Chiropractors attend four-year college programs that teach the art, science and philosophy of chiropractic—or do they? Currently, chiropractic colleges do a great deal to teach and to prepare chiropractors in the art, philosophy and delivery of the clinical science of chiropractic, but the colleges are not doing enough to train chiropractors in the science of case management. If the clinical chiropractor can create a more evidence-based practice approach utilizing diagnostic tests, the chiropractic profession would be able to gain the respect and acceptance of legislators that control healthcare dollars. Our national organizations could make a much stronger argument for the effectiveness of chiropractic care versus the next alternative, if the chiropractic profession would utilize diagnostic tests to provide the needed clinical evidence.
Chiropractors learn a great deal of philosophy and history in school that transforms them into very passionate and dedicated practitioners. I know this, because people I talk to about chiropractic in social settings outside of the office often state that they “believe in chiropractic,” as if chiropractic were a religion or faith that requires a higher than average conviction in order for them to accept what chiropractic does. In school, the chiropractor also learns a great deal on the art of chiropractic in the form of compulsory adjusting classes as well as other optional techniques offered during weekend seminars. The chiropractic profession is well equipped with a plethora of techniques to choose from, each with its own philosophy of the how and why of the adjustment.
The art and philosophy portion of chiropractic training does not need to be improved; it is the science portion of the training that needs modification, specifically the case management in clinical science. Doctors of chiropractic are very poor case managers. A majority of chiropractors recommend treatment plans that are baseless. This is a very serious weakness. Chiropractors wonder why insurance companies deem care to be “NOT MEDICALLY NECESSARY” when they have treated a patient over a 40-50 visit treatment schedule with no evidence from re-examinations and/or diagnostic tests that supports that level of care. A weakness of chiropractic case management lies in the fact that those chiropractors that actually do perform re-exams are performing exams that are useless. They are useless in that the initial examination and re-examinations performed contain orthopedic tests that are only positive 1 percent of the time and range of motion examinations are visualized or, at best, utilize testing equipment and procedures with very low levels of reproducibility. The same type of situation is evident for muscle testing and neurological testing on re-examinations. The majority of the evidence that chiropractors are gathering to determine the validity and effectiveness of their care is subjective, not objective.
The medical profession utilizes diagnostics tests for 90 percent of the care given to their patients. Actual treatment from the medical doctor makes up 10 percent of the care given to the patient. In chiropractic, just the opposite is true, ten percent of the care given the patient is diagnostic and the treatment portion makes up 90 percent of the care. A majority of chiropractors use X-rays as their only source of objective evidence to justify a patient’s care for 40-50 visits. That is not good enough. The insurance companies know that it is not good enough, and that is why they continue to deny care for chiropractic patients. Documenting a patient’s condition with objective evidence is the only way to prove that the care you provide in your office is medically necessary.
When a patient comes into the office with subjective complaints, a chiropractor must document those subjective signs and symptoms in the notes and then determine the exact nature of those complaints with objective evidence. As a chiropractor, you treat spinal conditions. The spine is comprised of three distinct tissues that need evaluation: 1) the bones, 2) the nerves, and 3) the muscles/ligaments/discs. In chiropractic college, chiropractors learn about myopathology, neuropathophysiology, and kinesiopathology. Chiropractors also learn to evaluate these entities with a number of orthopedic exams, range of motion evaluations, neurological exams, as well as palpation and percussion. This exam process is fine. The problem with this type of examination process, though, is that it stops there. The only evidence gathered from an examination process of this type, which is in chiropractic colleges across the country, is subjective in nature. The information that needs to be gathered on each of the tissue pathologies above needs to be objective in nature. The chiropractic physician needs to take the subjective signs and symptoms and put them in an objective form so they can easily be retested to determine that the treatment strategy chosen has worked. Gathering objective evidence and comparing that objective evidence throughout the treatment allows the profession to go from an “I believe that chiropractic works” profession to an “I know that chiropractic works” profession. Patients know they are getting better in an evidence-based practice, rather than relying on faith that the doctor can sense, in some mysterious fashion, that they are doing better and the treatment is working.
The diagnostic tests that should be performed on a regular basis in a chiropractic office or referred to a diagnostic testing center should include the following: computerized range of motion, computerized muscle testing, MRI, CT, X-ray, and NCV (Nerve Conduction Velocity). Other objective evidence needs to be gathered in the form of outcome assessment forms such as the Visual Analogue Scale, Rand-36 Item Survey, Low Back Pain Questionnaire, Neck Pain Disability Questionnaire, and the Roland Morris. If the patient has a decreased range of motion (ROM), then the doctor ought to evaluate the kinesiopathology of the patient utilizing computerized inclinometry (cROM) tests to document the exact loss of ROM. This initial ROM exam will be the standard to which future ROM examinations will be measured. Any future ROM examination should show an increase, if the treatment was effective. If the cROM tests do not show an increase, then treatment must change in a manner consistent with the evidence gathered. A decrease in muscle strength needs to be evaluated utilizing computerized muscle testing (cMT). The numbness, tingling, radiculopathy, hand pain, and arm pain need to be evaluated with electrodiagnostics and computerized muscle testing. Suspected disc problems should be viewed with MRI, disc degeneration with an X-ray, and osteoporosis should be evaluated with a dexa scan. These tests should be redone on a regular basis, for example, every 12 visits for cROM and cMT, or every three months for a dexo scan, so that the doctor can determine the treatment effectiveness.
The chiropractic profession is in a period of change, and we have to embrace that change. Whether it was for good or bad, the chiropractic profession joined the insurance industry; but the Mercedes 80’s are over. Doctors of all disciplines are being held more accountable for the level of care they are providing. The chiropractic profession must learn the rules of the insurance industry so they can receive a fair reimbursement for all services provided in the office. One of the bigger rules is documenting the level of care recommended; and the only way to objectively provide evidence is through the use of diagnostic tests.
Dr. Dwight C. Whynot is a 1999 graduate of Logan College of Chiropractic. He can be reached by email at [email protected].