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:

1. 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.