The 3-2-1 (three times a week for four weeks, two times a week for four weeks, one time a week for four weeks) schedule of chiropractic visits is commonly used in the profession. I have not found a specific reference stating who first originated the 3-2-1 treatment schedule, but Dr. Rick Wren of Sherman, Texas, a longtime Parker Seminars attendee and Parker team teacher, indicated to me that the practice began being taught in the Parker Seminars circa 1981.
Modern treatment guidelines are based upon the treatment of specific conditions, one example being low back pain. Those types of approaches have included the Mercy Center Consensus Conference guidelines,1 the U.S. Agency for Health Care Policy and Research clinical practice guideline on acute low back problems in adults,2 and among others, the American College of Physicians and American Pain Society's clinical practice guideline.3
Historically, prior to these formalized guideline processes, treatment recommendations in chiropractic varied widely from an occasional "as needed" capacity to extensive care consisting of selling a three-month service whereby the patient presented for evaluation (but not necessarily adjustment) six days per week over that time period;4 to even more aggressive treatment schedules advocated by practice management companies.
But what did D.D. Palmer, do in terms of treatment recommendations? What "Old Dad Chiro" recommended for his patients may surprise you.
Health Care at the Time of Chiropractic's "Birth"
Health care in the 19th century was quite different than that it is now. In that era, the healing arts were a hodgepodge of capricious theories, practitioners and practices. These approaches included allopathy, herbalism, Thomsonism, homeopathy, Grahamism, hydropathy, Seventh-Day Adventism, phrenology, Fletcherism, Christian Science, magnetic healing, osteopathy, patent medicines, Mesmerism, electro-medicine, divine healing and physical culture.5
Although allopathic medicine is the primary method of care in today's society, at the turn of the 20th century, a visit to an allopath was often a last resort. Patients were regularly afraid of the techniques of heroic medicine practiced by the medical regulars. The treatment was often more harmful than the disease itself. Allopathic physicians believed the harshness of the remedy should be in proportion to the severity of the disease. This meant the sickest patients often received the most invasive treatments.5
It must also be remembered that back then, there were no effective treatments for many of mankind's ailments. For example, penicillin would not be discovered until 1928 and would not become mass produced until 1943. The biggest killer of humans in the era of the founding of the chiropractic profession was not heart disease (a condition of the 21st century caused predominantly in the U.S. by an unhealthy lifestyle), but rather, the infectious diseases pneumonia and tuberculosis.
It should be no surprise, then, that D.D. Palmer, practicing his newly discovered healing art of chiropractic in the Ryan Building in downtown Davenport, Iowa, received patients presenting with a wide variety of disease entities – not the predominantly musculoskeletal complaints the modern chiropractic practice sees. His treatment recommendations were empirical or experiential and open-ended, as his patients were not relatively homogeneous in their presentations, as they are today.
D.D.'s Treatment Plan / Recommendations
Palmer maintained an inpatient facility with 42 rooms. Meals were also provided for many of his patients at a cost of 15 cents each. In 1897, he charged $3.00 for a weekly stay in one of his furnished rooms.6 By 1902, he charged a global fee of $7.00 per week for both room and board.7 Consultation with the doctor was free and treatment was charged by the week – essentially a case fee:
Treatments, $10 for the first week and $5 for each week afterwards, except lupus, cancers, tumors, and special cases, which are twice the above prices. Treatment and rooms to be paid for one week in advance.6
In 1897, Old Dad Chiro kept his office hours to the afternoon and evening, typically seeing patients from 1:00 p.m. to 6:00 p.m.6 By 1902, he had expanded his adjusting hours to 1:00 p.m. to 8:00 p.m.7 He adjusted patients six times per week: Monday through Saturday.
Six adjustments per week at a cost of $10 per week results in a per-adjustment fee of $1.67. In today's dollars, that would amount to about $275/week. Of course, health insurance would not be available until the 1920s to defer health care costs.
Rather than recommending lengthy treatment plans, he recommended care a week at a time:
"The osteopaths charge by the month. Why do I charge by the week? Because the Chiropractic cures many in one or two weeks. It would not be justice to charge such for a full month. Our patients average about two weeks' treatment."8
Additionally, he did not believe he could cure everything and every patient under the sun:
The system is not a cure-all, but the number of desperately bad cases successfully treated is so large as to excite amazement. When incurable cases come to Dr. Palmer, who is the soul of honor and honesty, [he] frankly informs those interested that there is no hope, saving them unnecessary disappointment and expense.7
D.D.'s Practice and Schedule vs. Yours: Different or Similar?
Patients presented to D.D. Palmer's chiropractic infirmary with a wide variety of ailments, as opposed to today's relatively homogenous patients with predominantly musculoskeletal complaints. As a result, there were no guidelines established to determine optimum treatment frequency or duration of care to achieve positive clinical outcomes.
The first published prospective, randomized trial, the gold standard for determining effectiveness and optimum treatment doses, would not occur until 35 years after D.D. Palmer's death.9 Without those types of scientific methods to evaluate health care interventions, treatment recommendations in the early years of chiropractic were based on empirical observation and experience.
D.D. Palmer reasoned he needed to see patients frequently enough to reduce their spinal subluxations, so that their natural healing powers could effect a cure. Consequently, he had an inpatient facility where he could adjust his patients six times per week. He recommended care on a weekly basis and it was claimed that the average case required about two weeks of ongoing adjustments. He believed he knew the limitations of his treatment method and did not accept every patient who presented to his infirmary.
References
- Hademan S, Chapman-Smith D, Petersen DM. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference. Gaithersburg, MD: Aspen Publishers, 1993.
- Bigos SJ, Bowyer OR, Braen GR, et al. Acute Low Back Problems in Adults. Rockville, MD: U.S. Department of Health and Human Services (Agency for Health Care Policy and Research), 1994.
- Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annal Intern Med, 2007;147:478-491.
- Marlow RS. R.S. Marlow System for Conducting a Chiropractic Office. San Antonio, TX: R.S. Marlow, 1937.
- Armstrong D. Metzger-Armstrong E. The Great American Medicine Show. New York, NY: Prentice Hall, 1991.
- Palmer DD. Dr. Palmer. The Chiropractic, 1897;9(17):1.
- "What We Treat With The Chiropractic Science" (paid advertisement). The Davenport Times, 14 June 1902:14.
- "I Offer Something Different=Better" (paid advertisement). The Davenport Times, 13 December 1902:15.
- Marshall G, Blacklock JWS, Cameron C, et al. Streptomycin treatment of pulmonary tuberculosis. British Med J, 30 October 1948:769-782.
Editor's Note: The Association for the History of Chiropractic (AHC) has preserved the credible history of the profession as its sole mission through the publication of the scholarly journal, Chiropractic History. Stories such as this one may be accessed through the pages of the AHC's journal (www.historyofchiropractic.org).
