Chiropractic Utilization
Sunday, February 14, 2010 at 2:43AM Len Siskin, D.C.
Promote Chiropractic
Co-Chair ICA Best Practices
How many of us would have become chiropractors if we knew how much scrutiny and justification would be required to simply try our best through our training to help our patients? In this world right now, where are students of chiropractic and chiropractic doctors? What does the research say and what do we know? My experience is many of us forget the power we have in helping people. Fear is a great way to stifle learning. It is the opinion of this author that knowledge can bring the confidence needed to allay these fears which result in neglect of both doctors of chiropractic and their patients.
I recently visited a chiropractic college and spoke with a group of middle and senior students about subluxation and chiropractic. Our discussion leaned in the direction of understanding why research is important and how to gage what research is worth taking seriously. I thought this was important because when discussing research I kept hearing students use the phrase, “The research says…” When asked, “What research? What were the outcomes of that research? How were variables measured? Were the conclusions of the researchers reasonable?” I received blank stares back from the group. For fun I asked how many of the students knew what a nasium view x-ray was. A few had an idea. When asked how many of them had experienced upper cervical evaluation x-rays for subluxation not a hand was raised. I went on to explain to the students I thought that was funny because when I was in school having upper cervical x-rays taken of myself was an academic requirement. They were shocked.
I had lunch with a younger colleague after visiting the chiropractic college. They expressed their frustration that they just felt they were not getting their patients better. They explained after about 2 weeks of care if the patient’s symptoms were not resolved they simply gave up. The same chiropractor was looking for ways to supplement their income because they were not making money as a chiropractor and the frustration was wearing on them.
In my own practice when patients ask, “Doc, when will I be fixed?” I generally respond by saying, “Well, I’m going to try to apply principles of physics and engineering to your spine under the silly notion that you might heal from your problem if we take the barriers to healing away. If we go a period of time and I have no evidence you are improving I am obligated to kick you out or send you to another professional. I hope your body does not put either one of us in that position.”
Why is it that I respond so differently than the friend I had lunch with when interacting with patients? We have the same basic education.
421 chiropractic treatment visits1
Apparently in 1930 this many visits were not considered overutilization. To the best of my ability to tell, this BJ Palmer case study represents the largest amount of chiropractic treatment documented on a single patient. In this particular case, the patient was not suffering from generalized non-complex low back pain. She was suffering from bronchial asthma, headaches, and nervousness with failed past medical history. Using HIO upper cervical technique caring for a C2 PR listing the patient was adjusted daily for 9 months, and then 5 times per week for 7 months. This all happened before the treating doctor recommended she go onto a schedule of maintenance chiropractic checks and treatments which she was encouraged to do as part of her lifestyle for the rest of her life as a proactive health maneuver.
I challenge anyone reading this to submit a treatment plan to your local insurance company looking like the one above. If you want to spend some time in jail relaxing this might do the trick. In 1930 it didn’t matter because in many places you would go to jail just because you were a chiropractor. At the time of publication of the case study the treating doctor noted that all the patient’s symptoms had, “Cleared up”. Her weight was normalizing and her attitude in general had become enthused and encouraged toward normalcy.
One chiropractic treatment visit
Out of approximately 1400 original human subjects based chiropractic research papers documented in the ICA Best Practices and Best Practice Guidelines2, 174 papers base their research findings on only one treatment visit. Why? When performing research it is important to have controls so you are more likely to measure the actual effect of the intervention performed in the research observing the patient quickly after only one treatment has been performed. Many studies choose to evaluate based on a single treatment. If you take into consideration the BJ Palmer paper and all the papers where they only treated one time you start getting a feel for how the average number of visits used to treat patients in chiropractic research ends up at about 23 visits.
Looking deeper, from 1909 to 1960 the average number of treatments showed as 27. From 1961-1980 the average number of chiropractic treatments shown was 47. From 1981-1990 the average number of chiropractic treatments shown was 22. From 1991-2000 the average number of chiropractic treatments shown was 25. From 2001-2007 the average number of chiropractic treatments shown was 24. Nobody knows why these numbers vary but the inclusion of chiropractic into insurance reimbursement might have something to do with the shift in treatment reported dropping after 1980. It makes me wonder whether the more recent numbers represent patient progress as much as they do the policies and laws governing chiropractic practice in the past three decades. Remember, this is not a report of what chiropractors did. It is a report of what chiropractic research reported in several arbitrarily selected ranges of time in published research.
According to officials at the ICA, they are currently receiving daily calls from chiropractors and the representatives of chiropractor’s worldwide making inquiry about the ICA Best Practices and Best Practice Guidelines2 document. These inquiries are being made for purposes of understanding what care plans are reasonable, how to protect against scrutiny from insurance and state board inquiries, and what is expected of chiropractors in today’s technological and documentation intense environment.
The ICA guidelines are available at www.ICABestPractices.org. These guidelines are extremely straight forward and simple to digest. They review and report on all original chiropractic research from 1909 to present. Recommendations in the guidelines are largely made based on research numbers and not from personal opinion (consensus of experts). Authors of the guidelines are professional chiropractic experts who are not on the payroll of any insurance company. They have been largely created by practicing chiropractors who are also ICA members. They were created in an effort to see if the evidence can support and defend the way a practicing chiropractor would practice in a real, clinical setting.
1. Palmer, Bj DC, PHC. Book: The Hour Has Arrived. 1930; Pages 53-71.