A Consensus Approach to Subluxation Based Chiropractic: Phase 1 Questionnaire Results

A Consensus Approach to
Subluxation Based Chiropractic:
Phase 1 Questionnaire Results

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:

FROM:   Chiropractic Research Journal 1994; 3 (4) ~ FULL TEXT

Christopher Kent, D.C., Patrick Gentempo, Jr., D.C., John Grostic, D.C.,
Ian Grassam, D.C., R. James Gregg, D.C., John A. Hofmann, D.C., and
Robert J. Hoffman, D.C.


Consensus methods have been employed by health care provider groups in an effort to standardize the management of various clinical problems. [1] Such techniques are generally developed within the conceptual framework of the allopathic paradigm. Specifically, diagnostic and/or treatment strategies are developed for specific diseases or clinical syndromes. Critics of the consensus method have suggested that developing formalized standards of practice leads to the practice of "cookbook medicine." It is feared that the unique circumstances of the patient, the condition of the patient, and the clinical insights of the attending doctor are subservient to the standards promulgated in the "cookbook." [2]

There are four major methods employed in the consensus process. They are the Delphi, the nominal group, the NIH (National Institutes of Health) and the Glaser. The major characteristics of each follows:

  1. Delphi.   Each participant is individually polled with a questionnaire. Several rounds are typically conducted until there is a convergence of opinion. [3, 4]

  2. Nominal group.   A structured meeting is held where each participant is given an equal amount of time to present their point of view. Each participant prioritizes his or her ideas and presents them to the group. An organized discussion follows. The ideas are prioritized by each individual and the group until all lists are exhausted. [5, 6]

  3. Glaser.   A core group of experts develop a position paper which is discussed and revised until there is agreement on a final draft. Outside consultants may also take part in consensus development. [7]

  4. NIH.   Practitioners, researchers, consumers, and health policy makers join together to develop a consensus. The goal is a consensus which can be practically applied as quickly as possible. [8]

Such consensus methods have been criticized. In addition to charges of "cookbook medicine," the selection of participants will significantly affect the outcome of the process. Sackman describes a "halo effect" where participants "bask under the warm glow of kind of mutual admiration society." As Shekelle [2] has observed, acceptance of practice standards has been poor. He cites some significant short comings of previous methods of constructing standards. Most commonly, an inadequate review of literature and/or an implicit method of achieving consensus were to blame.

In an effort to assess the practice characteristics of chiropractors, FACTS has undertaken a three phase program to develop a consensus process which is unencumbered by allopathic designs, and which gives due consideration to the unique circumstances of each doctor/patient relationship. This program differs markedly from those seeking to establish treatment and reimbursement guidelines for specific conditions, such as low back pain. Instead, clinical decisions are based upon the results of objective findings.

An expert panel of seven experienced chiropractors was selected. The panelists have diverse backgrounds. They include a representative to the Commission on Accreditation of the Council on Chiropractic Education, a national association and state board president, a state society president, a chiropractic college research director, several continuing education faculty members, and individuals who have served as test committee members, item consultants, or item reviewers for the National Board of Chiropractic Examiners. In addition, three of the panel members have published in peer reviewed journals, and made presentations at critically reviewed scientific symposia. Of particular importance is the fact that each member of the panel has extensive practice experience as a chiropractor.

The goal of the panel was to develop a consensus process which would address the vertebral subluxation complex. Thus, a common denominator was selected to serve as the focus for the consensus process, rather than specific diseases or symptoms. Specifically, the charge of the panel was to arrive at a consensus addressing the following questions:

  1. What are the generally accepted manifestations of the vertebral subluxation complex?

  2. What technologies are available to detect and quantify these manifestations?

  3. Are these technologies reliable?

  4. Are these technologies clinically useful?

  5. Under what circumstances should a given technology be employed?

  6. How can these technologies be used to determine clinical need for chiropractors care, and as outcome assessments to determine a favorable (or unfavorable) response to that care?


Part A.   A review of literature concerning various manifestations of the vertebral subluxation complex, and existing technologies for the assessment of these manifestations.

Part B.   A questionnaire survey of a small sample (155) of practicing chiropractors.

Part C.   Development of a statement by the panel of chiropractic experts.


Part A.   A review of literature of specific approaches to the analysis and correction of the vertebral subluxation complex.

Part B.   A more comprehensive questionnaire survey (N > 1000) of practicing chiropractors.


Convening a panel of chiropractic experts who have reviewed the Phase l and Phase 2 data. It must be emphasized that the consensus process is a dynamic one, and completion of this initial project should necessarily herald the initiation of a newer, better, updated process

Phase 1 Results

Part A.

A review of literature was completed which addressed the following procedures for the analysis of components of the vertebral subluxation complex:

  1. X-ray spinography

  2. Video fluoroscopy

  3. Pediatric imaging

  4. Computed Tomography and Magnetic Resonance Imaging

  5. Paraspinal EMG scanning

  6. Thermography

This review has been published by the International Chiropractors Association under the title, "The Documentary Basis for Diagnostic Imaging Procedures in the Subluxation-Based Chiropractic Practice."

Part B.

155 practicing chiropractors agreed to complete a 23 item questionnaire. These chiropractors were attendees at the first International Conference on Chiropractic and Pediatrics, and license renewal seminars sponsored by the Florida Chiropractic Society, the Michigan Chiropractic Council, and the Georgia Chiropractic Council. The results follow. Responses which were illegible, as well as questions not completed are listed as NR (non responsive).

Practice Characteristics

Approximately how many patient visits do you see each week?

              a.  Less than 50  05%     (08)
              b.  50 to 100     19%     (30)
              c.  101 to 300    55%     (85)
              d.  301 to 600    13%     (20)
              e.  Over 600      07%     (11)
                   NR                 <01%      (01)

Approximately how many new patients do you see each month?
              a.  Less than 5   04%     (06)
              b.  5 to 15       31%     (49)
              c.  16 to 30      42%     (65)
              d.  31 to 50      18%     (28)
              e.  Over 50       04%     (06)
                   NR                 <01%      (01)

How long have you been in practice?
              a.  Less than 2 years     15%     (23)
              b.  2 to 5 years          24%     (37)
              c.  6 to 11 years         23%     (36)
              d.  11 to 20 years        23%     (36)
              e.  Over 20 years         14%     (21)
                   NR                   01%     (02)

What is the approximate population of the town/city in which you practice?
              a.  Under 5,000                  07%      (11)
              b.  5,001 to 50,000              39%      (60)
              c.  50,001 to 250,000            28%      (43)
              d.  250,001 to 500,000           07%      (11)
              e.  Over 500,000                 17%      (27)
                   NR                          02%      (03)


Please estimate what percent of your new patients are x-rayed.

              a. Under 25%             05%      (08)
              b. 26% to 50%            04%      (06)
              c. 51% to 75%            06%      (10)
              d. 76% to 90%            14%      (21)
              e. Over 90%              70%      (109)
                  NR                  <01%      (01)

Please estimate what percentage of your x-ray studies demonstrate pathology. (This includes arthritic, metabolic and infectious conditions, as well as fractures, dislocations, congenital and developmental variants. It DOES Not include purely biomechanical abnormalities, such as spinal listings)
        a.  Under 1%              04%           (06)
        b.  1% to 10%             16%           (25)
        c.  11% to 20%            12%           (19)
        d.  21% to 50%            25%           (39)
        e.  Over 50%              40%           (62)
                   NR             03%           (04)

Do you use x-ray findings for biomechanical analysis of the spine, including listing determination?
     Yes        88%     (133)
     No         10%     (15)
     NR         02%     (03)

Do you employ "post" x-rays to evaluate patient response to chiropractic care?
     Yes        65%     (100)
     No         31%     (49)
     NR         04%     (06)

Do you ever use MRI examinations in your evaluation of patients?
     Yes        52%     (81)
     No         46%     (71)
     NR         02%     (03)

Instrumentation Do you ever use surface EMG in the evaluation of your patients?
    Yes         19%     (29)
    No          76%     (118)
    NR          05%     (08)

Do you ever use electrogoniometry (Metrecom analysis) in the evaluation of your patients?
     Yes        11%     (16)
     No         89%     (138)
     NR        <01%     (01)

Do you ever use skin temperature instruments in the evaluation of your patients? (NCM, Nervo-Scope, DTG, Visi-Therm, liquid crystal thermography, electronic thermography, etc.)
     Yes        47%     (73)
     No         51%     (79)
     NR         02%     (03)

Adjusting procedures Do you ever employ adjusting techniques which use your hands?
     Yes        100%    (155)
     No           0
     NR           0

Do you ever employ adjusting instruments? (Activator™, Pettibon, Sweat, Toftness, etc.)
     Yes        59%     (91)
     No         41%     (64)
     NR          0

Practice attitudes

Do you believe that the primary responsibility of a chiropractor is the location and correction of vertebral subluxations? (This includes the vertebral subluxation complex, VSC or VSS).

     Yes        95%     (147)
     No         05%     (08)
     NR          0

Do you provide chiropractic services to asymptomatic patients if subluxations are present?
     Yes        97%     (150)
     No         03%     (05)
     NR          0

Do you accept, as chiropractic patients, individuals with visceral disorders or organic conditions?
     Yes        96%     (149)
     No         04%     (06)
     NR          0

Do you believe that all patients with visceral disorders or organic conditions should be referred to an M.D. or D.O.?
     Yes        06%     (10)
     No         93%     (144)
     NR        <01%     (01)

Do you accept, as chiropractic patients, individuals with infectious diseases?
     Yes        92%     (142)
     No         07%     (11)
     NR         01%     (02)

Do you believe that all patients with infectious diseases should be referred to an M. D. or D.O.?
     Yes        12%     (19)
     No         84%     (130)
     NR         04%     (06)

Do you accept, as chiropractic patients, individuals presenting with neurological conditions? "Neurological conditions" include sciatica nerve irritation, radicular pain, asymmetrically decreased deep tendon reflexes, dermatomal sensory deficit, muscle we akness and/or motor loss, cauda equina syndrome, or similar findings.
     Yes        100%    (155)
     No           0
     NR           0

Do you believe that all patients with neurological conditions should be referred to an M.D. or D.O.?
     Yes        01%     (02)
     No         96%     (149)
     NR         03%     (04)

Do you believe that chiropractors should limit their practices to the treatment of musculoskeletal disorders?
     Yes        02%     (03)
     No         97%     (150)
     NR         01%     (02)

Part C.

Members of the expert panel were presented with the results of Parts A and B of Phase 1, the review of literature and the questionnaire results. There was unanimous agreement of the seven panel members on the following:

  1. The primary responsibility of the chiropractor is the detection and correction of vertebral subluxations. The chiropractor is also responsible for determining the appropriateness and safety of a given procedure in a specific case.

  2. Determination of the need for chiropractic care should be based upon objective indicators of generally accepted manifestations of vertebral subluxation. The panel has determined that the following procedures have progressed beyond the experimental stage, and are acceptable procedures for general clinical practice, provided they are determined to be clinically necessary:

    a.   Palpation (static and motion).
    b.   Postural analysis.
    c.   Orthopedic and neurological examination.
    d.   X-ray spinography.
    e.   Video fluoroscopy.
    f.   Computed tomography.
    g.   Magnetic resonance imaging.
    h.   Skin temperature differential analysis, including thermography.
    i.   Paraspinal EMG scanning.

  3. Chiropractic adjustment is indicated when generally accepted manifestations of vertebral subluxation, appropriate to the technique employed, are present.

  4. Examination procedures which employ ionizing radiation should be used only when clinical need is demonstrated. Clinical evidence of subluxation is an acceptable indication for radiographic examination. "Post" adjustment radiography is an acceptable technique for outcome assessment when clinical examination procedures are incapable of providing the information needed by the chiropractor to manage the case.

  5. Whenever possible, non-invasive procedures should be employed.

  6. Adjustment techniques may employ manual or instrument procedures.

  7. The effects of the vertebral subluxation may affect structures distant from the anatomical region of the spine where the subluxation exists.

  8. Vertebral subluxations may adversely affect any structure in the body.


1.   Fink A, Kosecoff J, Chassin M, Brook RH: Consensus methods: Characteristics and guidelines for use. Am J Public Health 1984; 74(9) :979-83.

2.   Shekelle P: Current status of standards of care. Chiropractic Technique 1990;2 (3) 86-9.

3.   Dalkey NC. The Delphi method: an experimental study of group opinion of experts. RM-5888-pr. Santa Monica, CA: RAND Corporation, 1969.

4.   Milhollard AV, Sheller SG, Heieck JJ: Medical assessment by Delphi: group opinion technique. N Eng J M3ed 1973;288:1272-5.

5.   Delberg A, Van de Ven AH: A group process model for problem identification and program planning. J Appl Behav science 1971;7:67-92.

6.   Van de Ven AH, Delbecq AL: The nominal group as a research instrument for exploratory health studies. Am J Public Health 1972; 62(3) :337-42.

7.   Glaser EM: Using behavioral science strategies for defining the state of the art. J Appl Behav Science 1980; 16:79-92.

8.   Perry S, Kalberer JT Jr: The NIH consensus development program and the assessment of health care technologies: the first two years. N Eng J Med 1980;303:169-72.

9.   Sackman H: Delphi Critique. Lexington, MA: Lexington Books, 1975.


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