TO: CCE Board of Directors
FROM: XXXXXXXXXXXXXXXXX
RE: Public comments on proposals
To
The Board of Directors of CCE:
This letter is in response to the open comment period on the three proposals
posted on your web site:
-
Proposed Definition of Diagnosis change to the
Standards.
This proposal would replace the existing statement on diagnosis with the
statement promulgated by the Association of Chiropractic Colleges. I
strongly oppose this change for the following reasons:
The
statement could have a serious and far-reaching negative impact on the
profession and, in essence, prohibit the practice of traditional,
subluxation-based chiropractic. It will open wide the doors to accusations
of malpractice for any doctor who limits his or her practice to the
detection and correction of vertebral subluxation.
By
maintaining that “The process of arriving at a diagnosis by a doctor of
chiropractic includes obtaining pertinent patient history; conducting
physical, neurological, orthopedic, and other appropriate examination
procedures; ordering and interpreting specialized diagnostic imaging and/or
laboratory tests as indicated by symptoms and/or clinical findings; and
performing postural and functional biomechanical analysis to determine the
presence of articular dysfunction and/or subluxation” the statement mandates
such procedures as an integral part of every chiropractic program of care.
The
wording does not provide latitude for the unique needs of each patient and
replaces the judgment of the attending doctor with a checklist of orthopedic
and neurological tests that may be irrelevant to the determination of
neurological function in the context of subluxation.
Further, the statement characterizes subluxation as nothing more than a
postural or biomechanical problem. Eliminating the neurological element not
only jeopardizes the doctor who uses instrumentation to assess neurological
function, it contradicts the ACC statement concerning organ system function
and general health.
To
rectify this error, the statement needs to be modified so that it says:
“performing appropriate postural and functional biomechanical analysis,
and/or using specialized procedures to determine the presence of articular
dysfunction and/or subluxation and its resultant neurological dysfunction.”
(changes in bold)
As
it stands now, the statement is in direct conflict with the ACC’s widely
endorsed position paper, which in part states that “Doctors of Chiropractic
establish a doctor/patient relationship and utilize adjustive and other
clinical procedures unique to the chiropractic discipline. Doctors of
Chiropractic may also use other conservative patient care procedures, and,
when appropriate, collaborate with and/or refer to other health care
providers.”
In
addition, the ACC position paper expressly states that “Chiropractic is
Concerned with the preservation and restoration of health, and focuses
particular attention on the subluxation. … A subluxation is evaluated,
diagnosed, and managed through the use of chiropractic procedures based on
the best available rational and empirical evidence.”
The
ACC Position Paper No. 1 does not mandate orthopedic or neurological tests,
nor does it ignore the vital issue of chiropractic’s unique diagnostic
methodology and procedures. This new statement violates, in word and spirit,
the intent of the ACC Position Paper.
Correcting the potentially devastating flaw in the wording of the statement
would be extremely simple. The statement should read: “The process of
arriving at a diagnosis by a doctor of chiropractic may include
obtaining pertinent patient history ...”
By
inserting the word “may,” doctors of chiropractic would be free to use their
best judgment as to the type and number of tests needed to arrive at the
proper chiropractic diagnosis. Those doctors who practice according to a
broader scope may include the full range of neurological and orthopedic
tests allowed by law in their state while those doctors who choose to focus
solely on the detection and correction of vertebral subluxation may include
those tests which are specifically required for that determination.
To
further strengthen the statement, I also recommend ending the statement with
the phrase, “in accordance with the judgment of the attending doctor and the
unique needs of each patient.”
I
strongly urge you consider these revisions if the statement is to be adopted
by CCE.
I
am also very concerned about the existence of a “physician-related
terminology subcommittee.” Given that the term “physician” is regulated by
state law, it seems inappropriate for an accrediting agency to attempt to
incorporate language which may be unlawful for use by a chiropractor in many
jurisdictions.
2.
Proposed Physiological Therapeutics language
addition to the Standards
I
strongly oppose any mandate to include physiotherapy in accredited Doctor of
Chiropractic programs. The use of adjunctive procedures is regulated by
state law. The use of procedures outside the state scope of practice may
result in charges of engaging in the unauthorized practice of medicine, and
tort liability.
For example, In
Treptau v. Beherens Spa, Inc., 20 N.W.2d 108, 247 Wis.438, a chiropractor
undertook to examine and treat a patient's foot using bandages and
diathermy. The Wisconsin Supreme Court stated, "Plaintiffs do not claim
there was malpractice on the part of the defendant while Beherens was
engaged in the practice of chiropracty (sic) by chiropractic manipulation or
adjustments of the spine. Instead, plaintiffs contend there was malpractice
when he and his associates went beyond the practice of chiropracty (sic) and
entered into the general field of the practice of medicine...in so far as
there was thus an invasion of the general field of that practice, the
methods thus used by defendant's employees in diagnosis and treatment were
subject to the rules applicable to the practice of medicine and surgery."
The court in Treptau
relied on Kuechler v. Volgmann, 192 N.W. 1015, 180 Wis. 238, 242-43. The
Kuechler court held, "When a chiropractor assumes to diagnose and treat
disease he must exercise the care and skill in so doing that is usually
exercised by a recognized school of the medical profession."
While the use of
physiotherapy may be lawful in some jurisdictions, the scope of such
authority varies. Furthermore, some jurisdictions prohibit their use by
chiropractors.
Of equal importance
is the fact that a growing body of scientific literature reports that
passive physical modalities are of little or no value in addressing
musculoskeletal pain, and may actually prolong disability.
While a review of the
relevant literature is beyond the scope of this letter, the following papers
illustrate the trend:
Van den Hoogen et al
published the results of a study involving 269 patients. The objective of
these investigators was to identify prognostic indicators of the duration of
low back pain in general practice, and the occurrence of a relapse. It was
concluded that receiving physical therapy was associated with a longer
duration of low back pain.
The authors reported,
"at every moment in time, patients receiving physical therapy had a 61% less
chance to recover in the following week than patients not receiving physical
therapy." (1)
Clinical
Guidelines for the Management of Acute Low Back Pain,
produced by the Royal College of General Practitioners in Great Britain, address
the appropriateness of physical agents and modalities.
The Guidelines
state that, "Although commonly used for symptomatic relief, these passive
modalities do not appear to have any effect on clinical outcomes." The
modalities listed in the Guidelines include ice, heat, short wave
diathermy, massage, and ultrasound.
In reference to bed
rest and traction, "Traction does not appear to be effective for low back
pain or radiculopathy. ... The evidence shows that bed rest with traction is
ineffective. It adds the complications of immobilsation to the deleterious
effects of bed rest."
Furthermore, "There
is no evidence that manipulation under general anesthesia is effective. It
is associated with an increased risk of neurological damage." (2)
The AHCPR
Guideline for Acute Low Back Problems in Adults concurs: "The use of
physical agents and modalities in the treatment of acute low back problems
is of insufficiently proven benefit to justify their cost.
"...Only two studies
evaluated physical agents and modalities in patients with acute low back
pain. Neither found significant differences in self-rated pain relief or
other outcome measures between patient groups receiving physical agents and
modalities (including diathermy, ultrasound, flexion/extension exercises,
massage, and electrotherapy) and groups receiving a placebo." (3)
What about TENS for
pain control?
A study of 324
patients found no differences in outcomes in those receiving three different
types of TENS and those given a sham TENS unit with indicator lights but no
output. (4)
Is ultrasound
effective?
Gam and Johannsen
reviewed 293 papers published since 1950 to assess the evidence of effect of
ultrasound for musculoskeletal disorders. Serious methodological problems
existed in many of the papers. However, in 13 cases data were presented in a
way that made pooling possible. The conclusion: "None of the methods gave
evidence that pain relief could be achieved by ultrasound treatment." (5)
Another meta-analysis
looked at 400 randomized clinical trials. Meta-analyses were performed for
disorders of the back, neck, shoulder and knee. Results indicated that, "In
general, the methodological quality of the studies appeared to be low, and
the efficacy of physiotherapy was shown to be convincing for only a few
indications and treatments." (6)
A controlled study
was performed comparing osteopathic manipulation and short-wave diathermy in
the treatment of non-specific low back pain The placebo group, which
received fake diathermy, did about as well as those receiving real diathermy
or osteopathy. The authors stated, "Benefits obtained with osteopathy and
short-wave diathermy in this study may have been achieved through a placebo
effect." (7)
In a study comparing
drug therapy, conservative physiotherapy and manipulative physiotherapy,
"Serial assessments of pain and spinal mobility showed similar response
rates in all three treatment groups and no significant difference between
therapies." (8)
If CCE purports to
encourage evidence-based practice, mandating the use of such modalities is
not in the interests of the profession or the patients it serves.
3.
Proposed CCE Policy; Exceptions and Waivers to
the Standards
I am opposed to the
proposed change in the waiver policy. The provision that would
permit a waiver of the 2 year requirement if an institution loses
accreditation states that the minimum wait is one year. This eliminates the
ability to grant wavers for reapplication of less than one year. Few
schools could survive one year without accreditation.
Thank you for your
kind consideration.
Sincerely,
REFERENCES
1. van den Hoogen HJM,
Koes BW, Deville W, et al: "The prognosis of low back pain in general
practice." Spine 1997;22(13):1515.
2. Clinical
Guidelines for the Management of Acute Low Back Pain. Royal College of
General Practitioners. September, 1996. Available at http://www.rcgp.org.uk
3. "Clinical Practice
Guideline Number 14." Acute Low Back Problems in Adults. Agency for
Health Care Policy and Research. December 1994.
4. "No better than
placebo. Another look at TENS units for low back pain." Spine Letter
1997;4(5):2.
5. Gam AN, Johannsen
F: "Ultrasound therapy in musculoskeletal disorders: a meta-analysis."
Pain 1995;63(1):85.
6. Beckerman H,
Boulter LM, van der Heijden GJ, et al: "Efficacy of physiotherapy for
musculoskeletal disorders: what can we learn from the research?" Br J Gen
Pract 1993;43(367):73.
7. Gibson T, Grahame
R, Harkness J, et al: "Controlled comparison of short-wave diathermy
treatment with osteopathic treatment in non- specific low back pain." The
Lancet 1985;1(8440):1258.
8. Waterworth RF,
Hunter IA: "An open study of diflunisal, conservative and manipulative
therapy in the management of acute mechanical low back pain." N Z Med J
1985;98(779):372.
