practitioners. In the absence of a clear rationale for the existence of restrictive policies by state boards, it is likely that such policies exist solely to protect the business interests of established doctors by restricting competition from an influx of new graduates. Such policies may help established practitioners in the short term, but undeniably damage the profession as a whole.
Examine the conduct of the board in your state. If you find it engages in insupportable restrictive policies, lobby for reform. If we want to "grow" this great profession of ours, we have to stop "eating our seed corn."
Robert Ward, DC
Long Beach, California

Responding to "All around the Licensure Bush"
Dear Editor:
The Minnesota Board of Chiropractic Examiners (MBCE) has reviewed a letter in a recent edition of "DC" (Sept. 25, 1995) concerning a request that its license examination be administered at an out-of-state location by a member of another board due to a health emergency in the applicant's family. Unless licensure is granted, the MBCE is unable to discuss the specifics of any particular application under the Minnesota Government Data Practices Act. Nevertheless, the MBCE would like to take this opportunity to comment on the policies which underlie MBCE examination procedures generally, and some of the difficulties posed by requests for exceptions.
The development of an examination takes the efforts of many people (including board members, staff, and the chiropractic community) many months to develop. One of the many details given a great deal of attention is the security of the examination. Any breach of security, whether intentional or unintentional, can have serious ramifications. For example, if 100 candidates take the examination and the board suddenly receives information that a certain population had access to the contents, what kind of decisions need to be made then? Do you simply pass everyone, to be fair to those who didn't have access to the exam? Or do you pass no one, re-administering a new exam? In the first case, you run the risk of passing those who may ordinarily be unable to pass an examination through poor preparation or possibly incompetence. In the second case, you require those who have already taken the exam in good faith to subject themselves to an additional mental anguish of retaking the examination, through something that was no fault of their own. Neither option is a good one, and all of them offer significant potential liabilities to the board, the profession, and the public. The only best option that exists is to prevent the possible breach of integrity of the examination from the beginning. The MBCE goes to exceptional lengths to this end.
A second issue to consider is that this examination is not just thrown out to untrained examiners to give. The examiners and proctors go through significant amount of discussion and training to provide this examination. A candidate will come into contact with 16 separate examiners during the course of a normal MBCE practical examination. This does not include three hours of written examinations, and x-ray practical examination provided on a separate day. The logistics of making all this available to one person in the state of Kansas appeared to be insurmountable. In taking this action, the MBCE not only protected the security of the examination, but protected it's integrity and quality as well.
Finally, requests for exceptions are submitted to the executive committee of the MBCE and reviewed thoroughly. Attempts to accommodate applicants, including the administration of the examination on a single day, rather than the normal two-day period, are made whenever possible. It may also be noted that in all cases, private written responses to applicant requests for exceptions are provided.
Larry Spicer, DC
Executive Director
Minnesota Board of Chiropractic Examiners