Editor's note: In July 1999, Israeli army orthopedist Dr. Haggy Amir launched the "One-Year Zrifin IDF Military Chiropractic Project" in conjunction with the Israeli Chiropractic Society (ICS). Dr. Amir had been introduced to chiropractic in the U.S. years earlier. The ICS members who volunteered to serve their military reserve duties as practicing chiropractors joined the main IDF Orthopedic Clinic.
There are no chiropractic laws, guidelines or an examination board in Israel. The Israeli Chiropractic Society has an ethics committee, but not all the chiropractors are members or abide by those by laws. There is a ministry of health professional recognition certificate and chiropractic malpractice insurance. As a result of no chiropractic law, chiropractic is not included in the state health care reform or in basic medical plans. By law, due to state liability, all army personnel may receive only medical services from the basic medical plan professionals who are employed or recruited by the army in the army clinics or hospitals.
The chiropractors who agreed to volunteer for the project were scheduled for a one-day session in a treating room that included a flat bench physiotherapy Hi-Lo table, an interferential/HVG multi-stim and suction device, and hot and cold packs.
The participating patients were soldiers from all the military divisions and branches, from the low-level ranks to generals, men and women on duty, ages 18 to 45. They were referred to the chiropractic project by Army Reserve orthopedists after receiving conventional analgesics and physiotherapy with no improvement.
The participating chiropractors were randomly ranked from different fields and educational experience on the common ground of volunteering for the project. Differences were expressed in terms of colleges attended; philosophy; examination and practicing habits; techniques used; and level of clinical approach (such as from a universal 3-5 minute adjustment/activator treatment approach, to a multilevel musculoskeletal approach that includes soft tissues, trigger points, rehabilitation and posture prevention advice). No specific guidelines were set forth, but a uniform examination chart, questionnaire and the Ronald-Morris Disability Index were mandatory.
The definitions of chiropractic given by the volunteered chiropractors to the army doctors varied, except for the common agreement that chiropractic treats the skeletal system by different means, especially by manual manipulation.
The main orthopedic medical diagnoses the patients received before entering the project were lower back pain from various sources. After 14 months of the project, the patients were contacted and given a questionnaire for their subjective impressions of the care, the duration of improvement, and overall satisfaction from the treatments.
Preliminary Report Results
- There were 120 patients: 57 percent were older, salary-based army personnel; 43 percent were young trainees.
- There were 1,561 treatments (visits) over the course of 185 working days. The average number of visits per working day was 8.5. The low number of average visits per day was attributed by the IDF chief orthopedist to variation in treatment schedules among the chiropractors, difficulties scheduling their visits, and the fact that the bases are a two- to-three-hour drive from the periphery of the country.
- The averaged treatments per patient were 14 for the older soldiers, and 11 for the trainees.
- The range of treatments was two to 77 visits, while 82.5 percent were treated for 20 visits or less.
- Seventy-five percent of the patients indicated overall improvement in function after treatments.
- Improvements held up to two months post-treatment while the patients went back to their units, but 13.3 percent reported no improvement.
- Five percent of the patients indicated that they had to change or modify their professional activities or work due to their ongoing medical and chiropractic problem. Examining the position or work modifications revealed that it was common in the patients who received more than 20 visits, i.e., 14.3 percent vs. 3.1 percent (p<0.05).
Impressions of the Chief Orthopedist
Impressions were based upon the chief orthopedist's subjective impressions. During the project he received patient feedback while he re-examined them, and verbal feedback from the chiropractors and medical management of the Zrifin Army Medical Center.
- Less than half of the chiropractors in Israel served their military duties in this project. It may be because they preferred developing their private practices; also, 20 percent of the chiropractors in Israel are women and cannot serve in the military reserves under Israeli law; or because 30 percent of them are above the age of recruitment or did not serve in the army at all (such as Jewish Americans); or it may be because chiropractors who serve as professional soldiers in their previous base units do not want to give up their positions in the army reserves; or it may be because chiropractic is not yet licensed in Israel, and the army cannot recruit legally nonestablished medical professionals and enforce them to serve as chiropractors.
- There is a significant variation among chiropractors in clinical expertise and treatments for the same complaints.
- Due to the short period of service among the chiropractors, the same patient was treated by an average of 2.2 chiropractors per case management. This, in fact, led to the above-mentioned problematic professional practice and interfered with the overall quality of chiropractic care.
- There was a tendency among the chiropractors to continue chiropractic care even though the patient was not progressing. It sometimes contradicted the medical/orthopedic quality assurance practice terms by which such patients are discharged from treatments or referred to another specialty.
- As the medical supervisors of the project, it was a great difficulty to oversee the quality of services rendered, due to our lack of chiropractic background (academic and scientific).
- Although there was clear evidence of significant patient satisfaction and patient recovery (75 percent) and a low disability average among the patients, some patient complaints and discrepancies in practices among the chiropractors did not favor the overall project.
- The large distances to the Zrifin Army Medical Center from the outlying areas interfered with providing good and efficient professional health care services throughout the country.
- Some partial solutions for the above-mentioned problems may be:
- Divide the country into three regions (North, Central and South) and establish regional military-based chiropractic clinics.
- Refer the army personnel with special vouchers to all the private chiropractic clinics in Israel, mandating specific modes of care guidelines.
- The same as above, but within the pain clinics of the regional main public hospitals.
- Discontinue the chiropractic services within the IDF until an established legislature, scope of practice and clinical guidelines for chiropractic are established in Israel.
We would like to thank all the volunteered chiropractors that spared time to join this project. We would like to especially thank Ofer Baruch,BSc, DC,DABCO, and Ronen Mandelzis,DC, for the time they spent helping organize this project. Chiropractic in Israel has a long way to go, yet with the state legislation, the consisted scientific literature and the practice guidelines, it has an important place among the health care professions.
Lieutenant Colonel Aaron Firestone,MD
Lieutenant Colonel Haggy Amir,MD
Chief Orthopedists of the IDF
Zrifin Army Orthopedic Department
Zrifin Army Medical Center