Dear Editor:
In the point of view that accompanied Herzog et al.'s recent Spine paper,1 Scott Haldeman,DC,MD,PhD reservedly comments on the limitations of the Herzog et al.
Unfortunately, the front-page article in the April 5, 1999 issue of Dynamic Chiropractic, "The Body's 'Global Response' to the Adjustment," by assistant editor Peter Crownfield, did not heed the reservations of Dr. Haldeman nor do justice to the peer reviewed indexed literature, by extrapolating the results of the study to the effectiveness of chiropractic adjustments.
The DC article claims that the Herzog et al. paper "provides direct evidence of the beneficial effects of the adjustment." However, the researchers' work makes no contention of direct evidence of benefit. On the contrary, the authors clearly state in their abstract, "There is a distinct possibility that these responses may cause some of the clinically observed benefits of SMTs." A "distinct possibility" and "direct evidence" are certainly two separate opinions and this artificial inflation of the "benefits of SMTs" does damage to the chiropractic profession who has in the past been plagued by false claims and inappropriate extrapolation from the literature.
Moreover, the DC article serves as an injustice to the work of the researchers. Good science is based upon a sequence of methods to test hypotheses. It is far too soon to extrapolate the results of this study as "direct evidence of the beneficial effects of adjustments."
In their study, Herzog et al. examined the magnitude and extent of reflex responses elicited by spinal manipulative treatments (SMTs) applied to 10 asymptomatic young male subjects to different regions of the spine. The authors found consistent reflex responses in a target-specific area within 50-200 msec after the onset of the treatment thrust that lasted for approximately 100-400 msec. Of interest, the authors also found EMG responses remotely distant from the treatment area. Notably, they recorded EMG responses in the treatment side deltoid muscles following SMTs applied to the upper and mid-thoracic spine and in SMTs applied to the sacroiliac joint in the side-posture position. EMG responses were also noted in the gluteus maximus following lower thoracic, lumbar and sacroiliac joint SMTs.
Herzog et al. were careful not to extrapolate these findings to be of significant clinical importance; however, the DC article did, as depicted in the title of the article and from Herzog's quote, stating, "We have a very global response to treatment." Just what this "global response" means appears to be in question. Are the distal EMG responses beneficial or deleterious? Is it the desire of the chiropractor to be "specific" and only elicit EMG responses locally, or is it the desire of the chiropractor to elicit broad-based "global" EMG responses following SMTs? Are they reflexogenic guarding responses on the part of the subjects, or are they beneficial responses that are necessary for optimal outcome?
Because this study was conducted on 10 asymptomatic subjects without any clinical outcome examined, such questions cannot be answered at this time. Our recent research accepted for presentation at the 1999 meeting of the International Society for the Study of the Lumbar Spine (ISSLS) noted significant differences in electromyographic responses to SMTs delivered with the Activator II adjusting instrument (AAI) in symptomatic patients vs. asymptomatic subjects.2 More discussion in this regard and the clinical significance of our findings are provided in our manuscript.
Inappropriate Activator Comparisons
Another point of contention regarding the DC article lies in a quote attributed to Dr. Herzog. According to DC, Herzog states, "By comparison, the reflex responses for the Activator-type treatment were very local and seemed to be a single receptor response, whereas in the SMTs, the response seemed to have a global effect on the body." One would assume that Herzog was referring to this study specifically; however, this study was not a randomized comparison on the effects of SMTs delivered with diversified vs. Activator thrusts. In fact, this study did not involve the use of the Activator instrument, so it is incomprehensible why Dr. Herzog felt it necessary to make mention of this. Inasmuch, in light of the lack of clinical significance of distal EMG effects away from the segmental contact point, Dr. Herzog's quote appears meaningless.
In the discussion portion of their paper, Herzog et al. cite a 1986 paper by Fuhr and Smith3 to compare the results of their study. This comparison is inadequate, as the objectives and methodology were emphatically different in the two studies. These issues, extrapolations, and other methodological flaws observed in the Herzog et al. paper have been submitted to the appropriate forum for such criticism, in the form of a letter to the editor of Spine.
Herzog has previously reported from his work that Activator thrusts have been found to elicit "reflex responses that have a shorter latency time, that are shorter in duration but similar in magnitude that occur specifically at the location of treatment application."4 While this may be a logical assumption (that Activator thrusts elicit more specific responses in the paraspinal musculature as opposed to diversified SMTs), again, the clinical significance of specificity versus broad-based responses is currently unknown.
In closing, it is unfortunate that this introductory research was inappropriately labeled as "direct evidence of the benefit of spinal adjustments" as touted by DC, when the clinical significance has yet to be established. Moreover, it was unnecessary to draw comparisons to the responses elicited by Activator adjustments, when a controlled comparison trial was not undertaken, and the clinical significance is unknown.
References
- Herzog W, Scheele D, Conway PJ. Electromyographic responses of back and limb muscles associated with spinal manipulative therapy. Spine 1999;24(2):146-52.
- Colloca CJ, Keller TS, Fuhr AW. Muscular and mechanical behavior of the lumbar spine in response to dynamic posteroanterior forces. Proceedings of the 26th Annual Meeting of the International Society for the Study of the Lumbar Spine, Kona, Hawaii. Toronto: ISSLS, 1999:138A.
- Fuhr AW, Smith DB. Accuracy of piezoelectric accelerometers measuring displacement of a spinal adjusting instrument. J Manipulative Physiol Ther 1986;9(1):15-21.
- Herzog W. mechanical, physiologic and neuromuscular considerations of chiropractic treatments. In: Lawrence DJ, Cassidy JD, McGregor M, Meeker WC, Vernon HT (eds.) Advances in Chiropractic. St. Louis: Mosby-Year Book, Inc., 1996:269-85.
Vice President, Activator Methods, Inc.
Phoenix, Arizona
"Chiropractic Education Is the Future of the Profession"
Dear Editor:
I was most dismayed to read a recent article by Dr. Reed Phillips, "Dis-ease in CCE: Is There a Subluxation in the House?" (see the April 5th issue of DC), wherein he discussed the prospect of two types of chiropractic education being accredited under one accrediting agency. What was most disheartening about this article was that the conclusion reached by Dr. Phillips was based upon theoretical rhetoric.
The chiropractic profession does not need additional fractionalization as advocated by Dr. Phillips. What the chiropractic profession needs is leadership that addresses issues based upon fact, not belief.
Dr. Phillips references "discordant" members of the CCE as a problem. Most of the members of the CCE were instrumental in developing the position papers of the ACC that were distributed to the profession a short time ago. These papers acknowledge the diversity within the profession, while reaffirming the principles upon which there is agreement. Specifically, the ACC papers discuss chiropractic as a health care discipline which emphasizes the inherent recuperative powers of the body to heal without the use of drugs or surgery. Furthermore, these papers contain a definition of subluxation and the parameters of chiropractic practice. These documents were signed by the chief executive officers of all chiropractic academic institutions accredited by the CCE. Are "discordant" CCE members the individuals who live within the boundaries of consensus these position papers define, or are they the individuals who violate the concepts of these documents?
And to what purpose? The issues confronting chiropractic today are more a matter of market share than education. Managed care organizations do not make distinctions between chiropractors based upon the anachronistic ideologies which the profession seems to enthusiastically support. Managed care is about making money. If a health care professional can provide unique, valuable services to patients, said practitioner will be reimbursed. If a health care profession provides the same services as other health care professions, someone must be cut out of the system. The practice of chiropractic as defined by the ACC "focuses particular attention on the subluxation." The wording of this statement is important because it does not restrict the practitioner but allows the chiropractor to practice in a fashion as broad or narrow as he or she chooses. The marketplace will determine what kind of chiropractor is needed to meet the health care needs of the public.
What about licensure laws? To my knowledge, their purpose is to protect the public. These laws do not make distinctions between chiropractors. Do the graduates of CCE accredited colleges pose such a threat to the public that additional requirements need to be developed? Before committing to the consideration of additional requirements or fractionalization, I want to see the facts that would support such consideration.
Market share is what chiropractors need to access more. The ACC, ACA and ICA have joined together in the Alliance for Chiropractic Progress in an effort to increase market share. The ACA has initiated a lawsuit which has been supported by many organizations and individuals in an effort to secure a portion of the market share. Chiropractic's increase of market share will not occur if the profession continues to fractionalize. Chiropractic will increase its share of the market by providing chiropractic service to the public. It is the public's demand for chiropractic that will be addressed by legislators and managed care companies. If the public perceives unique value in chiropractic care, it will be an ever growing part of the health care delivery system.
Chiropractic education is the future of the profession. It is not perfect, but it is evolving to address issues identified by current practitioners and organizations. The standards used in the accreditation process have evolved to address these issues. Has public safety been compromised by the graduates of CCE accredited institutions? Has chiropractic reimbursement been decreased as a result of chiropractic education? Has the public turned away from chiropractors as a result of the product of chiropractic education?
Chiropractic education must produce competent qualified chiropractors who recognize their place in the health care delivery system. Our unique place in the health care delivery system is based upon our clinical skills in addressing the subluxation, specifically, and the health care needs of the patient in general. Both these goals can be met without compromising the health of the public or the principles of the profession.
Another factor which is part of the dilemma facing chiropractic today is accountability. Certainly, accountability to a patient's well©being is a driving force in the education of a doctor of chiropractic. It is recognized and accepted that any compromise in the exercise of this professional accountability will result in the public's rejection of this profession. Because of this emphasis and adherence to the evolving, improving standards of the CCE, chiropractic education merits the confidence and respect of the profession and the public.
The chiropractic profession must recognize that the "philosophical" differences which we allow to divide us can and must be reconciled. Managed care organizations, politicians and the public care little about these issues. Yet these organizations and people have a profound effect upon our existence. Whatever success chiropractic has achieved over the past 100 years has, more often than not, been achieved in spite of chiropractors. The position papers of the ACC which recognize diversity and allow for unity are a starting point for healing the schism within chiropractic. The future success of the profession is not vested in continued division or fractionalization. The future success of the profession depends on mutual respect, action and unity.
Frank Zolli,DC President, University of Bridgeport College of Chiropractic Bridgeport, Connecticut
"... the Mercy Guidelines document has not been rejected in New Jersey."
Dear Editor:
My response to Dr. Taub's comment is, "What rock did you crawl out from under?" (Reference: "View from New Jersey," DC, March 22, 1999.) The Mercy guidelines (Guidelines for Chiropractic Quality Assurance and Practice Parameters) is not only set up for uncomplicated cases of lower back pain, but also for complicated cases. If you don't believe me, pick up a copy and read it in its entirety, with special emphasis on chapter 8. Ignoring the Mercy guidelines is only done by those people with hidden (or not so hidden) agendas.
As far as the statement, "It should also be remembered that the chiropractic board in New Jersey has voted on several occasions to reject the Mercy guidelines" shows that people with hidden (or not so hidden agendas) such as Dr. Taub, and/or his "buds" infest the New Jersey chiropractic board. The statement also indicates the Mercy guidelines document has not been rejected in New Jersey, showing that the majority of doctors of chiropractic in New Jersey know the truth when they see it. The truth wins in the end.
Gerardo Vergara,DC
San Antonio, Texas
Are Part IV Exams Pushing DCs to Be Like MDs?
Dear Editor:
Thank you for your article ("The Difference") in the March 22, 1999 issue. Patients have less than 24 seconds to explain their problem to the MD. This is tragic! As chiropractors, we are supposed to see the patient as an individual in whom we desire to restore health and vitality.
In school, we are taught to do multi-hour exams. On Part IV national exams, we are given five minutes to hear the patient's complaint and do all the testing one can regurgitate. It seems as though we are headed in the same direction as the MDs.
I know that Texas Chiropractic College did a great job teaching me what I needed to know about orthopedics, neurology and chiropractic procedures.
Part IV represents a money-laundering opportunity before these overdebted young doctors even get a state license. This type of testing also discriminates against doctors pursuing a subluxation practice by concentrating on medical procedures and tests.
Ed Castaneda,DC
Lynchburgh, Virginia