By Robert Jusino, DC, MPH

Editor’s note: The following is Dr. Jusino’s unabridged essay that presents a solution to the divisiveness that continues to characterize the chiropractic profession. If you would like to comment or respond to his essay, please contact the editor by e-mail at lsegall@chiroeco.com.

The chiropractic journals are filled with passionate and heated debate over this profession’s definition. There are calls from many different groups of leaders to define and unite the profession. It is quite sad that a profession that is over one hundred years old and has so many health benefits to offer is still struggling to define itself and is so misunderstood by the public. However, there is always hope.

The analysis of the chiropractic profession is multi-factorial. These factors were examined and developed in a detailed work entitled “Strategic Plan for the Chiropractic Profession” published in [ITAL]Chiropractic Technique [/ITAL]in the May 1998 issue. I will address the definition issue from a narrower and updated context for purposes of this essay.

A common history

All doctors of chiropractic have a common history with founder D.D. Palmer, pioneer B.J. Palmer and their theories of health and disease. Central to this profession is the founder’s belief that by removing traumatic nerve interference, toxins and negative autosuggestions, the human body innate mechanisms and recuperative powers will maintain biological homeostasis and health.

He emphasized the adjustment and manipulation of the individual vertebras in the human spine for the purpose of health and wellbeing. These early chiropractic health beliefs have common ground with modern day holistic health approaches that promote the mind-body connection, physical fitness, nutrition and exercise.

B.J. Palmer radicalized the profession by advocating his ideas on the chiropractic subluxation — vertebral dysfunction — as the paramount cause of all disease and the atlas-axis vertebral adjustment, hole-in-one, as the main paramount treatment.

The early differences between the founder’s ideas and those of his pioneering son seem to mark the beginning of a rift of thought within the profession. Other groups of chiropractors with different opinions left the Palmer school and founded their own schools, like the National College of Chiropractic in Illinois. There has been disunity in this profession from its early beginnings.

At present, although preadmission requirements (ranging from two to four years of college) different among colleges, all doctors of chiropractic have a common educational experience. All schools are required by the Council of Chiropractic Education (CCE) to teach a similar curriculum of basic sciences, clinical sciences and chiropractic techniques. And all doctors of chiropractic are required to take the board examinations administered by the National Boards of Chiropractic Examiners, NBCE.

Many common grounds

Leaders in some groups have done a lot of hard work in creating definitions for the profession. One of the most recent collective works was done by the Association of Chiropractic Colleges (www.chirocolleges.org), which published its “Chiropractic Paradigm,” with definitions of chiropractic, subluxation and scopes of practice.

The American Chiropractic Association and the International Chiropractors Association have each published similar works. Please refer to their appropriate Web sites for details.

In general, these chiropractic definitions have some common ground — most notable, the agreement on the importance of the body’s natural, “innate”, recuperative powers and the notion of promoting optimal wellness.

Also important is the theory — philosophy — of vertebral segmental dysfunction — subluxation — and its effects of human health. There is also strong agreement in that the practice of chiropractic is drugless and non-surgical.

Definitions’ drawbacks

The main drawback of these professional definitions is that they are lengthy descriptions expressed in industrial shop-talk rhetoric that obscures the gist of the profession. Neither the lay public nor healthcare administrators understand these definitions very well.

Worse yet, some of the language used, such as subluxation, is controversial and has a totally different meaning in the world outside of the chiropractic profession. In normal use, the word subluxation means “a partial dislocation of a joint.” This would be a contraindication to manipulation. One of the statements found on a patient’s radiology report of a normal x-ray study is; “no fractures, dislocations or subluxations noted”. With this radiology report, it would be inappropriate for a chiropractor to diagnose this patient with a subluxation, since it has already been ruled out by x-ray diagnostics! Also, it would be cumbersome to convince the patient or his primary care physician of this diagnosis after they have read the x-ray report.

The chiropractic profession does not have to speak a different language to remain separate and distinct from the practice of allopathic medicine. It just has to practice differently from allopathic medicine.

Part of the problem in collective definition writing is the melding of different and sometimes controversial point of views. Even at chiropractic research agenda consortiums, such as RAC4, the controversy in definitions is epidemic, because our best minds are not in consensus on a simple definition of the chiropractic vertebral subluxation.

Professional differences

The most notable differences in definitions are noted in comparing the ACA and the ICA definition statements. Despite the above-mentioned similarities, the definitions are different in context and tone.

The most notable difference between these two definitions is the physician status for doctors of chiropractic noted in the ACA definitions but absent in the ICA definitions. Also different is the ACA modern language description of the chiropractic scope of practice in modern language, suitable to describe this healthcare profession as a present-day type of specialty physician.

The ICA definitions do not include the physician status and offer a more limited description of scope of practice. The definition of the chiropractor’s purpose is to detect and correct subluxations. Also the definitions are based on philosophical statements not expressed in modern terms. Many statements are confusing to the lay reader.

Although many chiropractic techniques and gurus exist, these two associations — the ACA with approximately 20,000 members and ICA with approximately 8,000 members — represent the two main camps of thought in this profession of approximately 60,000 doctors. Ironically, the majority of doctors of chiropractic do not belong to an association.

One group, known as the “mixers,” advocates a holistic approach to health in which multiple factors, such as spinal health, physical fitness and nutrition, are balanced to avoid disease. Their practice encompasses a “mixed” variety of natural and mechanical methods, including chiropractic adjustments, physical therapy, acupuncture, nutritional supplements, exercise and meditation to aid the body’s healing process.

This group utilizes medical diagnosis methods, including blood work and other diagnostics. It tends to accept scientific methodology for the validation of clinical practice. As chiropractic physicians, they work with — and want to be a part of — the larger established medical system.

The other group, known as the “straights,” advocates that the chiropractic vertebral subluxation — segmental dysfunction — as a paramount cause of disease. This group also limits the chiropractic practice to the correction of vertebral subluxations by manual adjustments in order to remove nerve interference and to let the body’s innate intelligence flow.

This group prefers to use chiropractic analysis instead of medical diagnosis. They have historically preferred to use chiropractic philosophy as the basis for their clinical practice instead of scientific methodology. Members of this group are opposed to being regarded as chiropractic physicians. They prefer to be called chiropractors. They strongly advocate chiropractic to be a separate, distinct and different practice from the medical system.

Despite the common historical, education and definition backgrounds, these two camps have irreconcilable differences in the opinions. This is evident in the controversy surrounding any government administrative and legislative attempt that involves the profession. The CCE accreditation and NBCE certification process also has its share of ideology controversy.

A tree-like analogy

The chiropractic profession can be likened to a tree: This profession is composed of historical “roots” and a “trunk” of knowledge with two very different “branches.” The roots (history) and trunk (knowledge) supply the raw materials and the branches (mixers and straights) are supposed to supply the energy to keep the professional tree healthy.

The problem? Neither of the branches wants to be a [ITAL]branch. [/ITAL] Each wants to be the tree. This controversy is weakening the profession and stunting its growth. Regardless of which branch chiropractors choose to belong to, they cannot kill the other branch to become the trunk.

The reality is that there is room for other branches. These branches represent different ways to apply professional knowledge.

Other professions have diffused the pressure of differing opinions about the nature of their profession by creating specialty branches. For example, the engineering profession has a similar common historical and educational background, not without controversy. However, engineers co-exist peacefully within their specialty branches, chemical, electrical, mechanical, civil, aerospace etc.

The medical and osteopathic professions also have a similar historical and educational background, not without controversy. But they also co-exist peacefully within their many specialty branches — internal medicine, psychiatry, pathology, orthopedics, etc. The medical and osteopathic physicians are defined in the Medical Act of the State of Illinois as physicians licensed to practice medicine in all its branches.

The same is true about lawyers, computer programmers, business specialties and others.

In any case, you do not find the professional infighting in these professions as you find in chiropractic. They do not involve themselves in ideological fascism, the forceful imposition of your ideas upon others. They are not trying to impose or change their colleague’s professional practices. They have evolved in peaceful co-existence.

Small window of opportunity

The recent healthcare industry’s interest in spinal manipulative therapies opens a window of opportunity for chiropractic. But those opportunities are accompanied by threats to our profession:

• The osteopathic profession has resurrected their elective osteopathic manipulative therapy courses (OMT) and is adding them to their core curriculum. Osteopaths will be board certified in family medicine and OMT!

• The physical therapy profession has raised its educational standards and is including orthopedic manipulative therapy as a specialty. Physical therapists are quickly becoming doctors of physical therapy (DPT). They are also advocating physical fitness, nutrition and exercise as key factors in health and integrating them in their therapeutic interventions.

The strategic actions of these two professions pose a serious threat to the integration of doctors of chiropractic into the health system. It would be a strategic mistake to believe that these integrated professions cannot develop excellent skills in spinal manipulative therapy.

It would also be very naïve to assume that the public will not go to them and that they would prefer doctors of chiropractic, even when they will probably have less insurance coverage and more out-of-pocket payment.

Doctors of chiropractic have survived and flourished in the past but they did not have their competitors offering similar services.

For doctors of chiropractic, integration into the healthcare system means more patient access, more secure employment, more employment mobility, more economic rewards, and better access to research and education opportunities. Isolation means the opposite.

Doctors of chiropractic do not have to be isolated to be separate and distinct from the practice of medicine. They simply have to practice differently from allopathic medicine.

The many insurance caps and lack for coverage for chiropractic services are an expression of isolation from the system, an apparent lack of relevance and a limited definition of the chiropractic scope of practice — detecting and correcting subluxations.

The criticized limitation of the Medicare system, which one day could be our national healthcare system, reflects the “straight” camp limiting view — detecting and correcting subluxations. The chiropractic services of “correcting subluxations” are probably not well understood by the plan’s administrators and its beneficiaries. These services are mandated by the Medicare Act but are greatly underutilized and are presently being reviewed in litigation at the federal court system.

Medicare’s administrators and beneficiaries are looking for optimal wellness, cost savings and safe/effective pain relief. They do not really understand what chiropractic subluxations are. It is very possible that part of the reason for Medicare’s lack of reimbursement for examination and x rays is that some chiropractors claim that they do not diagnose. Yet, Medicare pays for procedures to render diagnosis and does not pay for services unrelated to correcting a subluxation by an adjustment.

The Federal Employees Claim Act (FECA) for workers’ compensation has the similar language that limits coverage to “correcting a subluxation demonstrable by x-ray.” It also requires an explanation as to how the subluxation is the result of the work injury. FECA will only pay for chiropractic manipulative therapy to correct a spinal subluxation.

Many other ERISA insurance plans, such as the Blue Cross Blue Shield Empire plan for the Marriott Corporation, are adopting a similar, limited, “straight” chiropractic definition. They only pay for chiropractic manipulation. Many of these ERISA plans will probably choose the most limited definition of chiropractic, much to the delight of our competitors.

The professional definition has a direct influence on the integration, utilization and economic re-imbursement for chiropractic services.

What can the profession do?

The solution is a comprehensive strategic plan to be executed nationwide. However, it would be difficult to execute such a plan with the present division and lack of definition in the profession.

A large group of chiropractic leaders organized by Kent Greenawalt, CEO of Foot Levelers Inc., has undertaken a collective effort to unite the profession’s public relations message. Crucial to this effort is creating the best possible definition of chiropractic combined with an attractive health message that is well understood and well liked by the general public and health care administrators.

The key for success in this definition-writing process is to formulate a universal statement that is short, simple and expressed in easy-to-understand terminology. Also important is that this definition correlate with the profession’s common areas and allows both “mixers and straights” branches to exist.

The definition-writing process is not the place to embark on lengthy theoretical discussions or on micro-detailed descriptions that can limit future growth and activity.

The ICA and ACA definition and the ACC’s “Chiropractic Paradigm” have some very good common-ground concepts, such as spinal health, optimal wellness and practice without drugs or surgery. These concepts should be used in further definition work. However, these have to be simplified and expressed in modern terms with appropriate semantics. Also, a new definition should be expressed in language that will be well understood by the lay public and health care administrators in order to benefit the chiropractic profession’s public relations effort and their standing in society.

Finally, further definition work should acknowledge, separate and classify the two main camps of thought — straights and mixers — in order to unify the profession by allowing the co-existence of ideas without adversarial ideological friction.

A simple proposal

I propose the following simple and concise definitions for the chiropractic profession’s consideration:

• Chiropractic: A system of healthcare that promotes optimal whole-person wellness, physical fitness and spinal health. Chiropractic physicians treat human ailments without the use of prescription drugs or incisive operative surgery.

• Branches of chiropractic: Chiropractic has two branches, chiropractic sinology and chiropractic medicine.

Chiropractic spineology is the branch of chiropractic that studies the effects on health of vertebral segmental dysfunctions in the human spine. Doctors of chiropractic spineology optimize wellness and treat human ailments mainly by manual adjustments to dysfunctional vertebras on the spine.

Chiropractic medicine is the branch of chiropractic that studies the combined effects on health of proper spinal function, physical fitness, mental/emotional fitness and nutrition. Doctors of chiropractic medicine optimize wellness and treat human ailments with spinal manual adjustments, as well as with natural, mechanical and other common domain health care methods.

This proposed modern terminology professional definition reflects concepts expressed in the late 1800’s by David Palmer, DC and his son B.J. Palmer, DC. It also capitalizes on the public’s healthcare needs for this new millennium and on the strengths of the chiropractic profession.

I proposed that once a consensus on definition is achieved, a comprehensive campaign of definition review should commence to update chiropractic definitions in every dictionary, encyclopedia, web-site, state and federal statutes.

A good professional definition and health message should be at the center of a unified public relations campaign. The public, government officials and healthcare administrators should be aware that chiropractic stands for whole-person wellness, spinal health, physical fitness, mental fitness and proper nutrition.

In this definition, both branches of chiropractic, “straight and mixers,” are recognized and separated as branches. Through education, recognition and classification of the two branches, the chiropractic profession will find peace, unity and strength.

The purist “straight” doctors of chiropractic can choose to practice by mainly providing manual spinal adjustments to their patients. The innovative “mixers” can choose to provide evidence-based treatments in conjunction with their adjustments.

These two branches — chiropractic spineology and chiropractic medicine — should be recognized, accepted and formalized by the use of elective coursework and short post-graduate training and board certification. Only then will these camps of thought recognize themselves as branches and stop tearing apart this profession.

A board certification in one of these two branches — such as a diplomate in chiropractic spineology (DCS) or a diplomate in chiropractic medicine (DCM) — would give the chiropractic profession needed credentialing in knowledge and methodologies that are highly relevant to their practice.

Membership to either branch should be a matter of study, dedication and choice. It should not be a matter of opinion, dogma and ideological fascism.

Good luck to us all.

Robert Jusino, DC, MPH, practices in River Forest, Ill. He can be contacted at Jusino@comcast.net