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Primary Spine Care Practitioners

Primary Spine Care Practitioners

The Chiro.Org Blog

SOURCE:   Chiropractic & Manual Therapies 2011 (Jul 22); 19: 17 ~ FULL TEXT

The following is an interesting and well crafted article that posits yet another fanciful way to bring chiropractic “out of the closet”.   I do have some issues with a few of Dr. Murphy’s recommendations, however:

1. In the Necessary Skill Set section of the article under point#2, he states that the “primary spine care practitioner” would employ those methods shown to be evidence-based, minimally invasive and cost-effective…one of them being the prescription of non-steroidal anti-inflammatory and non-opioid analgesics to their patients.

Our Iatrogenic Injury Page contains numerous articles detailing how NSAIDs and other analgesics are associated with the death of tens of thousands of people every year, for solely relying on them for pain relief. I just don’t see me EVER recommending them.

This is a genuine scientific conundrum:
how can anything that kills that many people still be referred to as “evidence-based”?

2. In the Obstacles To The Implementation section under point#5, Dr. Murphy states that “For whatever profession or professions that respond to the need for a primary spine care practitioner, this will be a significant disruption to the traditional practice patterns or self-image of these professions. As a result, the role that we are introducing here will be actively resisted”. Oh how true!

When you look closely at the “expanded practice” movement, the first thing I noticed was that this movement is being promoted by the chiropractic schools that have the lowest enrollment of students. I suspect that they are hoping to (or already have) developed an “expanded practice” program that will attract more students, and that’s understandable, if expanding your income is your primary objective.

3. Finally, there is the subtle hint that becoming an “expanded practice chiropractor” (or medi-practor) will increase the doctor’s “market share”. It may even be true. But, if that also means embracing the kind of evidence-based care that kills thousands a year, I say “no thank you, sir”.

Please don’t get me wrong: I have tremendous respect for Dr. Murphy and the other authors. This article is well written and logical… to a point. I am posting it on our blog because I agree that our profession needs to review this material and see if it can be tweaked just a bit. Most of these suggestions are valid. I just don’t see the need to grab for prescription rights….not when there’s such considerable scientific evidence for recommending Omega-3 fatty acids for pain relief.

I hope you will enjoy the following new article:

The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States

Donald R Murphy (rispine@aol.com)
Brian D Justice (bjustice@rochester.rr.com)
Ian C Paskowski (ianp14@yahoo.com)
Stephen M Perle (perle@bridgeport.edu)
Michael J Schneider (mjs5@pitt.edu)


One of the most talked about issues in the United States (US) is health care reform. In other countries as well, discussion commonly revolves around the issue of how health care services can be improved while containing costs. Many in the US have described the current health care situation as a “crisis” [1-4]. In March 2010, the US Congress passed and the President signed into law the Affordable Care Act, which puts in place comprehensive health care reform measures [5]. While various models for providing care to patients have been considered, such as accountable care organizations [6], it is recognized that any meaningful approach to health care reform will require three goals to be achieved:

1.   improved patient health;
2.   improved patient experience;
3.   decreased per capita costs [7].

Spine-related disorders (SRDs) are among the most common, costly and disabling problems in Western society. For the purpose of this commentary, we define SRDs as the group of conditions that include back pain, neck pain, many types of headache, radiculopathy, and other symptoms directly related to the spine. Virtually 100% of the population is affected by this group of disorders at some time in life. Low back pain (LBP) in the adult population is estimated to have a point prevalence of 28%-37%, a 1-year prevalence of 76% and a lifetime prevalence of 85% [8, 9]. Up to 85% of these individuals seek care from some type of health professional [10, 11]. Two-thirds of adults will experience neck pain some time in their lives, with 22% having neck pain at any given point in time [12].

The burden of SRDs on individuals and society is huge [13]. Direct costs in the United States (US) are US$102 billion annually [14] and $14 billion in lost wages were estimated for the years 2002-4 [13]. Other indirect costs are substantially higher than this. As far back as 1996 it was estimated that in The Netherlands total costs for neck pain was US$686 million, with half of that cost arising from disability [15]. And the problem appears to be worsening. In the years between 1997 and 2005, expenditures for back and neck pain rose 65%, adjusted for inflation [14]. During this time measures of mental health, physical functioning and work, school and social activity among patients with SRDs declined [14]. With regard to work-related LBP, this is the most common disorder that leads to lost work days [16] and while it comprises up to 25% of injuries in the workplace it accounts for up to 1/3 of all workers’ compensation costs [17, 18].

A variety of physicians and other providers have traditionally been involved with the diagnosis and treatment of these patients. This includes primary care physicians, chiropractic physicians, orthopedic surgeons, neurosurgeons, physiatrists, osteopathic physicians, physical therapists, psychologists, massage therapists, kinesiologists, naprapaths and acupuncturists. This has resulted in what has been termed the “supermarket approach” to the management of SRDs [19]. That is, the SRD patient is faced with an environment in which there is a large number of practitioners, each offering a solution to SRDs, with the patient left to sort out which of these disparate approaches is best for his or her particular problem. Oftentimes this determination is based more on salesmanship and marketing than on science, clinical benefit and costeffectiveness [19].

Treatment for SRDs has become increasingly specialist-focused, imaging-oriented, invasive and expensive. According to Deyo, et al [20] between 1994 and 2004 LBP related Medicare expenditures in the US increased 629% for epidural steroid injections, 423% for opioid medications, 307% for magnetic resonance imaging and 220% for lumbar fusion surgeries. This dramatic rise in medical costs was not shown to have resulted in improved outcomes for SRD patients. In fact, despite the tremendous amount of time and money spent on the diagnosis and treatment of patients with SRDs, chronicity and disability related to these disorders appears to be steadily on the rise [14, 20, 21]. We are not aware of any other health condition in which a similar level of worsening outcomes has occurred despite significant increase in health care expenditures.

One approach to health care reform would designate primary care physicians (PCPs) or groups of PCPs as “patient homes”, responsible for the comprehensive care and management of a designated patient population under a risk-sharing agreement. However, there is a projected gap between the availability of traditional PCPs and societal needs in the near future, especially if a national health care program is implemented [22]. Currently, LBP is the second most common reason for symptomatic physician visits [23-25] and increasing the number of SRD patients seeing PCPs will serve to further exacerbate the problem of under-availability of traditional PCPs. Thus, in the area of SRDs, a different approach to primary care is needed.

In their book Redefining Health Care [26], Porter and Teisberg state that for health care reform to be successful, it must incentivize competition based on value, i.e., outcome per dollar spent. To maximize value in health care, they recommend physicians and other health care providers organize themselves around conditions in which they have maximal expertise and experience (chronic kidney disease, diabetes, SRDs) rather than around medical specialties (orthopedics, internal medicine, neurology, etc.) and compete on the level of providing the best health outcomes for these conditions at the best possible cost (i.e., providing value). Having groups organized based on their medical specialty rather than their focused expertise is inefficient because different health conditions require different diagnostic strategies, treatment approaches, outcome measurements and monitoring [26].

SRDs have specific features that differentiate them from other types of health conditions. For example, diagnosis is challenging because, unlike conditions such as heart disease and diabetes, there usually is no well-defined lesion that can be clearly detected via imaging studies or other special tests [27]. In addition, many, and perhaps most, cases of SRDs are multifactorial, involving somatic, neurophysiological and psychological processes that interact to produce the suffering experienced by the patient [28, 29]. Thus, management of patients with SRDs requires a level of expertise that can respond to these challenges.

In our view, a fundamental problem lies at the heart of the “supermarket approach” to SRDs; the lack of a “general practitioner” who has advanced training in spine care , who understands the multifactorial nature of SRDs and who can sort out the most appropriate clinical choices for the patient with low back or neck pain. Essentially, we think that the health care system needs an appropriately trained and skilled clinician who can fill the role of a primary care provider for the diagnosis and non-surgical management of SRDs; a “primary care physician for the spine”.

Primary Care for the Spine

“Primary care” is defined by the American Academy of Family Physicians (AAFP) as “that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis” [30]. The role of the traditional PCP is to apply comprehensive knowledge about the differential diagnosis of conditions that might arise in any bodily system, including the spine and musculoskeletal system. However, recent studies have shown that traditional PCPs are not well trained in the differential diagnosis and management of musculoskeletal disorders [31-33], probably due to the heavy emphasis on internal diseases in medical school education and in primary care residency programs. Even those traditional PCPs who profess to have a special interest in SRDs tend to have anachronistic beliefs about best practices for managing these disorders [34]. And guidelines do little to change practitioners’ beliefs and practice [35]. The traditional PCP is not likely to be the best choice in the primary care of SRDs [36].

We are not using the term primary care in the context of a generalist who provides medical care for any condition involving virtually any organ system. We are using the term primary spine care in the context of a focused practitioner who provides medical care for all patients with problems related to a specific organ system – the spine. This model is analogous to the general dentist, who provides “primary care” for oral health. To paraphrase the AAFP definition for our purpose, “primary spine care” can be defined as “that care provided by practitioners specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral, or social), involving the spine”.

Primary spine care would be provided by practitioners who are specifically trained to diagnose and manage the majority of patients with SRDs with the most evidence-based methods. They would also coordinate the referral and follow up of the minority of SRD patients who might require special tests (e.g. radiographs, MRI or electrodiagnostic testing) or more intensive (e.g. multidisciplinary rehabilitation) or invasive (e.g. injection and surgery) procedures.

The primary spine care practitioner would function as the first contact for patients with SRDs, i.e. the first practitioner that a patient consults when he or she develops a spine problem. The primary spine care practitioner could also function as a resource for traditional PCPs (family practice physicians, general internal medicine physicians, pediatric, obstetrical/ gynecological physicians, primary care nurse practitioners or physician’s assistants) to refer patients who present with SRDs.

The Necessary Skill Set of the
Primary Spine Care Practitioner

The primary spine care practitioner would require several important characteristics in order to provide maximum value to society. Some of these characteristics include:

1.   Skills in Differential Diagnosis: Serious pathology as a cause of spinal pain occurs in only 1% of patients [37]. However this means that the busy primary spine care practitioner could potentially see at least one case every couple of months. Thus, skill in the recognition of serious pathology is essential, as many of these disorders require immediate investigation or treatment. This includes an understanding of what diagnostic tests to order when certain “red flags” are present. Also essential in this regard is an understanding of when diagnostic testing is not necessary [38] as efficiency and cost-effectiveness would be an essential aspect of primary spine care.

2.   Skills in the management of the majority of patients with spine pain: Any primary level practitioner should ideally be able to manage the majority of patients he or she sees without the need for referral. The first-line treatments that the primary spine care practitioner would employ would include those methods shown to be evidence-based, minimally invasive and cost-effective. There is a variety of such treatment methods that have been found to be effective and have broad application which include manual therapies, particularly manipulation and mobilization [39, 40], the McKenzie method [41], neural mobilization techniques [42-44], various forms of exercise [45-47], patient-specific, evidence-based education [47, 48], non-steroidal anti-inflammatory and non-opioid analgesics [27] (most of which are available over-the-counter) and nutritional approaches [49, 50]. The primary spine care practitioner would be required to be knowledgeable and skilled in the application of these strategies without the need for referral.

3.   A wide ranging understanding of spinal pain: SRDs are currently understood to be a complex mixture of biopsychosocial phenomena [29, 51, 52]. It is increasingly being recognized that the experience of spinal pain and its related disability involves a combination of biological and psychological processes that occur within a certain social context. The primary spine care practitioner would require a keen understanding of these disparate but interrelated processes. Patient satisfaction in spine care is closely tied to the clinician providing a clear explanation of the problem [53, 54]. Therefore, the primary spine care practitioner would be required to clearly articulate the complexities of spine pain to patients in simple terms. The ability to recognize the many facets of some complex SRDs [28], educate the patient about his or her condition, its natural history and the patient’s role in recovery [55], and then motivate the patient to actively participate in care [56] are all necessary, but quite refined, skills that the competent spine provider must have.

4.   The ability to detect and manage psychological factors: It is increasing recognized the psychological factors play an important, and in many cases the most important, role in the perpetuation of pain, suffering and disability in patients with SRDs [57-60]. The primary spine care practitioner would have to be knowledgeable and skilled in the detection of processes such as fear-avoidance, catastrophizing, passive coping, poor self-efficacy, cognitive fusion and depression and to be able to address these as part of the overall management strategy [61]. As a purely psychological approach may not be effective [62] itis essential that management of these factors is incorporated by the primary spine care practitioner into the management of the somatic factors [63, 64].

5.   An appreciation of minimalism in spine care: The primary spine care practitioner would have to understand that often in spine care “less is more”. That is, an approach that focuses on education regarding the natural history of SRDs, maximizes patient empowerment and minimizes practitioner-driven intervention is likely to be most beneficial [65, 66]. This would allow the practitioner to focus on the value of care (i.e. outcome per unit cost [67]) which would not only benefit patients with SRDs but also the health care system and society as a whole by helping control costs while expediting early return to a productive life. This approach would also minimize the growing problem in spine care of patient dependency, whether on pharmaceuticals, interventional procedures, passive modalities or other practitioner-provided services [56].

6.   An understanding of the methods, techniques and indications of intensive rehabilitation, interventional treatments and surgical procedures: It would be the responsibility of the primary spine care practitioner to coordinate the referral and follow up for the minority of patients who need secondary and tertiary level treatment. This would require knowledge and experience regarding the appropriate indications for these interventions, an ability to explain them to patients and an ability to follow up with these patients after the intervention to monitor the progress and outcome [68].

7.   An understanding of the unique features of work-related SRDs: SRDs that begin in the workplace have particular features that differentiate them from those that are not perceived as work-related [69-71]. Many physicians, particularly traditional PCPs, are uncomfortable with work-related back pain and have misperceptions about the important role that early return to work and return to other normal activities plays in recovery [72-74]. The primary spine care practitioner would be required to understand the nuances of work-related SRDs and the unique aspects of management that are required to effectively care for this patient population [75].

8.   An understanding of the unique features of SRDs related to motor vehicle collisions: Similar to work-related SRDs, those related to motor vehicle collisions (particularly whiplash associated disorders) have particular features that require specialized knowledge. The primary spine care practitioner would require an understanding of issues that are unique to this type of patient such as injury mechanisms [76, 77], patterns of injury [78-80], risk factors for chronicity [81], medicolegal reporting and the delicate balance between the need for early, aggressive treatment [82] and the potential role this can play in chronicity [65, 66].

9.   Public Health Perspective: The primary spine care practitioner would require a broad perspective regarding how spine problems and spine care fits in the grander scheme of public health. For example, many of the health conditions that are the focus of public health education and promotion campaigns are associated with SRDs as complicating factors. These include: smoking, obesity, type II diabetes, lack of physical exercise, and mental health disorders. Public health campaigns regarding SRDs are in the early stages [83, 84] and it can be expected that further public health efforts regarding this widespread set of problems will be undertaken [85] and will require input from primary-level practitioners with expertise in this area.

10.   The ability to coordinate the efforts of a variety of practitioners: As we stated earlier, a high-quality primary spine care practitioner should be able to manage the majority of patients with SRDs without the need for referral. However, in those patients who require specialized services, the primary spine care practitioner would have to be skilled in the coordination of these services and in follow up to ensure that maximum benefit is derived.

11.   The ability to follow patients over the long term: As SRDs typically take on a recurrent course [86, 87] that is life-long [88] the primary spine care practitioner would have to be skilled in the long term follow up of patients to monitor recurrences, teach patients how to effectively interpret and self-manage the majority of these recurrences, and provide management of those recurrences for which self-management is not effective.

The Primary Spine Care Practitioner:
Potential Benefits For Patients

Any patient benefits that may result from a focused management strategy with a well trained primary spine care practitioner would have to be investigated through a rigorous research effort. However, based on the current understanding of SRDs we would anticipate a number of such benefits. Some examples include:

1.   Faster recovery: By providing targeted, evidence-based care the well-trained primary spine care practitioner would avoid unnecessary treatment, promote active care plans and patient empowerment and appropriately triage when necessary [89]. This can be expected to facilitate maximal outcomes in the shortest time.

2.   Cost savings: The primary spine care practitioner could save patients considerable time and money both at the point of encounter and in the future by ordering diagnostic tests only when necessary, applying evidence-based treatments, avoiding unnecessary treatment and taking a “less is more” approach through education and motivation in self-directed care [27].

3.   Avoiding iatrogenic disability: Judicious use of imaging and appropriate communication of findings may also help avoid the iatrogenic disability that can arise as a result of the medicalization of imaging findings that are of questionable clinical significance, such as “disc degeneration” [90]. Inappropriate communication of diagnostic test results can lead to unnecessary catastrophizing of benign spine pain that may result in prolonged disability [91] and unnecessary invasive procedures [92]. Having a primary spine care practitioner who understands when advanced imaging is necessary and when it is not necessary, and who can put into the proper perspective the findings of these tests, can help to reverse the costly imaging- and specialist-dominated culture that has developed in the area of SRDs.

4.   Increased productivity: Encouragement to remain active, particularly with workrelated SRDs and engaging in a targeted stay at work/ return to work strategy [93, 94] would lessen the likelihood of work loss and its resultant economic hardship [95].

5.   Decreased likelihood of becoming a “chronic pain sufferer”: Appropriate care plans that focus on active care and patient empowerment are likely to help the patient avoid becoming a chronic pain sufferer [96]. The recognition of “yellow flags” of psychosocial involvement can lead to early intervention, before these factors lead patients down the path of prolonged disability [58, 61].

6.   High patient satisfaction: In the age of consumer-driven health care, the importance of the patient’s overall experience of health care is of great importance [97]. Cost effective and clinically effective care provided by a practitioner who has good communication skills to educate, motivate and empower the patient will likely lead to high levels of satisfaction [54, 98].

7.   Shared decision making: The primary spine care practitioner would have a wideranging understanding of the various diagnostic and management strategies available to patients with SRDs and thus could provide information, resources and support in making decisions regarding their care.

8.   Focus on prevention: While no program of prevention of future SRDs has been shown to be completely successful, it has been demonstrated that taking a preventative approach can help limit disability related to SRDs [82, 99, 100] and well as reduce the frequency of future episodes [101, 102].

The Primary Spine Care Practitioner:
Potential Benefits To Society

As with patient benefits, research would be required to determine any societal benefits that may result from the institution of a primary spine care practitioner. However we anticipate that there are many potential benefits to society of having a practitioner who is charged with providing primary care for patients with SRDs. Some examples include:

1.   Knowledgeable care coordinator: A wide variety of practitioners is currently involved in the management of SRDs with little coordination of their efforts [19]. This leads to inefficiency and compromises value [26]. In our view it would be much more efficient and valuable to create teams of professionals with expertise in SRDs working together to provide efficient and effective patient care [26]. The primary spine care practitioner could play the role of “team captain” by organizing and supervising the work of the various disciplines that may be contributing to the management of any particular patient. This could be expected to improve outcomes by turning what is oftentimes a disjointed effort into a coordinated effort.

It would also be likely to help control costs by having a single person in charge of monitoring a particular treatment to determine if it is bringing about meaningful improvement and should continue or is not bringing about meaningful improvement and should be altered or stopped.

2.   SRDs as a public health initiative: Increased recognition is being given to the potential of a public health approach to SRDs [84, 85]. The primary spine care practitioner can spearhead efforts in this area to facilitate and implement such public health campaigns as well as reinforce public health messages on an individual level with patients. Community-wide approaches to back pain have been successful in the past [84]. These programs involve a consistent evidence-based approach by primary contact providers coupled with community-wide education programs to inform the public on how to prevent disability related to SRDs and what to do if spine pain occurs. The success of these programs requires an understanding on the part of the primary spine care practitioner of the essential public health messages regarding SRDs. A community-wide public health initiative regarding SRDs has the potential to save millions of dollars and to prevent needless human suffering [84].

3.   Improved worker productivity: SRDs trigger significant amounts of absenteeism 103] and “presenteeism” (the worker being present at the workplace but with significant losses in work productivity) [104, 105]. The economic impact of these losses to a community is substantial. The establishment of a primary spine care practitioner could potentially lead to significant community-wide savings in both direct [14] and indirect [106] costs of SRDs.

4.   Less long term disability: A significant portion of health care costs related to SRDs goes toward the management of chronic and recurrent conditions [17, 107]. Appropriate initial evaluation and treatment can significantly reduce the number of acute pain patients who become chronic [82], and to reduce the cost of medical care, lost productivity and disability. A “culture of disability” can spread through a family or business or community, creating emotional and financial hardship for society [108]. Having a primary spine care practitioner who is skilled in disability management could potentially help reduce the risk of long term disability by acting at the early stages of a SRD episode [109, 110].

The Primary Spine Care Practitioner:
Potential Benefits For The Health Care System

At present the delivery of health care to patients with SRDs follows the inefficient and expensive “supermarket approach” [19]. Having a primary spine care provider to manage patients with SRDs may benefit the health care system in a number of ways, including:

1.   Controlling costs: The health care system in Western Society has been burdened with runaway costs. In no area is this more an issue than with SRDs [20]. By having a primary spine care practitioner who has the skills to manage the majority of patients with SRDs without the need for special tests or referral to specialists or other practitioners, a dramatic decrease in the cost of SRDs could be realized.

2.   Unburdening traditional PCPs: The traditional PCP has the responsibility of managing the overall health needs of his or her patients. This includes, in many cases, multiple co-morbidities. The primary spine care practitioner would handle a significant portion of the traditional PCP’s current case load, increasing the PCP’s availability to the numerous other responsibilities of these practitioners. Thus, traditional PCPs would benefit by being relieved of the burden of caring for a large group of patient complaints for which they have little training [31-33]. This could also potentially result in a decrease in the projected PCP shortfall [22]. Having a primary spine care practitioner to whom traditional PCPs can refer patients with SRDs, or whom these patients can consult directly without having to see their PCP (a more efficient pathway), would remove from the alreadyoverbooked schedule of traditional PCPs those conditions (SRDs) for which they have minimal training in diagnosis and management. This will allow them to focus on what they do best.

3.   More strategic specialist referrals: Specialists who care for patients with SRDs would benefit for a similar reason as would traditional PCPs. Many patients with SRDs who see specialists such as orthopedic surgeons, neurosurgeons, interventional physiatrists or pain management physicians have no indications for surgery, injections or other invasive procedures. In addition, it has been found that in many cases these specialists do not have a keen understanding of the management of non-surgical SRDs [111]. This is likely because the bulk of the training of these specialists is focused on the application of interventional and surgical procedures in complex cases. By having all SRD patients see the primary spine care practitioner, who is trained to recognize those who require more invasive procedures, only those patients who need such procedures would be channeled to the surgical or interventional specialist. This would allow these specialist practitioners to focus their practice on doing what they do best – applying skilled surgical or interventional procedures.

4.   Disruptive innovation: The establishment of clinicians who can provide primary spine care would represent a significant “disruptive innovation” [112] in health care. According to Christensen, et al [112] disruptive innovation is the process in which complex, expensive products and services are transformed into simple, affordable ones. Disruptive innovation in any industry occurs when a company, a group of individuals, or a profession comes along with new ideas and a new approach that leads to the transformation of the industry so that products and services become dramatically more affordable and accessible. This happened in the 1970s when Toyota disrupted the auto industry and in the early 1980s when Apple disrupted the computer industry [112]. We suggest that the introduction of the primary spine care practitioner can serve as a disruption in the delivery of spine care services that could potentially lead to dramatic improvements in the delivery, accessibility, cost and outcomes of this care. This viewpoint is supported by the example of the Spine Care Program at Jordan Hospital in Plymouth, Massachusetts where the primary spine care practitioner model has been implemented in an ACO-style environment. Preliminary evidence indicates that this program has been successful in the areas of outcomes, patient satisfaction and cost efficiency [113]. In addition, 80% of the patients in this program are referred by traditional PCPs supporting our viewpoint that the primary spine care practitioner model would be helpful in reducing the burden on these practitioners.

5.   Standardization of care: Inconsistent clinical decision-making, unnecessary ordering of imaging studies, overutilization of invasive procedures, overprescription of pharmaceuticals and excessive reliance on passive care approaches all trigger huge health care losses both in money and time [20]. A standardized, evidence based patient care pathway followed by knowledgeable
practitioners has the potential to greatly minimize these costs.

6.   New evidence and technologies: Currently, new treatment approaches or technologies regarding SRDs are often driven into the health care system more by marketing efforts than by good science [19]. With the introduction of a single group of primary spine care practitioners throughout the health care system, quality, evidence-based technologies and procedures could more quickly and efficiently be introduced.

Obstacles To The Implementation Of The
Primary Care For The Spine Model

There are a number of hurdles to overcome for the successful implementation of a primary care of spine model. These obstacles include:

1.   Educational changes: Currently, none of the major health care educational institutions are consistently graduating providers who meet all the criteria necessary to be successful primary spine care practitioners. However with some basic fundamental changes, and a commitment from state and federal governments, trade organizations and school administrators and faculty, this obstacle can be overcome. Institutions of chiropractic medicine, for example, provide training that is focused primarily on the spine. Many of the skills required of the primary spine care practitioner are already taught at these schools. By instituting some specific changes, that are already being discussed within this health care profession [114, 115], these institutions can become at least one source of appropriately trained primary spine care practitioners. Other disciplines that include some level of spine care training within their respective curricula are institutions of osteopathic medicine and physical therapy. The primary focus of most osteopathic programs in the US is the diagnosis and treatment of internal disorders with a majority of osteopathic physicians working in the field of family medicine. Physical therapy education does contain some spine related coursework, but is more broadly focused on musculoskeletal, neuromuscular, cardiopulmonary, and wound care. Thus, significant changes in these curricula would be required if they are to successfully train primary spine care practitioners.

2.   Incentivizing value: Traditionally, in the area of SRDs and as in other areas of health care, providers have typically been paid by the procedure, thus incentivizing more procedures. This would have to change for successful implementation of primary spine care services into the health care system. Primary spine care practitioners would have to be adequately paid for activities such as patient education, coordination of care and stay at work/ return to work strategies. In addition, they would have to be financially incentivized to take a “less is more” approach. There are signs that this is starting to occur, however. As the health care system moves from fee for service toward a shared risk management model, providers and care pathways that add value to the system will be the leaders, thus increasing the support of their programs and services [67, 97]. The concept of the primary spine care practitioner fits well into this model, allowing a “less is more” approach that involves fewer procedures and greater patient empowerment to replace the present “supermarket” approach [19] to SRDs.

3.   Overcoming prejudice: It is likely that the best candidates to be groomed to become primary care spine providers may not come from the allopathic medical profession. This may be resisted in some aspects of the medical community. It would be important that a competent, appropriately trained provider be accepted regardless of the degree after his or her name. The institution of new models of health care in general, including primary spine care, will require non-traditional ways of thinking about which provider will become the “team captain” for any particular medical condition.

4.   The detrimental effect on those invested in the “supermarket approach”: For health care practitioners who currently see a large volume of patients with SRDs and who remain invested in the current incentive system in which more procedures are emphasized without regard for outcome or value, the institution of a primary spine care practitioner could be detrimental. If a system in which value rather than volume is rewarded, some practitioners will be negatively impacted and some may even go out of business [26]. Thus, the disruption of the health care system that the institution of a primary spine care practitioner will be a part of will undoubtedly be resisted by some individuals or groups who are unable or unwilling to embrace this change. However, such resistance has occurred in response to major disruptions of other industries [112] and we would anticipate that the benefits of the disruption we are suggesting will overcome any opposition that will inevitably arise.

5.   Resistance from within the profession(s) that could potentially be the source of primary spine care practitioners: For whatever profession or professions that respond to the need for a primary spine care practitioner, this will be a significant disruption to the traditional practice patterns or self-image of these professions. As a result, the role that we are introducing here will be actively resisted [115]. However, given the fact that SRDs affect virtually 100% of the population it can be expected that whatever profession accepts the role of primary spine care practitioner will likely dramatically increase the volume of patients that seeks its services.

6.   Implementation: The implementation of primary spine care services will require support from several areas of the health care system, including the profession(s) from which the non-surgical spine care practitioner will arise, third party payors, who will have to provide the financial incentive to bring value to spine care, regulatory and legislative bodies that may have to institute changes in allowing this area of health care to fully realize its societal benefits and other members of the health care system who will have to support and accept the implementation of primary spine care services. Again, disruptive innovations in other industries have required such changes and we would anticipate that the same can occur in response to the primary spine care innovation.

7.   Sustainability: Any disruptive innovation has to be sustained in order for society to fully realize its benefits. Because of the great need we have presented here for high-quality, low cost (i.e., valuable) spine care, we feel that this need, and the benefits realized as a result of the institution of primary spine care services, will drive the sustainability of these services. However, this sustainability will also be dependent on the consistent supply of practitioners who are appropriately skilled in providing primary spine care. As we indicated earlier, this will require commitment on the part of whatever health care profession(s) elects to supply the system with appropriately trained practitioners.


The need for some type of reform in our health care system is recognized by the public, industry and providers. The exact form that health care reform will take is not known but it is widely held that primary care services will have a significant clinical and administrative role and that shared risk among all stakeholders will be beneficial. Any meaningful approach to health care reform will require that three goals be achieved:

1.   improved patient health,
2.   improved patient experience
3.   decreased per capita costs.

That is, emphasis must be placed on value in health care. To achieve these goals, health care services in general must be redesigned away from the traditional fee-forservice model to a model based on value that is accessible, practical and sustainable.

It is our view that the addition of a primary spine care provider who is responsible for front-line diagnosis, management and triage would help achieve these goals, bringing greater value in the care of patients with SRDs. Moreover, the addition of this practitioner would be aligned with developing models of health care such as the patientcentered medical home and the accountable care organization. The establishment of
such a practitioner is not unprecedented; primary oral health care is currently provided by the general dentist, who manages the majority of society’s oral health needs him- or herself, with referral to specialist practitioners in those relatively few circumstances in which it is warranted. We think that the same model can be applied to SRDs.

The primary spine care practitioner will require a particular skill set that includes the ability to apply evidence-based procedures, appropriately educate and motivate patients and effectively prevent and manage disability related to SRDs. The benefits in terms of improved outcomes of care for SRDs, improved patient satisfaction, and reduced costs (i.e., the value of care for SRDs) would be well worth the effort of grooming practitioners toward filling this role.


The authors have nothing to disclose.

Author Contributions

DRM originally conceived of the conceptual basis of the paper and wrote the initial manuscript. BDJ, ICP, SMP and MJS then made individual contributions to various sections of the manuscript. All authors took part in editing and revising the manuscript on multiple occasions. All authors reviewed the final manuscript prior to submission.


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8 comments to Primary Spine Care Practitioners

  • I’ll need to read more of this but for now I just say that I align myself with the expand care movement. However, I view expanded care in three ways that stem from scope of practice ideas. One is where scope of practice is defined by the modalities used but not by conditions treated. The other is by conditions treated and not by modalities used. The last is a combination of the previous two.

    One thing I can say for sure is that I do NOT want chiropractic to be pigeon-holed as spine specialists only.

    The other thing I can say for sure is that I do not want chiropractic to be only “non-invasive.”

    This of course leaves many ways in which a final scope notion could emerge depending on the degree to which one goes on any of these parameters. Never the less, the overarching view should be constructed in ways so that when better treatments come along then we will be able to use them. Keep in mind that exercise, SMT, acupuncture and massage have only been shown to be mild to at best moderately effective. Expect progress and change.

    As a final note, I’m starting to move in a direction where we get rid of the term “chiropractic subluxation” but haven’t fully gone that way yet.

    • Hi Dr Szlazak,

      It saddens me to see that some DCs would prefer that the debate over the use of terms like “adjust” and “subluxation” would go away. I guess I am a traditionalist. Of course, I learned philosophy from Virgil Strang, so I am biased.

      I have no objection to DC expanding their practice, and I don’t believe the profession is threatened by that wish…however, it IS threatened by organized medicine, who is clearly in an uproar against poaching on their preserve.

  • Here are two reasons I think the term chiropractic subluxation could be replaced. They are mostly from a pragmatic or utility point of view and are based on some assumptions which of course maybe incorrect.

    Who really is the target audience for the terms “chiropractic subluxation?”

    If it’s patients/public then I don’t think replacing or even using those terms matters all that much.

    If it’s chiropractors then I think these terms have evolved away from initial ideas and more specific categories could be used now to describe various spinal disorders that respond to SMT. Basically, I view “chiropractic subluxation” as an older category that _could be_ broken up into newer categories with more specific or accurate definitions.

  • While I don’t necessarily want to be pigeon holed either, the spine care pie is so large that if pie were given to us I would be okay with it.

  • Peter G. Furno

    Despite chiropractic’s longevity, the profession has not succeeded in establishing cultural authority and respect within mainstream society, and its market share continues to dwindle. I am concerned that the common perception (which is well supported, in my experience) that chiropractors are only interested in “selling” a lifetime of chiropractic visits may be one of the primary factors behind our low standing in the minds of members of the public [1]. The recommendation for repetitive life-long chiropractic treatment compromises any attempt at establishing a positive public health image and needs to change. Public health is ultimately about self-empowerment and teaching people how to take care of themselves, with an emphasis on prevention and health maintenance. The chiropractic profession should adopt the American Public Health Association’s (APHA) scientifically-grounded emphasis on nutrition and exercise as the “keys to wellness”

    I see the future chiropractor as a “non-surgical spine & musculoskeletal specialist”, enjoying full cultural authority, legitimacy and trustworthiness – but only under the following circumstances:

    1) Chiropractic must abandon the Subluxation as a foundational premise.

    The maxim in the computer world is: Garbage in, garbage out. Consequently, if we present a false premise, any conclusions based on this premise must also be false, to wit, the subluxation! The chiropractic subluxation stands pretty much today as it did at the dawn of the 20th century: an interesting notion without validation.

    The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are much more rampant in our profession than in other healthcare professions [2.] This must be done on an individual practitioner basis as well as by the political, educational and regulatory bodies. In this way the profession can fulfill its responsibility to the social contract. This will dramatically increase the level of trust in, and respect for, the profession from society at large.

    We must finally come to the painful realization that the chiropractic concept of spinal subluxation as the cause of “dis-ease” within the human body is an untested hypothesis [3]. It is an albatross around our collective necks that impedes progress. There can be no unity between the majority of non-surgical spine specialist chiropractic physicians and the minority of chiropractors who espouse metaphysical, pseudo-religious views of spinal subluxations as “silent killers” [4]. The latter minority group needs to be marginalized from the mainstream majority group, and no longer should unrealistic efforts be made toward unification of these disparate factions within the profession.
    The chiropractic profession must establish a clear identity and present this to society. In the beginning, DD Palmer invented a lesion, and a theory behind this lesion, and developed a profession of individuals who would become champions of that lesion. This is not what credible professions do. A credible profession is one that is established by society to meet a need that society itself has decided must be met [5]. Based on all the evidence regarding chiropractic practice and education, there is only one societal need (but it is a huge one) that chiropractic medicine has the potential to meet: non-surgical spine care. Our education and training is focused on the spine, and clearly if there is a common bond among all chiropractors, it is spine care [6.] While there are a variety of practitioners who offer spine care (physical therapists, osteopaths, movement specialists, and massage therapists) there is no physician-level specialty that has carved a niche as society’s one-and-only non-surgical spine specialist whose expertise is focused on the diagnosis and management of spine disorders.

    2) Chiropractic education must be science-based, must be standardized, and must fall under the auspices of state universities.

    One of the problems that are encountered frequently in our chiropractic educational institutions is the perpetuation of dogma and unfounded claims. Examples include the concept of spinal subluxation as the cause of a variety of internal diseases and the metaphysical, pseudo-religious idea of “innate intelligence” flowing through spinal nerves, with spinal subluxations impeding this flow[18]. These concepts are blatantly lacking in a scientific foundation [3][7][8]and should not be permitted to be taught at our chiropractic institutions as part of the standard curriculum. Much of what is passed off as “chiropractic philosophy” is simply dogma [9], or untested (and, in some cases, untestable) theories [3] which have no place in an institution of higher learning, except perhaps in an historical context. Faculty members who hold to and teach these belief systems should be replaced by instructors who are knowledgeable in the evidence-based approach to spine care and have adequate critical thinking skills that they can pass on to students directly, as well as through teaching by example in the clinic.
    Ideally, the profession must undergo its own version of the Flexner Report that medicine underwent, and/or the Selden Commission Report and Educational Enhancement Project that podiatric medicine subjected itself to. That is, we must take a critical look at our educational institutions, find what is substandard, correct those deficiencies and standardize education across the board. Additionally (and this is essential), chiropractic education (manual medicine, if you will) must eventually merge with state university medical schools.

    The long term vision must be to integrate fully with mainstream medicine through the elimination of private, self-serving, tuition-based chiropractic colleges (I mean so-called, “Universities” –“whatever you want we’ll make up the course and offer it to you, as long as you pay, pay, pay the tuition…and once you do that we’ll make up a “Certification” course, where you’ll pay some more, and then a “Diplomate” course, where you’ll pay even more, and then you’ll have to keep these certifications up to date with yearly courses and conferences…. blah, blah, blah…..!), and the establishment of chiropractic manual medicine departments under the support of the state university system, which, in and of itself, the university will attract a higher caliber chiropractic student, who will already have an entrance B.S. degree, and who will undertake the basic sciences together with his/her medical counterpart, which will consist of 4 years of standardized science-based education. Understandably, there will be unavoidable intellectual collaboration, discussion and the understanding of the roles of each health care provider in the public domain.

    The second phase of the student’s education will commence at the termination of the basic science educational stage, whereupon the medical student will follow his/her studies in allopathic medicine, and the chiropractic student will pursue his/her chiropractic studies of an EVIDENCE-BASED, STANDARDIZED curricula for the following 4 years. Upon matriculation, both medical and chiropractic graduates will undertake and complete appropriate internship and residency programs. Graduated Chiropractic Physicians will follow a 3-year residency: Internal Medicine (1 year) and Orthopedics/Physical Medicine & Rehabilitation (2 years).
    It is essential that the chiropractic profession establish hospital-based residencies [10]. There is a significant void in how chiropractic graduates develop any meaningful hands-on clinical experience with real patients in real life situations. It is widely recognized in medical and podiatric education that abundant exposure to clinical environments is essential to developing top-quality professions. The Council on Chiropractic Education requirement of 250 adjustments forces interns to use manipulation on patients whether they need it or not, and the radiographic requirement forces interns to take radiographs on patients whether they need them or not. Rather than focus on interns meeting certain numerical requirements, interns should be encouraged to develop clinical decision making and patient management skills. Further, the emphasis on achieving a certain number of procedures as opposed to the acquisition of skill and knowledge impedes the development of professional moral reasoning by training interns to use patients as a means to meet their own goals, rather than focusing on the needs of the patients themselves. The chiropractic internship should, as with medicine and podiatry, occur after graduation. Chiropractic regulatory bodies such as state boards of chiropractic medicine should move in the direction of requiring the completion of postgraduate residency training as a condition of licensure.

    What this will mean for chiropractic is a giant step towards Cultural Authority and Legitimacy. It will mean a higher standard of chiropractic student (intellectually, morally & ethically) entering the State University of their choice, i.e., a real university offering transferable subject matter to any other university in the nation). It will also mean an enhanced understanding and respect between the two healthcare professions, which will then result in later professional corroboration and professional inter-referral mind-set based on mutual trust, respect and the appreciation of the individual skill-sets each practitioner brings to the table.
    3) Chiropractic must seriously consider amalgamating with the physical therapy profession by means of education and attaining the Doctor of Manual Medicine (DMM) degree
    Because the chiropractic profession has a very unique skill set that is desperately and immediately needed within the health care system – non-surgical spine (MSK) care – the PTs and DCs could unite forces and collectively stake a claim to all MSK care, and partition primary care into two basic categories:

    (1) primary care for internal disorders which will be triaged and managed by PCPs, PAs, NPs, and DOs, and
    (2) primary care for musculoskeletal disorders, which will be triaged and managed by DCs and PTs…along with some PM&R docs and DOs who have an MSK focus.

    My sense is that this may be the opportunity we are missing!

    It seems reasonable and pragmatic that chiropractic could change its name to “Doctor of Manual Medicine” (DMM) – remember the chiropodists with no cultural authority, who are now podiatrists with all kinds of cultural authority? – and integrate itself into a state university Doctor of Physical Therapy (DPT) program. Doctors of Physical Therapy have long enjoyed cultural authority, legitimacy and trustworthiness and, perhaps with a post-graduation residency in orthopedics (3 years), a Doctor of Manual Medicine (DMM) could be conferred? Such a paradigm shift would immediately position [chiropractic] within mainstream health care, thus affording the gratification of the cultural authority, legitimacy and trustworthiness so dearly sought after, as well as the willing and free-flow of referrals of those patients suffering uncomplicated spine & musculoskeletal injuries and/or conditions, from medical physicians, and others, to the DMM. This is, of course, dependent upon #1 above.
    No matter how one looks at it, or what one would like reality to be, chiropractic medicine is about back pain, neck pain and headache. Instead of fighting that fact (or denying it), we should embrace it fully and focus on becoming society’s “go-to” profession for disorders in this area.

    First, spine-related pain is one of the largest markets in all of health care. Considering neck/arm pain, back/leg pain and headache, virtually 100% of the population is potentially included [11][12] (contrast this with the fact that only 5% of the population currently see a chiropractor [3]).

    Second, no medical specialty has successfully carved a niche for itself in this area (although the physical therapy profession is moving rapidly in this direction).

    Third, spine-related disorders create a great deal of suffering on the part of patients, in addition to exacting great costs on employers, the healthcare system and society at large. Providing much-needed high quality care to individuals suffering from spinal pain, as well as initiating and taking part in public health campaigns designed to educate people about spinal pain, would be a great service to society, and would bring millions of new patients to the offices of Doctors of Manual Medicine [chiropractic], patients who would not ordinarily consider seeing a chiropractic physician.

    The chiropractic profession fairly recently had a unique opportunity to catapult itself into the role of society’s non-surgical spine specialists. In 1994 the Agency for Health Care Policy and Research (AHCPR) released its guidelines on the management of acute low back pain in adults [13]. These guidelines recommended spinal manipulation as one of the only treatments for which adequate evidence existed for its efficacy. The report received a great deal of media coverage, with some media outlets actually mistakenly identifying “chiropractic”, rather than “manipulation” as the recommended first-line approach. Leadership with any vision at all could have used this as a springboard to moving chiropractic into the mainstream as the premier non-surgical spine specialists in society. However, the profession did not jump at the chance, largely, in my view, for fear of being “limited” by the image. Ironically, the profession chose to avoid being “limited” to the management of a group of disorders (back pain, neck pain and headache) that affect virtually 100% of the population through all stages of life [14]. In the interim it has seen its market share dwindle from 10% of the population [4] to less than 5% [3][15]. Even amongst patients with back pain, the proportion of patients seeing chiropractors dropped significantly between 1987 and 1997, a period of time in which the proportion seeing both medical doctors and physical therapists increased [16].

    The convoluted thinking of chiropractors constantly amazes me, inasmuch as it is interesting that chiropractors have traditionally prided themselves on being “holistic”. The emerging model of modern spine care is the “biopsychosocial” model [17]. That is, it is increasingly recognized that in order to provide optimum care for patients with spine-related disorders, one has to consider the whole person. Thus, non-surgical spine care provides chiropractic medicine with a wonderful opportunity to provide truly holistic care for patients, and to be recognized for expertise in this area. This would certainly be a drastic departure from the reductionistic, subluxation-only approach, which “reduces” the cause and care of health problems to a spinal subluxation. Further, because the biopsychosocial approach often requires multidisciplinary involvement, embracing this model will further help to integrate chiropractic medicine into mainstream health care.

    Certainly there is opportunity for chiropractic medicine to become what it can and should be: a profession of non-surgical spine specialists who not only offer one useful modality of treatment for spinal pain (manipulation), but offer something much greater and more important – expertise in the diagnosis and management of spinal pain patients. This includes understanding the vast mechanisms of spinal pain as well as diagnosis, treatment and coordination of the treatment with other members of the healthcare team. It also means mastering a variety of non-surgical methods other than just manipulation that are useful in the management of patients with spinal pain. But, most importantly, it means becoming experts in patient management, i.e., helping patients overcome spinal pain, whether that means providing adjustments, exercise, referral for short-term medication use and/or education regarding the issues related to LBP provided in a cognitive-behavioral context. Currently, there is no profession that adequately fills that role, although as noted earlier, the physical therapy profession is moving quickly in this direction.

    The opportunity is there for us to correct our mistakes, but we must act now. The only question is whether the chiropractic profession has the integrity, vision and self-reflection required to make the necessary changes. Time will tell…..but don’t hold your breath!

    1. Gallup poll: Americans have low opinion of chiropractors’ honesty and ethics
    Dynam Chiropr 2007., 22(3):

    2. Foreman SM Stahl MJ: Chiropractors disciplined by state chiropractic board and a comparison with disciplined medical physicians.

    J Manipulative Physiol Ther 2004, 27(7):472-476

    3. Keating JC Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF: Subluxation: dogma or science?
    Chiropractic & osteopathy 2005, 13:17

    4. Carter R: Subluxation – the silent killer.

    5. Hughes EC: Professions. Daedalus 1962, 92:655-668.

    6. Nelson CF Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T: Chiropractic as spine care: a model for the profession. Chiropr Osteopat 2005, 13:9.

    7. Mirtz TA: The question of theology for chiropractic: A theological study of chiropractic’s prime tenets. J Chiropr Human 2001., 10(1):

    8. Mirtz TA: Universal intelligence: A theological entity in conflict with Lutheran theology. J Chiropr Human 1999., 9(1):

    9. Seaman D: Philosophy and science versus dogmatism in the practice of chiropractic. J Chiro Human 1998, 8(1):55-66.

    10. Wyatt LH Perle SM, Murphy DR, Hyde TE: The necessary future of chiropractic education: a North American perspective. Chiropractic & osteopathy 2005, 13(10):1-15.

    11. Cote P Cassidy JD, Carroll LJ, Kristman V: The annual incidence and course of neck pain in the general population: a population-based cohort study.Pain 2004, 112(3):267-273.

    12. Cassidy JD Cote P, Carroll LJ, Kristman V: Incidence and course of low back pain episodes in the general population. Spine 2005, 30(24):2817-2823

    13. Bigos S, Bowyer O, Braen G Brown K, Deyo R, Haldeman S: Acute Low Back Problems in Adults Clinical Practice Guideline Number 14 AHCPR Pub No 95-0642 Rockville, MD Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services.

    14. Hartvigsen J, Christensen K: Pain in the back and neck are with us until the end: a nationwide interview-based survey of Danish 100-year-olds. Spine 2008, 33(8):909-913.

    15. Barnes PM Powell-Griner E, McFann K, Nahin RL.: Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004, 343:1-19.

    16. Feurestein M, Marcus SC, Huang GD: National trends in nonoperative care for nonspecific back pain. Spine J 2004, 4(1):56–63.

    17. Pollard H Hardy K, Curtin D: Biopsychosocial model of pain and its relevance to chiropractors. Chiropr J Aus 2006, 36(3):92-96.

    18. Palmer College of Chiropractic – Identity (2013)

    • Hi Peter

      I read your post with interest.

      I have heard the argument that the word “subluxation” is leading us to ruin, and I just don’t buy it.

      Here’s the definition of subluxation, as adopted by the American Chiropractic Association and the Association of Chiropractic Colleges

      “A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity, and may influence organ system function and general health.”

      There is simply nothing to argue about. Joint fixation leads to abnormal changes, and the neurologic consequences are unpleasant. Finally, most patients agree that Chiropractic Care is corrective of their complaints.

      Further, recommending Maintenance or Wellness Care is NOT a bad idea, as you maintain. There is a growing body of research that suggests that continued (non-symptomatic) care IS beneficial. [2]

      Finally…every Profession has a small number of questionable individuals, who *might* reflect on the rest. However, no one has given up on Medicine because there are a few bad apples in their pie, so why would it happen to us???

      What set us back (IN REALITY) was decades of organized mis-information campaigns, sponsored first by the AMA, and later by a tiny group of pseudo evidence-based malcontents. [3, 4] If enough people hear those lies and rumors, for DECADES, of course it will have an adverse impact on our *assimilation*.

      Your suggestion that Chiropractic Education be assimilated by the University system has missed the boat. It’s already been tried, and has failed miserably. At least three different Universities, which adopted DC programs failed in the last 15 (or so) years. I’d LOVE to see DC students (and our Schools) get the same breaks other Universities get, but I’m not holding my breath.


      1. What is The Chiropractic Subluxation?

      2. Maintenance Care, Wellness and Chiropractic

      3. Chiropractic Antitrust Suit ~ Wilk, et al vs. the AMA, et al

      4. The Quack Watchers

  • Peter G. Furno

    Hello Frank:

    I appreciate your position and comments. Thank you.

    With all due respect there is plenty to argue about…….!

    Whereas the definition promulgated by the ACA and ACC is an interesting one, it is certainly an eon-removed from the original DD Palmer definition – you know, the one that all of the scientific world identifies us with!

    Although the ACC model of subluxation has been widely endorsed and has become somewhat of a “standard” for the chiropractic profession, I do have a problem with it.

    First, the hypothesis that subluxation is some “complex of functional and/or structural and/or pathological articular changes that compromise neural integrity” is offered without qualification, that is, without mention of the uncertain, largely untested quality of this claim. The nature of the supposed compromise of “neural integrity” is unmentioned. Just saying it, doesn’t make it so.

    Secondly, the dogmatism of the ACC’s unsubstantiated claim that subluxations “may influence organ system function and general health” is not spared by the qualifier “may.” The phrase could mean that subluxations influence “organ system function and general health” in some but not all cases, or that subluxation may not have any health consequences. Although the latter interpretation is tantamount to acknowledging the hypothetical status of subluxation’s presumed effects, this meaning seems unlikely in light of the ACC’s statement that chiropractic addresses the “preservation and restoration of health” through its focus on subluxation. Both interpretations beg the scientific questions: do subluxation and its correction “influence organ system function and general health”?

    Lastly, the ACC claims that chiropractors use the “best available rational and empirical evidence” to detect and correct subluxations. This strikes me as pseudoscience, since the ACC does not offer any evidence for the assertions they make, and since the sum of all the evidence that I am aware of does not permit a conclusion about the clinical meaningfulness of subluxation. To the best of my knowledge, the available literature does not point to any preferred method of subluxation detection and correction, nor to any clinically practical method of quantifying compromised “neural integrity,” nor to any health benefit likely to result from subluxation correction, regardless of whether “Joint fixation leads to abnormal changes, and the neurologic responses to it are unpleasant” (Classic “Post Hoc Ergo Proper Hoc” fallacy!).

    I believe that whether chiropractors are actually treating lesions, or not, is a question of immense clinical and professional consequence. Resolution of the controversy will not be found through consensus panels nor through semantic tinkering, but through proposing and testing relevant hypotheses.
    There is precious little experimental evidence available supporting the theoretical construct of the chiropractic subluxation. I believe it to be a legitimate, but untested hypothesis (in scientific terms). The evidence to date hardly supports the widespread notion among the chiropractic community that it is meaningful in human health and disease. It is this notion still prevalent today in chiropractic that brings ridicule from the scientific and mainstream health care communities. Over the years (last two decades, or so) many chiropractors preeminent theoretical constructs remains unsubstantiated and largely untested. There has been little if any substantive experimental evidence for any operational definition of the chiropractic lesion offered in clinical trials.

    Notwithstanding strong intra-professional commitment to the subluxation construct and reimbursement strategies that are legally based upon subluxation, there is today no scientific “gold standard” for detecting these reputedly ubiquitous and supposedly significant clinical entities, and inadequate basic science data to illuminate the phenomenon . The chiropractic subluxation continues to have as much or more political than scientific meaning.

    I don’t think the clinical meaningfulness, if any, of subluxation can be established by definition. The notion that subluxation is inherently pathological, perhaps because some dictionary equates subluxation with ligamentous sprain, does not mean that joint dysfunction merits clinical intervention

    The magic and mystery of subluxation theories all too frequently direct the chiropractor’s attention to a search for the “right” vertebra, instead of addressing the legitimate question of whether subluxation (or any other rationale for manipulation) may be relevant in a patient’s health problem?

    Many chiropractors bombard themselves and the public with subluxation rhetoric, but rarely hint at the investigational status of this cherished idea.

    Hypothetical constructs involve tentative assertions about physical reality. They serve as essential tools in the development of science, and permit the empirical testing of the non-obvious. However, when the speculative nature of an hypothesis or hypothetical construct is not made obvious, an otherwise acceptable proposition becomes a dogmatic claim. Such is the history of subluxation in chiropractic.

    The dogma of subluxation is perhaps the greatest single barrier to professional development for chiropractors. It skews the practice of the art in directions that bring ridicule from the scientific community and uncertainty among the public. Failure to challenge subluxation dogma perpetuates a marketing tradition that inevitably prompts charges of quackery. Subluxation dogma leads to legal and political strategies that may amount to a house of cards and warp the profession’s sense of self and of mission. Commitment to this dogma undermines the motivation for scientific investigation of subluxation as hypothesis, and so perpetuates the cycle.

    It seems to me that as long as we as a profession rely on CONSENSUS STATEMENTS concerning subluxation dogma as though it were validated clinical theory, the cultural authority we so desperately need to enter mainstream health care, will continue to elude us.

    With regard to Maintenance Care: My suggestion that “maintenance care” or “wellness care” is inappropriate is directed ONLY to those chiropractors (the majority, I fear), who sell life-long treatment programs to HEALTHY people, on the ASSUMPTION that chiropractic adjustments of magical “subluxations” keep HEALTHY people HEALTHY (remember there is no SCIENTIFIC PROOF that it is efficacious!) I am well aware of the handful of studies that support maintenance care – but if you read them carefully you’ll notice that they are designed for REAL patients under management for RECURRING BACK PROBLEMS, in an attempt to deter recidivism.

    I wish I could agree with you regarding your statement that “every profession has a small number of questionable individuals, who *might* reflect on the rest”. Most polls put chiropractors far below the MD with regard to cultural authority, legitimacy and trustworthiness! Chiropractors, generally, are looked upon as the “Gizmo Guys”, and as charlatans, and in many cases a step above the second-hand car salesman! The fact that our market-share now hovers somewhere between 3%-5%, from a high of about 15% just a decade ago, should tell you something!

    As to your assessment that chiropractic has “missed the boat”, through the failures over the past 15 years of being assimilated into REAL university settings, begs the question, WHY? Might it be because of our metaphysical, pseudoscientific, semi-religeous, magical thinking basis we rely on? I know of one instance where the effort of becoming a REAL PROFESSION was scuttled by our own “Fountain Head” – Palmer College! We are indeed our own worst enemy, are we not?! Now that we realize that in order to survive, we MUST be accepted into mainstream health care, we lean towards our usual old “Pity Party” antics by trying to bamboozle the states legislatures with semantical gobblydegook and filing law suits, rather than acting as adults and PROVING ourselves worthy on a fundamental SCIENTIFIC level. The main impediment in our acceptance as a “real” health care profession is the basic premise of the “magical” subluxation. Get rid of it, and the “profession” will be a big step closer to being considered legitimate rather than a bunch of bug-eyed, frothing-at-the-mouth, finger-pointing charlatans.

    In summary, I stand by my assertions, that if we want to be included in mainstream health care, we must get rid of the subluxation theory, become part of state universities in terms of education, and develop chiropractic physicians who are evidence-based, ethical and upstanding. At this point in time the most expedient method would be to join ranks with the physical therapists,implement a Doctor of Manual Medicine degree (DMM),by taking their DPT degree course, do a 3-year residency (1 year internal medicine; 2-years orthopedics/rehabilitation) and graduate with the DMM degree. That would immediately bestow the mantle of cultural authority, legitimacy and trustworthiness upon us, and allow us to function as PRIMARY SPINE CARE PROVIDERS. We could work side-by-side with the physical therapy profession – there is certainly far more non-specific, spine-pain/musculoskeletally compromised patients available than our two professions could handle!

    But, what do we do? We circle the wagons…. and you know the rest!

    The chiropractic leadership MUST step-up and make the paradigm shift – or slowly watch the demise of chiroipractic as a profession……we have a long road to hoe!


    Peter G. Furno, D.C.

  • Baiju Khanchandani, DC

    Dr Furno,

    You make some excellent points but miss the big picture. The article in question discusses the role of chiropractors in primary care. This means screening patients, deciding the best plan of care, referring out, collaborating with other health professionals, giving general health advice to promote the WHO definiton of health, promoting public health, and caring for patients. Caring for patients means treating their problem and managing their problem which may be acute or chronic. Care includes chiropractic care, ergonomic advice, life-style advice. Further care may include prevention. This depends on the patients’ wishes. And further care may concentrate on performance: dancers, athletes or people that just want to live better (and longer!)

    Evidence based care includes applying the best evidence, patient’s wishes, and the experience of the practitioner. Patient-centred care includes predictive, preventive and personalised care. Chiropractic primary care employs the knowledge, skills, values/personal attributes and competences of the practitioner for the benefit of the patient.

    Have a wonderfuld day.

    Kind regards, Baiju

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