Malicious Intent In The Misuse Of The Title Chiropractor?
An Invited Commentary

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

An Invited Editorial about this article:
Inappropriate Use of the title Chiropractor and term Chiropractic Manipulation
in the Peer-reviewed Biomedical Literature
Chiropractic & Osteopathy 2006 (Aug 22); 14 (1): 16 ~ FULL TEXT

By Adrian B Wenban, B.Sc., B.App.Sc., M.Med.Sc.

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In 1995 Dr. Allan Terrett, Associate Professor of Clinical Orthopaedics and Clinical Neurology at RMITU’s Division of Chiropractic Studies, had a paper published [1] in JMPT wherein he documented various levels at which the title chiropractor was being misused. I recently had a review published [2] that is very much built on Terrett's work from the 90's and that further documents the continued inappropriate use of the title chiropractor and term chiropractic manipulation by biomedical researchers from specific countries.

A number of colleagues have asked me the question, Do you think the biomedical authors, largely from Germany and Spain, who are inappropriately using the title chiropractor have malicious intent toward the chiropractic profession?

The conclusion that Terrett came to regarding that question, based on the cases he studied back in the 90’s [1], seems to be that medical authors, respected medical journals and medical organizations did have a bias against chiropractic. In contrast, my answer to that question, based on the cases that I have studied to date, is that no such bias is apparent.

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Four observations lead me to believe that there is no bias or malicious intent. The first is that the authors of the case reports and case series that I have reviewed over the last 3 years seem to have been involved in authoring only the one related publication. That is to say there does not appear to be one or two, or a group of authors using the title chiropractor inappropriately on repeat occasions.

Secondly, as far as I have been able to determine to date, the authors of different case studies are not related or part of some umbrella organisation. They appear to be individuals, from unrelated institutions, who make one-off publications on the topic of manipulation induced injury and then go back to researching and writing about other health-related matters.

Thirdly, if there was a bias against chiropractic such that specific biomedical researchers from Spain and Germany were inappropriately using the title chiropractor in association with injured patients, in order to negatively influence the image of the chiropractic profession, one would not expect to see the title chiropractor also being used inappropriately in association with reports of patients benefiting from care. I can, however, point to a number of research reports from Germany [3, 4] where patients have benefited from the care provided by non-chiropractors but the authors have chosen to use the title chiropractor in their report. Therefore there are cases where the inappropriate use of the title chiropractor has worked against the chiropractic profession, and there are cases where the inappropriate use of the title chiropractor has worked in favour of our profession.

Fourthly, and finally, those biomedical authors in question, who are reporting these cases, and with whom I have now communicated, all seem to think of chiropractic not as a separate and distinct profession with internationally agreed and regulated minimal education standards. Instead, they think chiropractic is a set of manipulative techniques used by a range of professions that perform SMT. As a result, the authors I have spoken to are likely to use the term 'chiropractic manipulation' despite whether the care provider was a physical therapist, a medical manipulator or an orthopaedic surgeon.

The other question colleagues then ask me is Why then do I think this is happening if not because of malicious intent?

I suspect part of what is perpetuating the inappropriate use of the title chiropractor by some biomedical authors is that they are publishing their case reports based on the local understanding of who is a chiropractor. Unfortunately the local understanding of who is a chiropractor, in most the cases I have investigated, is at variance with that of organizations like WFC [5] and WHO [6]. This is because most of the countries where the authors of these case reports reside do not have laws in place to protect the title chiropractor and to regulate the practice of chiropractic. As a result a case report from Germany may associate a patient's injury to the care provided by a practitioner who has less than a year of part-time training in SMT, and in doing so, use the title chiropractor throughout the case report. The fact that the care providers in these case reports are not trained to CCEI standards is not being made explicit by the biomedical authors involved. This is creating genuine problems because the authors are publishing in international biomedical journals and their case reports are therefore being read, and have implications, even in countries where chiropractic has been regulated by governmental registration boards for years (ie. Australia, US, Canada). Readers from countries with laws, which set minimal educational standards that must be satisfied before a care provider can use of the title chiropractor, assume the same standards apply in countries like Spain and Germany. However, as was revealed by my recently published review [2], the so called 'chiropractors' being implicated in these case reports, specifically from Spain and Germany, do not fulfil the criteria laid down by WFC and WHO in relation to who is a chiropractor.

Despite the cause of the inappropriate use of the title chiropractor, this whole issue underscores the importance of the title and practice of chiropractic being regulated by law. If there was a law in Spain and Germany that stated, and enforced, the requirement that all registered providers of chiropractic care had to fulfil stringent educational requirements, consistent with CCEI standards, as is the case in Australia, the UK, Canada and the US, it would be more obvious to the biomedical authors in question that the care providers who's care it is that they are associating with injury, are not chiropractors as defined by the standards set out by CCEI, WFC and WHO.

I believe we need to deal with this issue on three levels -

Education - The chiropractic profession needs to continue to maintain high educational standards; we need to educate the public so they know the difference between a chiropractor and non-chiropractor; we need to educate other health care professions and biomedical researchers regarding our high standards and the fact that chiropractic is a profession and not just a set of manipulative techniques.

Research - We need large and better quality prospective studies aimed towards better quantifying the incidence of injury and the characteristics of those at risk. A recent systematic review [7] aimed to find and summarize all such prospective studies carried out to-date. The authors found five investigations that met their inclusion criteria, which in total included over 2000 patients. It is encouraging that not one case of serious injury was reported amongst the patients from those 5 studies. However, despite the encouraging results and the fact that all of those studies were prospective, each was weakened by certain design limitations. We therefore still need to do bigger, more refined studies to better quantify the incidence.

Legislation - It is in the best interest of all chiropractors, even if you live and practice in a country that has favourable legislation protecting the title of chiropractic, to support and work towards achieving legislation in those countries that still lack it, ie., Germany and Spain. North America and Europe may be separated by an ocean and various borders but what gets published in European biomedical journals flows freely via the internet to all corners of this planet with little regard for distance, oceans and international borders.

The chiropractic profession has worked hard towards dealing with some of the above issues in the countries where the profession is now well established. However, as chiropractic continues to grow and get a foot hold in new countries, a lot of work lies ahead in order to control and ultimately bring to a halt the inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' in the peer-reviewed biomedical literature.

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References:

1. Terrett AGJ:
   Misuse of the Literature by Medical Authors in Discussing
   Spinal Manipulative Therapy Injury
   J Manipulative Physiol Ther 1995 (May);   18 (4):   203–210
   

2. Wenban AB.
   Inappropriate Use of the title Chiropractor and term Chiropractic
   Manipulation in the Peer-reviewed Biomedical Literature
   Chiropractic & Osteopathy 2006 (Aug 22); 14 (1): 16
   

3. Hulse M.
   Cervicogenic Hearing Loss
   HNO 1994 (Oct);   42 (10):   604–613
   

4. Hulse M, Holzl M.
   Vestibulospinal Reactions in Cervicogenic Disequilibrium. Cervicogenic Imbalance
   HNO 2000 (Apr);   48 (4):   295–301
   

5. WFC policy statement –
   Use of the Title Chiropractor (2001, amended 2003)
   

6. World Health Organization (WHO)
   WHO Guidelines on Basic Training and Safety in Chiropractic
   Geneva, Switzerland: (November 2005)
   

7. Ernst E.
   Prospective Investigations into the Safety of Spinal Manipulation
   J Pain Symptom Manage 2001; 21:238-42

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