Over the past three decades, the profession has held sway over spinal manipulation and adjustment by sheer weight of inertia and the absence of competition. This is a fact memorialized scientifically by Shekelle, et al.,16 when they observed that in the late 20th century, DCs performed 94 percent of billed manipulation procedures. Osteopathic medicine, an early player in the field, had essentially abandoned its interests in favor of adopting the allopathic mantle. Physical therapists officially disavowed any familiarity, interest or need for spinal manipulation in-patient care. By default, chiropractic providers were granted jurisdiction over an area deemed of marginal value.
Then came the Agency for Health Care Policy and Research (AHCPR)b and its publication of the guidelines for treatment of acute low back pain in adults. That consensus process of experts reviewed the scientific literature and established a formal recognition of clinical value for the use of high-velocity, low-amplitude thrusting procedures in care of these patients.2 It was a watershed event.
Table 1. The Stages of Professional Development and Jurisdictional Control
|Theory Formulation||Collation of observations and knowledge base into a theoretical foundation for the discipline|
|Claim to Authority||Provision of services to the public for a fee|
|Claim Legitimization||Legislative licensure and regulation of providers of services, setting standards of, and basis for, protection of the public|
|Competition||Other groups claim authority and legitimacy to perform the same services|
Will chiropractic continue to dominate this field of health care? What does it take to sustain jurisdictional control? The answers to these questions depend on many factors, not all of which are under the profession's direct control. There is, however, substantive information to help construct a successful long-range strategy.1,23 There are many lessons to be learned from the study of other health professions and their evolution. How jurisdictional control is granted to a group of professionals and how it is maintained is a matter of study for those who specialize in organizational management. Abbott (1988)1 produced a landmark work that summarizes these steps, and can be used in creating strategy to meet modern challenges.
Abbott divides professional development into four stages (Table 1). The underpinnings of chiropractic jurisdiction were established by the formulation of an initial distinct theory of health/disease and the use of adjustment/manipulation as a primary means to intervene. Claims of authority were made by the teaching and spread of practitioners throughout North America and now, the world. Legitimization was completed in the United States by the granting of licensure status in the state of Louisiana in the early 1970s. While established in over 60 countries,4 the processes of regulation and recognition continue throughout the world, even today. Beginning in earnest during the 1990s, we have entered the era of competition. With the advent of the AHCPR (and other) guidelines, organizational naysayers of the past now are scrambling for ownership of spinal manipulation. The tortured logic of Medicare14 and the APTA,13 as they strive to circumvent the will of Congress and take control of spinal manipulation for the elderly by seeking regulatory versus statutory legitimization, is well known.
Similar efforts are being undertaken in many states and in Canada. Stanley Paris,PT,PhD, has opened a school for physical therapists in Florida with emphasis in manual medicine and high-velocity spinal manipulation. Medical manipulators challenge chiropractors in Europe. Osteopathic colleges offer web sites claiming to be the scientific and clinical experts in spinal manipulation and its application in musculoskeletal and nonmusculoskeletal health and disease. The medical specialty of physiatrists now claims greater knowledge and use of alternative medicine therapies than general practitioners with recommendations that these methods (particularly manipulation, acupuncture and biofeedback) "be incorporated into physiatry residency training and be the focus of future research ... to meet the public demand for such approaches in the decade to come."12
Chiropractic, as the incumbent by default and by experience, faces substantial challenges to future social authority and jurisdictional control. So, how does one sustain jurisdiction over professional services and fend off spurious claims? Again, Abbott's study of the growth and development of professions documents how challengers succeed or fail at subsuming jurisdictional authority over services.
"If the incumbent's efficacy is poor, efficacy will be emphasized by its challengers. If, on the contrary, theoretical efficacy is high, but discipline is poor, a challenger will argue that its disciplinary power augments its overall efficacy enough to offset any advantages of the incumbent's theory."1
So, are we more efficient? Can chiropractors perform this service within their practices with greater skill and effectiveness than our competitors? Pardon me while I flinch from the resounding, "Of course we are! Of course we can!" OK, where is the evidence?
In a recent edition of Dynamic Chiropractic (October 1, 2001), a casual survey of the profession yields only 28.9 percent who claimed to be excellent in adjusting skills. In another DC survey (October 29, 2001), the opinions on the time in practice necessary to be considered skillful ("really good") exceeded two years in practice for 42.9 percent of respondents. Cohen, et al.,5 produced data to show that mere training under typical classroom conditions was insufficient to provide skill. Moreover, crossover skill from one procedure to another does not occur. Experienced chiropractors could not translate their proficiency in practiced procedures to comparable skill in familiar but unpracticed procedures. In the study by Curtis, et al.,6 family practice physicians were specifically trained in a few osteopathic procedures during weekend warrior courses. They were explicitly trained for familiarity, but not to be "experts." Their result in use of these procedures on low back pain was no better than for standard medical practice without manipulation! Skill seems to matter!
How do we move our professional pride and confidence to the legislative halls and effectively define our superior knowledge and application? One powerful element would be the ability to quantitatively define the administration of a "good" versus a "bad" adjustment/manipulation and then demonstrate that trained and licensed DCs are able to perform that level of service at a minimum! This is not a pipe dream. The technology to accomplish this is at hand. The cost is extremely reasonable. What we need is the professional will and confidence to put it to use.
Building on the work of a number of authors (for example, those referred to in references 3;5;7;8;10;11;17;19-22), a clinically useful, instrumented treatment table has been constructed that is able to accurately sense the loads acting through the patient during a spinal adjustment.15 Recent work in our laboratory has demonstrated that with this device we can measure the improvement that occurs in student performance over the course of training. More importantly, we now have evidence that specific aspects of skilled performance can be targeted. With use of additional new technology to provide individual, quantitative feedback of performance during training, students can now be given meaningful homework assignments in technique to practice and electronically turn in results to their professors. In fact, in a randomized trial, students following a regular schedule of rehearsal at home in addition to classroom training outperformed their counterparts who relied only on classroom training on some measures by as much as a factor of nine times 18! Graduating and licensing doctors of chiropractic who are "certified expert adjusters/manipulators" is within our grasp.
What now remains is the work to show that opinions on what constitutes performance of a "good" versus a "bad" manipulation/adjustment relates to a successful clinical outcome. Logic and professional pride force that conclusion. Future science will tell. What may be more important is that we are now empowered to find out. Do we have the professional will? At the end of the game, what will be the final score for our team?
- The National Institute for Neurological, Communicative Disorders and Stroke (NINCDS) was an agency of the US government and a branch of the National Institutes of Health. It has now been reorganized into separate agencies.
- This organization has been renamed the Agency for Health Quality Research (AHRQ).
- Abbott A. The System of Professions an Essay on the Division of Expert Labor. Chicago: The University of Chicago Press, 1988.
- Bigos S, Bowyer O, Breen G. Acute Low Back Problems in Adults. Rockville, MD. 1994. Clinical Practice Guideline No. 14.
- Byfield D. Cervical spine: manipulative skill and performance considerations. European J Chiropractic 1991;39:45-52.
- Chapman-Smith D. The Chiropractic Profession. Des Moines, IA: NCMIC Group, Inc., 2000.
- Cohen E, Triano JJ, McGregor M, Papakyriakou M. Biomechanical performance of spinal manipulation therapy by newly trained vs. practicing providers: does experience transfer to unfamiliar procedures? J Manipulative Physiol Ther 1995;18:347-52.
- Curtis P, Carey T, Evans P, Rowane MP, Garrett JM, Jackman A. Training primary care physicians to give limited manual therapy for low back pain: patient outcomes. Spine 2000;22:2954-9.
- Gal JM., Herzog W, Kawchuk GN, Conway PJ, Zhang Y. Biomechanical studies of spinal manipulative therapy (SMT): quantifying the movements of vertebral bodies during SMT. J Can Chiro Assoc 1994;38:11-24.
- Gatterman MI, Hansen DT. Development of chiropractic nomenclature through consensus. J Manipulative Physiol Ther 1994;17:302-9.
- Goldstein M. The Research Status of Spinal Manipulative Therapy. Bethesda, MD: US Department of Health, Education and Welfare, 1975.
- Herzog W, Conway P, Zhang Y, Gal J, Guimaraes ACS. Reflex responses associated with manipulative treatments on the thoracic spine: A pilot study. J Manipulative Physiol Ther 1995;18:233-6.
- Kawchuk GN, Herzog W. Biomechanical characterization (fingerprinting) of five novel methods of cervical spinal manipulation. J Manip Physiol Ther 1993;16:573-7.
- Ko GD, Berbrayer D. Complementary and alternative medicine: Canadian physiatrists' attitudes and behavior. Arch Phys Med Rehabil 2000;81:662-7.
- Petersen DM. APTA Claims Rights to "Correct a Subluxation." Dynamic Chiropractic 2001. http://www.chiroweb.com/archives/19/13/02.html.
- Petersen DM. Senator Thurmond questions Shalala's report. Dynamic Chiropractic 2001. http://www.chiroweb.com/archives/17/14/17.html.
- Rogers CM. Response characteristics and fidelity analysis of a spinal manipulation treatment table with an imbedded force plate. Masters dissertation in biomedical engineering, University of Texas at Arlington 2001.
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med 1992;117:590-8
- Triano J. Biomechanics of spinal manipulation. Spine 2001;1:2,121-230.
- Triano JJ, Rogers CM, Combs S, Potts D, Sorrels K. Developing skilled performance of lumbar spine manipulation. JMPT (in press).
- Triano JJ, Schultz AB. Motions of the head and thorax during neck manipulations. J Manipulative Physiol Ther 1994;17:573-83.
- Triano J, McGregor M, Skogsbergh D, Mior S, Sportelli L. Rating of skill in SMT. ICSM Conference Proceedings, Foundation for Chiropractic Education & Research, Arlington, VA: 1994.
- Triano J, Schultz AB. Loads transmitted during lumbosacral spinal manipulative therapy. Spine 1997;22:1955-64.
- Triano J, Skogsbergh D, Mior S, Sportelli L. Biomechanical parameters of skill in lumbar SMT. ICSM Conference Proceedings, Foundation for Chiropractic Education & Research, Arlington, VA:1994.
- Triano JJ. Chiropractic personnel in the 21st century depends on the strategy today. Top Clin Chiro 2000;7:27-32.
Co-director, conservative medicine Director, chiropractic division
Texas Back Institute