In the words of Bob Dylan,
“Come gather ’round people
Wherever you roam
And admit that the waters
Around you have grown
And accept it that soon
You’ll be drenched to the bone.
If your time to you
Is worth savin’
Then you better start swimmin’
Or you’ll sink like a stone
For the times they are a-changin’.”
While change is a constant, there are times when those changes are critical. The dinosaurs are a good example. Adapt or die is the law of survival.
The chiropractic profession has been in a fight for survival from its beginning and this is the time for the choice that will determine whether the profession lives on as viable alternative to drug based medicine or vanishes into the world of physical medicine. While there are many who view the latter as a good step, there are just as many who are strongly opposed.
There have always been divisions within the profession but never on such a critical scale. The creation of these divisions has two separate foundations: the first being the dedication to the theory of vertebral subluxation as cause and the second being reimbursement for service rendered.
On the Theory of Vertebral Subluxation as Cause.
The original concepts of a misaligned vertebra and the theory of nerve root pressure creating nerve interference and therefore dysfunction, to this day has not been supported. It is still a theory1. This fact has left the basic concepts of the entire profession as questionable. Meanwhile, we still have a great number of chiropractors staunchly defending this theory and using the positive results of Chiropractic care as their proof. As the basic concept of vertebral subluxation is not supported there is no explanation offered as to how these results are achieved. Instead of focusing on “why” the adjustment gets results, the hardcore of the profession continues to defend vertebral subluxation as the heart and soul of Chiropractic. This has only served to alienate the side of the profession not accepting the old theory.
What has exacerbated the problem is that the Chiropractic colleges, in attempting to bring their curriculum up to university standards, have found it necessary to drop much of the old chiropractic theories and education. This shift has pushed the profession toward physical medicine and away from any connection with the adjustment and neurological responses. In so doing, they have ignored the century old history of fantastic responses to Chiropractic care in areas beyond pain relief or improved joint function.
On the Influence of Reimbursement for Service Rendered
The other mitigating factor in the shift of the profession lies in access to health insurance for services rendered. The inclusion is not so much about being recognized as a health profession as it is about security of income. In the beginning the profession saw its inclusion as vindication and acceptance. The long road, now in place, has shown this to be a misconception. The misconception lies in more than one area, one being the terms used such as, “Health” insurance. It has little to do with health and is really medical care insurance which in turn exposes number two misconception inclusion. Unless chiropractic becomes a medically modeled profession, it will be totally excluded. Once again the Colleges are well aware of this and will continue to move their education toward a model that will garner income for their graduates. (Remember that Colleges are profit run organizations even though they may claim not to be.)
On the Effects of Politics on Scope of Practice.
All of these challenges, opinions, and political maneuverings have had a dramatic effect on the “Scope of Practice” of Chiropractic and then you have to add in the local effects of States, Provinces, and/or Countries. There have been two documents produced which address the Chiropractic Scope of Practice. One is the Mercy Documents2 and the other the Council of Chiropractic Practice (CCP) guidelines3.
While both are registered documents, the Mercy guidelines are very medically modeled and dated 1993. The CCP guidelines are much more Chiropractic modeled and have gone through a series of updates with the latest being 2013. The CCP organization is composed of elected members from a worldwide base. Elections are held each year and the updates are from member reviews of new research. The update includes current research that pertains to Chiropractic. One of the most important changes in the last Guidelines update is as a result of the information regarding the research on the effect of the chiropractic adjustment on central nervous system function. Three papers now show that the adjustment directly alters CNS function4,5,6. This information dramatically shifts the focus position of vertebral subluxation nerve root interference as cause, to the effect of the adjustment to improve brain function.
The new information takes the old concepts of vertebral subluxation as representing the best and only interest of Chiropractic and places it in the history books. This does not suggest that vertebral subluxation does not exist, but rather places it in the perspective of a third level response. Compromised Neural Integrity (CNI) due to neurological stress overloads and inappropriate neural responses are the primary damage. This in turn creates abnormal muscle activity throughout the body’s various systems and in the case of the structural system, the vertebral subluxation.
This research has changed the playing field for the Chiropractic profession. As the profession has been affected by the shift in the education toward physical medicine and structurally based care, not only has the scope of practice been reduced, but the very future of the profession is in jeopardy.
It is interesting to note that at the time when the colleges have turned away from the core principles of Chiropractic, along comes this groundbreaking research to support the greater picture of Chiropractic. The challenge now lies in “how” and “if” the profession is willing to entertain the new direction. This has to start at the grass roots level. Change does not come from the higher levels of education as they are the standard of yesterday. The changes start with the research being made available to the profession and with it must come evidence based application in the practice environment.
The profession has a history of outrageous claims based on non-supported concepts so the responsibility lies on those presenting the new direction to provide solid, reproducible, objective evidence to the effectiveness of the adjustment to alter CNS function. This includes certified accurate instrumentation.
That said, there are other aspects that needs consideration, which include understanding and defining the subluxation as applied to both the profession’s historical standing and current research. The chiropractic adjustment also needs defining in this context.
On the New Direction for the Profession
The CCP guideline committee took on this task during the 2013 update. In light of the new research on the adjustment and the CNS responses the committee, after 2 years of work, listed this definition.
“Subluxation is a neurological imbalance or distortion in the body associated with adverse physiological responses and/or structural changes, which may become persistent and progressive. The most frequent site for the chiropractic correction of subluxation is via the vertebral column.” CCP Guidelines 2013.
This not only represents a radical shift of the definition but also a radical shift for the entire profession. It shifts the direction away from the structural model and restriction to spinal or joint care to a total neurological foundation. It opens the scope of practice from a pain reduction model to a model based on functional neurology. This model supports all technique approaches and calls for Chiropractors to look to the appropriateness of their care plans. This also calls for neurological assessments pre and post care.
Defining the adjustment from a neurological assessment calls for new approach as well. As the research now shows that the adjustment alters CNS function, we can no longer use terms such as realignment or joint play to describe an adjustment. The new definition calls for a two-step clarification.
Step one – The definition of feedback is important.
Feedback: A procedure whereby the consequence of an action serves to continually modify further action.
As that is exactly what the adjustment does within the CNS an appropriate definition of the adjustment is:
A Chiropractic procedure whereby the consequence of an action serves to continually modify further action within the nervous system with the intent of creating harmony within the body’s systems.
The impact of the new information is in a shift from the physical concepts of Chiropractic – this being: vertebral misalignment or vertebral subluxation and its correction as the main focus of chiropractic, to a total neurological foundation based on the effectiveness of the chiropractic adjustment’s ability to improve neurological function. The neurological recovery ability is a key factor of the effect of the adjustment which is the connection to the cataloging of the adjustment as a neurofeedback response.
The researchers dealing with bio/neurofeedback over the last 50 to 60 years have established the science of this field7 and once we were able to show the adjustment’s responses and subsequent ongoing changes in neurological function, it became self-evident that the chiropractic adjustment is a feedback event.
The next step was to use the adjustment as a neurological pattern interrupt and then apply bio and neurofeedback as a method to train the patient’s neurological pattern to a more ideal response.
This brings us back to scope of practice. To date there are no license requirements in place governing bio/neuro feedback. Australia has just taken the first steps to regulation but not so in North America. These are both valuable tools in the field of Neurologically Based Chiropractic and need to be included in our practice guidelines. They are included in the CCP guidelines for Chiropractic practice. That said, correct application is a necessity and those using the system should require training.
On the Intent of this Letter
This letter is intended to provide information, evidence, and be thought provoking, not just to Chiropractors in practice but across the scope of bodies governing the practice of chiropractic worldwide. Throughout North America, we have State and Provincial boards comprised of Chiropractors and the public controlling the profession based on concepts that are over100 years old or thinking that Chiropractic is just another branch of medicine. Neither of these is acceptable. The boards are responsible for the protection of both the public and the profession; however, when they make rulings based on outdated information they serve neither.
I am calling for the profession to get activated, to get involved because you can’t change something from outside or through inactivity. So you don’t like your State or Provincial association position – get active and change them. The scope of practice for Chiropractic is in your hands. You can let medical insurance coverage or the product of the chiropractic education system define Chiropractic and reap the consequences. Talk to your Boards and Associations! It is time for Chiropractors to define Chiropractic and its scope of practice.
Chiropractic is not medicine. Chiropractic deals directly with neurological function. Medicine deals with pathology. Change will only happen through action!
Come writers and critics
Who prophesize with your pen
And keep your eyes wide
The chance won’t come again
And don’t speak too soon
For the wheel’s still in spin
And there’s no tellin’ who
That it’s namin’.
For the loser now
Will be later to win
For the times they are a-changin’.
1. Bolton P (2000). “Reflex effects of vertebral subluxations: the peripheral nervous system. An update.”. J Manipulative Physiol Ther 23 (2): 101–3
4. Richard Barwell, DC; Annette Long, Ph.D.; Alvah Byers, Ph.D; Craig Schisler, B.A., M.A., DC. The Effect of the Chiropractic Adjustment on the Brain Wave Pattern as Measured by EEG. – A Four Case Study
International Research and Paper symposium 2005 Awarded the best research paper in review Sherman Chiropractic College
5. HeidiHaavikTaylor*,BernadetteMurphy Cervical spine manipulation alters sensorimotor integration: A somatosensory evoked potential study. Human Neurophysiology and Rehabilitation Laboratory, Department of Sport and Exercise Science, Tamaki Campus, University of Auckland, Private Bag 92019, 261Morrin Road, Glen Innes, Auckland, New Zealand Accepted 11 September 2006
6. Takeshi Ogura, oc, PhD; Manabu Tashiro, MD, phD; Mehedi Masud, MD, phD; Shoichi Watanuki; Katsuhiko Shibuya, us;Keiichiro Yamaguchi, MD, phD; Masatoshi Itoh, MD, phD: Hiroshi Fukuda, MD, phD; Kazuhiko yanai, nro, prroCerebral Metabolic Changes in Men After Chiropractic Spinal Manipulation for Neck pain.
7. Alvah P Byers (1998) The Byers neurotherapy reference library: Version 1.02