White House Commission on Complementary and Alternative Medicine Policy
March 1, 2001

Joseph M. Kaczmarczyk, MD
White House Commission on Complementary
And Alternative Medicine Policy
6701 Rockledge Drive
Suite 1010
MS-7707
Bethesda, Maryland 20817

VIA E-mail KaczmaJo@mail.nih.gov

Dear Dr. Kaczmarczyk:

The American Chiropractic Association (ACA) appreciates the opportunity to respond to the questions posed in a letter sent on January 29, 2001 by Stephen Groft, Chairman of the White House Commission on Complementary and Alternative Medicine Policy. Representing nearly 20,000 members, the ACA is the largest chiropractic professional organization in the United States. In this capacity, we welcome and encourage an on-going dialog with the Commission as it develops its formal policy recommendations. In addition, if this commission develops chiropractic-specific policy recommendations, we would respectfully request the opportunity to review them prior to their submission to Congress.

In response to the Commissions specific questions, the ACA respectfully submits the following responses:

1. Are there national educational standards for chiropractic undergraduate, postgraduate and continuing education? Should those national educational standards include exposure to conventional or western medicine as well as CAM?

In the United States an individual pursuing a doctorate in chiropractic must meet educational and training requirements including a minimum of six years full-time university-level education followed by national and state licensing-board exams. Of those six years, two years must include university credits in qualifying subjects and then a four-year undergraduate program at a chiropractic college.

To apply to a chiropractic college, a student is required to have at a minimum two years of pre-professional college education with a curriculum concentrated in the basic and biological sciences. Some chiropractic colleges are now requiring a bachelors degree. The purpose of the basic science component of the chiropractic curriculum is to give the student a thorough understanding of the structure and function of the human body in health and disease. With this foundation, students progress through the clinical sciences, where they begin to develop the knowledge and skill necessary for examination, diagnosis, and treatment.

A chiropractic college curriculum consists of a minimum of four academic years of professional education averaging a total of 4,822 hours. There are five curricular areas that are emphasized in chiropractic education: adjustive techniques/spinal analysis, averaging 555 hours of clinical program, principles/practice of chiropractic, averaging 245 hours; and biomechanics, averaging 65 hours. The clinical courses offered in chiropractic colleges dealing with diagnosis and chiropractic principles are allocated the most time, followed by orthopedics, physiologic therapeutics and nutrition. Three areas - adjustive techniques/spinal analysis, physical clinical laboratory diagnosis, and diagnostic imaging - account for an average of 52 percent of the education in clinical sciences. In addition, during internship, two years of hands-on clinical experience is focused on manipulation as the primary treatment procedure thus the emphasis in chiropractic clinical sciences is clearly on diagnosis and manipulative therapy. Postgraduate specialties include, but are not limited to, chiropractic sciences, neurology, nutrition, orthopedics, radiology, and rehabilitation and sports chiropractic. The Council on Chiropractic Education (CCE) is the accrediting agency for chiropractic education programs in the United States. It was recognized by the U.S. Department of Education in 1974.

The CCE and its Commission on Accreditation is an autonomous national organization recognized by the secretary of the United State Department of Education as the authority on the quality of training offered by chiropractic colleges. Certain requirements must be met before accreditation status can be initially received or renewed. The CCE Standards for Chiropractic Programs and Institutions includes criteria for assessment and planning, governance and administration, facilities, services and policies, instructional program objectives and content, faculty qualifications, admissions requirements, outcomes assessment, clinical competency and research. The CCE is a member of the Council on Higher Education Accreditation and the Association of Specialized and Professional Accredators.

Post Graduate Standards
Virtually all states have a mandatory continuing education requirement for doctors of chiropractic to maintain or renew their license to practice. Most prevalent is at least 12 hours per year in topics such as diagnostic skills, chiropractic techniques, risk management, public health, and professional boundary issues.

Recognizing that doctors of chiropractic must keep abreast with new data and advanced procedures in health care, the chiropractic profession has supported continuing education as a yearly requirement for licensing. Each accredited chiropractic college maintains a postgraduate (continuing) education division to provide postgraduate education to better assist the doctor of chiropractic in the care of the public. Each postgraduate division or department produces programs, courses, and seminars that are designed to upgrade the competence, knowledge and ability of graduate doctors of chiropractic.

All CAM providers who have direct access to patients should possess the ability to differentially diagnose and to refer and/or co-manage their patients' treatment if the condition is beyond their scope of expertise.

There is a significant amount of exposure in chiropractic education to conventional or western medicine, since the typical chiropractic curriculum utilizes the same text and scientific information provided in medical schools. This is especially significant in the realm of the basic sciences and diagnostics (e.g. clinical exam, laboratory, imaging, clinical testing). Some chiropractic colleges include courses in materia medica to better train their practitioners in the medical options available. Chiropractic colleges also provide courses in alternative forms of CAM.

One issue of significance is the limited ability for the chiropractic student to observe and manage a broad spectrum of conditions and or diseases as typically seen in a teaching hospital. While some chiropractic colleges and medical teaching institutions have had occasional collaborative activities, typically there is a lack of cooperation from the medical institution side. This is particularly egregious given that most of these institutions are supported by state and federal taxes. These public institutions should provide any accredited institution, traditional medicine or CAM, the opportunity to broaden the student practitioners' knowledge and clinical expertise.

2. Should there be national standards or certification to provide CAM practices and products? If so, how and by whom should national standards be established, to whom should they apply and how should they be implemented?

In the United States, the practice of chiropractic is recognized by statute in all 50 states. Most common among all state laws is the ability of a patient to directly seek care from a doctor of chiropractic (primary care) and the duty and right of a doctor of chiropractic to perform an examination and provide a diagnosis.

Under the auspices of all chiropractic colleges, students are required to pass a practical examination on their manipulation skills and a clinical competency exam prior to internship. In addition, the chiropractic profession is held to rigorous skill testing for licensure. The principle testing agency for the chiropractic profession in the National Board of Chiropractic Examiners (NBCE). Established in 1963, the NBCE develops and administers a standardized national exam. In the development of the test, the NBCE utilizes no particular philosophy but formulates its test plans according to information provided collectively by chiropractic colleges, state licensing agencies, field practitioners, and subject specialists. Among the top goals in administrating standardized exams are the promote of high standards of competence and assisting state licensing agencies in assessing competence.

In its role as an international testing agency, the NBCE conducts the following examinations: Part I Basic Science subject exams - General anatomy, spinal anatomy, physiology, chemistry, pathology, microbiology and public health; Part II Clinical subjects exams - General diagnosis, neuromusculosketal diagnostic imaging, principles of chiropractic, chiropractic practice, and associated clinical sciences; and Part III Written Clinical Competency Examination Case - history, physical examination, neuromusculosketal examination, diagnostic imaging, clinical laboratory and special studies, diagnosis or clinical impression, chiropractic technique, supportive techniques and case management.

In addition, all states require a practical examination prior to licensure. This state licensure skill testing includes at a minimum, diagnostic imaging, differential diagnosis, chiropractic technique and case management.

3. Should the numerous chiropractic organizations come together to form a community? If so, how and by whom should that community be formed?

There already exist chiropractic "communities" that bring together the various chiropractic organizations in the promotion of research, education and practice. Among these organizations are:

The World Federation of Chiropractic, which is made up of national associations from over 60 countries. The WFC represents these groups as well as the chiropractic profession in the international community. The WFC has ties to the World Health Organization and is a member of the Council of International Organizations of Medical Sciences. The goals of the WFC are to work with the national and international organizations to provide information on chiropractic, and to promote high standards in education, research and practice. Every two years, the WFC holds a meeting to review scientific research and continuing education information.

The Congress of Chiropractic State Associations was formed in the late 1960s and is a non-profit organization consisting of state chiropractic associations. The mission of the Congress is to provide an apolitical forum for the promotion and advancement of the chiropractic profession through service to member state associations. The purpose of the Congress as stated in its Rules and Regulations is: to form a coalition of official chiropractic state organizations, serve as a forum or clearing house to help solve mutual state programs on a non-partisan basis, cooperate with other organizations in the advancement of natural health and chiropractic, assure that chiropractic attains its rightful place in the healing arts and to initiate, encourage and support programs and projects for the advancement of the chiropractic profession.

The ACA has also encouraged member participation in the American Public Health Association. Within the APHA is a Chiropractic Health Care Section. The section serves as a vehicle for chiropractic participation in mainstream public health activities and works to enhance chiropractic communications, education and credibility on public health matters. Additionally, the ACA would certainly consider other national interdisciplinary health care organizations that would be based on parity of the professions and are dedicated to improve health for everyone.

4. Should there be condition-specific or modality-specific practice guidelines and why or why not? If so, how and by whom should these guidelines be developed, to whom should they apply and how should they be implemented.

Any guidelines, whether condition or modality specific, must be developed through consensus by the chiropractic profession and reflect mainstream chiropractic practices. It is important to note that guidelines are dynamic, changeable and revisable as the profession, research and practice of chiropractic grows in knowledge and develops in the future.

The practice of chiropractic may include a variety of responses to a particular clinical program and that adherence to any particular guidelines is voluntary. Except as provided otherwise, all practice guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of a specific procedure must be made by the practitioner in light of the individual circumstances presented by the patient.

5. Are your members concerned about malpractice liability associated with providing CAM practices and products?

Every profession has procedures that have risks associated with them. The fact is that virtually all interventions by medical doctors have complication rates higher than most commonly used chiropractic interventions. While there is no reliable method to determine which patient may be prone to adverse reactions, some patterns have emerged - and doctors of chiropractic are educated in the screening of high-risk patients. Thus, through initial examination, doctors of chiropractic are able to help avoid adverse incidents by making the effort to recognize those patients who could be at risk from treatment. The goal of the profession is to reduce those risks to zero and to help educate the medical profession about the dangers of the untrained application of spinal manipulation.

Chiropractic is one of the safest forms of treatment available today. According to a study by the RAND Corporation, a serious adverse reaction from cervical manipulation occurs once in 1 million manipulations. The complication rates for manipulation of the lumbar region of the spine are even lower. The same study showed that on the rare occasion of an adverse reaction it is often the result of improperly trained health care providers performing the manipulation procedure.

When compared to the number of illnesses and death that will occur this year from the appropriate use of prescription and over-the-counter drugs, the number of serious complications from chiropractic treatment is extremely low. A 1999 Institute of Medicine report concluded that medical errors kill anywhere from 44,000 to 98,000 hospitalized Americans each year. In addition, a study published in the April 15, 1998 issue of the Journal of the American Medical Association found that more than 2 million Americans become seriously ill every year from reactions to correctly prescribed drugs and 106,000 die from those side effects.

6. Are there any risks associated with CAM that may be of concern to your members? If so, can you suggest ways to minimize those risks?

In a study addressing the safety of chiropractic spinal manipulation/adjustment, it is cited that improper adjusting technique is a major risk factor. Since "the greatest contraindication to manipulation is lack of training and skill, full-time practice is essential." (S.R. Geiringer, "Manipulation Appropriate Low Back Pain Treatment? Questions and Answers," Journal of Musculoskeletal Medicine 7 (1990) 13-14.) More recent authors have supported this particular position as well.

Duly licensed chiropractors utilize spinal manipulation/adjustment in treatment regimens nearly 100% of the time and are rigorously skill tested spine examination, and diagnosis in this treatment technique (spinal manipulation). Therefore, they are equipped to recognize and avoid clinical contraindications.

Several states, including Tennessee and West Virginia have taken statutory steps to limit the risks of improperly trained health care providers performing spinal manipulation by mandating a minimum number of classroom and clinical hours a provider must master prior to performing chiropractic spinal manipulation.

7. Should there be a mechanism to address consumer concerns or grievances about the quality of CAM practices or products. If so, what should that mechanism be?

State licensing boards are by statute empowered to protect the public health safety and welfare. A chiropractic license is considered a privilege that may be suspended or revoked if a chiropractor is found in violation of established laws and regulations.

State statutes require a licensing board to regulate each licensed profession. Their responsibilities are to investigate consumer complaints, oversee the general application of health care laws, help update and develop regulations that better define appropriate conduct, continually review required credentialing for doctors to practice safely and effectively, and apply appropriate disciplinary action,

In addition to state-specific chiropractic licensing boards, there is also the Federation of Chiropractic Licensing Boards (FCLB), which was founded in 1926 to maintain higher, uniform standards in areas related to chiropractic licensure, regulation, discipline, and education. As part of its mission, the FCLB conducts an annual conference for the unified adoption of resolutions protecting the professions examining regulatory standards and the consumer.

All health care professionals, including CAM providers that market their services to the general public, should be under the auspices of a licensing board to ensure proper credentialing and safety to the public.

8. What information should a conventional health care provider communicate to a CAM practitioner? What information should a CAM practitioner communicate to a conventional provider either with a referral or without a referral as when a consumer self-refers?

Doctors of chiropractic are trained and licensed to perform examination and diagnostic procedures. Accordingly they, like any other health care provider, should provide any pertinent historical information, examination findings or treatment outcomes to any other licensed health care provider that would assist that provider in treating the patient. This process should be reciprocal among all licensed health care providers.

9. What policy recommendations would you like to make to assure the quality of CAM practices and products, whether they are provided by a practitioner or used as self-care?

All CAM providers should be held to equivalent criteria as other licensed health care providers in the areas of education, licensure, oversight from licensing boards and public opinion. Care must be taken that the principles of each CAM practice be maintained and not supplanted by allopathic philosophy. As an example, prevention and wellness are a principle of the chiropractic profession and should be utilized as the cost effective mechanism they have been shown to be, not discouraged in managed care programs as a quick fix for cost controls. Rather than make CAM fit the medical model, for the well-being of all consumers, guidelines must be in place for responsible, interdisciplinary collaborative work between allopathic and CAM providers.

The ACA appreciates the opportunity to work with the Commission on the development of CAM policies. If you have any questions regarding our response, or require additional information, please contact Ingrida Lusis, Director of Government Relations, at 703/276-8800 or by email ilusis@amerchiro.org.

© 2002, American Chiropractic Association. All Rights Reserved. 1701 Clarendon Blvd, Arlington, VA 22209 • Phone 800/986-4636 • Fax 703/243-2593