|Preston Fitzgerald, Sr., the founding director of the National Board of Forensic Chiropractors, has nearly 20 years of extensive clinical, consulting, administrative, teaching, and courtroom experience as a nationally recognized expert witness in litigation.
We cannot escape regulation. Whatever we do in our practices requires that we learn our rights, scope of practice, standards of practice, and choice of manual therapies and modalities. Virtually no activity of chiropractic practice escapes regulation. In my perspective as a forensic chiropractic examiner, widespread criticisms of practice and theory go largely unchallenged from a scientific standpoint. DCs have not developed explicit evidence-based practice guidelines that are framed as recommendations for best practices in prevention, diagnosis, and treatment of common conditions seen in our practices. Such guidelines can challenge the criticisms of our practices and improve the efficiency and effectiveness of prevention, care paths and management - by reducing the wide variance in practices, then by moving the mean or median of process and outcomes statistics toward recommended levels.1
This column is designed to provide the chiropractic professional with insight into the application of rigorous forensic scientific and intellectual processes currently expressed at greater length and in greater detail, by a variety of stakeholders.
The Medical and Scientific Criticism of Chiropractic Tenets
Critics say that chiropractic is based on unscientific and unproven theory, and that although it has had more than 100 years to make its case in the medical and scientific arenas, it has utterly failed to do so. Critics are also aware of a chiropractic profession that is divided and struggling to find a way to prove its basic tenets. In other words, we are viewed as a profession seeking a standard of practice. The scope of practice in chiropractic varies from state to state and is regulated by the licensing and regulatory agencies. Each state also may have legal interpretation by an attorney general. Our scope of practice is further defined in legal statues as restrictive or broad-spectrum.
For example, in some states with restrictive scopes of practice, the chiropractic professional cannot perform vital signs. The evidence-based literature clearly indicates that vital signs are an essential part of measuring health. The war of words from the medical and scientific communities requires the chiropractic profession to evaluate the evidence and determine what part of chiropractic examination, manual procedures, knowledge areas and professional functions have failed to make its case in the medical and scientific arenas. We have many skill sets that are being criticized. A careful forensic analysis of all the elements of chiropractic practice must be undertaken in order to respond in an evidence-based approach that includes case history; physical examination; neuromusculoskeletal examination; X-ray examination; laboratory and special studies; diagnosis; chiropractic technique; adjunctive care; case management; and the specific knowledge areas.2
The first step in the DC's response to medical and scientific criticism is evidence-based. The profession should focus on conditions commonly seen in a chiropractor's office. The focus should be on identifying and evaluating the high-quality medical studies that relate to chiropractic. For every topic, there should be a search of the National Library of Medicine's MEDLINE database. There should be a review of each article that is relevant to answering the question at issue, and that meets the following criteria:
- The article is written in the English language with any of the following attributes:
- It is a systematic review or meta-analysis of the relevant medical literature;
- the article reports a controlled trial - randomized or controlled;
- the article reports a cohort study, whether prospective or retrospective; or
- the article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention, the outcome of which is being assessed.
Chiropractic is playing an increasingly important role in helping injured workers recover and return to productivity, and the costs of chiropractic are growing as a total percentage of workers' compensation costs. There has been significant variation in treatment patterns from one chiropractic provider to another, and there is lack of agreement among payors and other providers concerning the appropriate role of chiropractic.
The only national guidelines for the chiropractic profession, the Mercy Guidelines,6 were published in 1992 and are no longer current. Furthermore, they were developed as "consensus" guidelines, whereas current medical practice and recent court decisions are demanding that guidelines be based on scientific evidence - specifically, high-quality medical studies published in the peer-reviewed medical literature. In recent years, there has been burgeoning growth in such studies. For example, the MEDLINE database has 364 studies involving low back problems in 1990, compared with 1,148 in 2001. Even more dramatic, a search of chiropractic manipulation results in only one study in 1990, compared with 27 in 2001.
Evidence-based medicine is driving the need for new chiropractic guidelines, and increasingly, the evidence is there to support (or refute) the use of various chiropractic treatments for various conditions.
An Overview of Evidenced-Based Chiropractic Guidelines
In 2000, I was involved in the first attempt to establish chiropractic guidelines by the Work Loss Data Institute (WLDI).3 The primary focus of the guidelines was to provide normative standards for time away from work for every illness and injury, and to identify those factors that make a difference in return-to-work. Later, the WLDI added "Best Practice" Physical Therapy Guidelines, and since then, many of their subscribers have requested that it also add chiropractic guidelines. In addition to providing guidance to the guidelines, I have had numerous discussions regarding the need for chiropractic guidelines with the principals of WLDI and executives from Marymount College, as well as Dr. Jay Triano of the Texas Back Institute, who was affiliated with the Council on Chiropractic Guidelines & Practice Parameters (CCGPP).4 The latter collaboration resulted in the development of a proposed chiropractic guidelines project to be published by the two groups.
This cooperative venture will enable the CCGPP to produce a document that will assist its stakeholders in providing and or assessing efficacious chiropractic health care, while simultaneously enabling the WLDI to have viable and contemporary chiropractic health care guidelines to market to potential clients. A Web site is being set up as a vehicle for stakeholders to provide input on draft versions of the guidelines.7
Our editorial advisory board for chiropractic guidelines will be led by Philip L. Denniston, Jr., editor-in-chief; Charles W. Kennedy, Jr., MD, medical editor, and myself, as chiropractic editor; Dr. Kennedy, in addition, has been a member of the American Academy of Orthopaedic Surgeons; Board of Councilors; Evidence Analysis & Clinical Guidelines Development Committee; and Complementary & Alternative Medicine Committee.
In future articles, I will invite chiropractic professionals, medical researchers, epidemiologists, criminal and legal forensic experts to contribute to this discourse on forensic issues. I will address also the contemporary forensic issues that affect chiropractic professionals and their practices.
It will be my attempt to help you understand the lexicon of high-quality research methodology and algorithms of forensic chiropractic, such as an analysis of the specificity, sensitivity, and predictive power of mechanisms of illness or injury, symptoms, signs and tests. Guidelines have existed for centuries, in forms ranging from Sanskrit and Greek protocols for practice, to folk medicine practices, to rigorous, scientifically tested algorithms.5
- Journal of the American College of Occupational and Environment Medicine. Development, Use, and Evaluation of Clinical Practice Guidelines. Vol.39, Number 1, January 1997
- National Board of Chiropractic Examiners. Job Analysis of Chiropractic. Greeley, Colorado; January 2000.
- Work Loss Data Institute. Official Disability Guidelines (ODG) 2002, 7th annual edition., Corpus Christi, TX 78471. www.worklossdata.com.
- The Council on Chiropractic Guidelines for Practice Parameters (CCGPP). www.ccgpp.org.
- Field MJ, Lohr KN. Clinical Practice Guidelines. Washington, DC: National Academy Press; 1990.
- Haldeman S, Chapman-Smith D, Petersen D. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference. 1992 Aspen Publications, Gaithersburg, Maryland.
Preston Fitzgerald, Sr., DC, CDE-I, CICE, CIFCME
Manning, South Carolina
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