How Will Research Determine the Future Role of Chiropractic?
SOURCE: Clinical Chiropractic (March 2010)
By Scott Haldeman DC, MD, PhD, FRCP(C)
Department of Neurology, University of California, Irvine, United States and the Department of Epidemiology, School of Public Health, University of California, Los Angeles, United States
The past 20 years has seen a marked increase in the amount of research into the epidemiology, diagnosis, and treatment of disorders associated with the spine, especially back and neck pain. The therapeutic benefit of spinal manipulation for back and neck pain is no longer seriously questioned and there are growing research efforts to look into the impact of this treatment approach on other conditions, especially certain types of headache. At the same time, we are in a serious healthcare debate that is, amongst other issues, focusing more attention on cost containment and preventative heath care.
The research support for spinal manipulation has resulted in the situation where chiropractors are generally accepted as valuable members of the healthcare team. The acceptance of chiropractic has resulted in a debate within the profession concerning the future role it wishes to play within this team. There are three roles that chiropractors could potentially fulfill in the future and each requires consideration.
The first potential role is that chiropractors decide to limit their practice to that of a skilled practitioner of spinal manipulation or adjustment. Most chiropractors already practice in this role, but it does have its limitations. A practitioner skilled in a limited field classically accepts patients from the primary care clinician who sees the patient first. When the skilled treatment has been offered, is expected that the patient will be released back to the primary care clinician. There is some competition for this position particularly from physical therapists who are increasingly conducting research and offering manual therapy to patients.
The second potential role is to attempt to assume the role as a wellness/holistic clinician focusing on preventative healthcare therapies. The problem with this approach is that almost every other healthcare clinician, including family physicians, specialists, naturopaths, Chinese medicine practitioners, nurse practitioners and physical therapists are already very active in offering this service and the chiropractic profession is not active in research into any of the preventative or wellness therapies. It is unlikely that chiropractic could attain the level of expertise or conduct the amount of research necessary to compete and be recognized as the authority in these fields.
Recent publication of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders and a Special Issue of The Spine Journal on Evidence Informed Management of Chronic Low Back Pain stressed the high cost and disability associated with spinal disorders, especially back and neck pain. These publications emphasized the fact that many of the treatments that have been demonstrated to be effective in the management of back and neck pain such as exercise, education, mobilization, manipulation and NSAIDs are neither high tech nor expensive and could easily be offered by chiropractors. It also became evident from these and other studies that there are multiple professions and treatment approaches for these conditions but no profession has attained the cultural authority to be considered a primary spine care clinician knowledgeable about all current methods of managing spinal disorders and who would be readily available to patients. This gap provides an opportunity to the chiropractic profession that would lead to a much greater role in the management of patients.
The position of primary spine care clinician assumes that the chiropractor will become the most knowledgeable clinician in the field. This will require a change in the culture of the profession. Practising chiropractors will be expected to attend the major chiropractic research meetings such as the World Federation of Chiropractic and the RAC conferences. They will have to participate in greater numbers in the inter-professional spine research meetings such as the North American Spine Society Congress. They will also be required to subscribe and read the major spine journals in order to achieve the knowledge necessary to become the authority on the spine. Chiropractic colleges will have to change the curriculum to train students to accept this role. Graduate continuing education programs will have to include a strong scientific component.
It is not yet clear whether individual chiropractors, the colleges or the state and national associations have the desire or have made the decision to become the primary care spine clinician, will try to compete in the delivery of wellness services, or will elect to maintain their limited role as a practitioner offering spinal manipulation. It will be very interesting to see what role the chiropractic profession will decide to assume in this very exciting evolution of health care.