Dear Editor:
I just came back from a license renewal seminar, and you would have to be blind not to see what is happening to the chiropractic profession.
It is difficult to believe the ACA's statement that the average DC makes over $100,000 per year. Do they average DCs who are not able to make a living in chiropractic? Is this just the top 5% of the practitioners?
I have heard the arguments that what we need are more DCs. What hogwash. The DCs that we have now can't make a living.
I encountered one DC who has sent five students to chiropractic school. He snowed them with claims that the profession is a cash cow. I asked him how in good faith could he encourage someone to enter a profession that he himself cannot make a living at (he sells insurance on the side). His reply: "Just because I can't do it, doesn't mean they can't."
The chiropractic schools are less than truthful. Their only concern is to increase their enrollment. I would love to know the statistics of how many DCs leave the profession in the first five years after graduation. It must be a nightmare for the new graduates to open up a practice. The way things are with insurance reimbursements and the costs of maintaining a practice, many new practices don't last a year.
P. Hall, DC
Detroit, Michigan
Consult the Work of Drs. Harrison and Pettibon
Dear Editor:
In response to Dr. Dulhunty's article, "A Mathematical Basis for Defining Vertebral Subluxations and Their Correction" (DC, Sept. 22): I think he is re-inventing the wheel. Love him or hate him, Don Harrison has done extensive work on defining a mathematical model of the spine. His work has been published in indexed journals and is clinically viable.
With apologies to Dr. Keating, the chiropractic profession is the first and only profession to develop a normal mathematical model of the spine. Drs. Harrison, Pettibon, et al. should be credited and recognized for their contributions to the still evolving spinal model.
To those practitioners who argue that patients improve even without their radiographs showing change, I suggest the following definitions: 1) spinal manipulation -- clinical procedure by which mechanical methods are used to activate intrinsic anti-nociception, without regard to reducing vertebral subluxation; 2) chiropractic adjustment -- spinal manipulation which activates intrinsic anti-nociception, and additionally seeks to move subluxated vertebrae towards the mathematical normal/optimal model.
I hope this will stimulate discussion.
George Kukurin, DC, DACAN
Pittsburgh, Pennsylvania
Getting the "Factoids" Straight
Dear Editor:
Considering Dr. Cooperstein's past opinions about CBP technique and published research, I thought it would be a good idea to let your readers know that his x-ray "factoid" is not from anything CBP has ever published.
CBP has several published articles that show the reliability of the measurements made on the lateral cervical and lumbar x-ray. We have never made the statement that the results of these x-ray articles prove the technique.
While such studies may seem insignificant or mundane to Dr. Cooperstein, they are necessary proofs that the measurements used in future studies are reliable and accurate. For instance, the journal Spine recently published an article by Harrison et al. describing a normal cervical curve, and JMPT recently published his article describing a normal lateral lumbar curve. Neither of these articles could have been written without the previous article on measurement.
More recently, Harrison et al. published an article in JMPT regarding the desirable outcome and clinical significance of the normal cervical curve. This is most significant to the profession.
Arnold Taub, DC
Nutley, New Jersey
Drugless and Proud of It
Dear Editor:
I just read your article about the drug companies, "Unbridled Aggression" (DC, September 8, 1997). I have noticed all the drug ads in the magazines and on television. They really are going for the throats of the American public.
I was unaware that the drug companies are making such deals with large managed care organizations. Thanks for standing up for the truth. Chemicals are so rampant in our society, it is a wonder anyone can think straight anymore. May your magazine continue to light the candles in the darkness. I am so glad I am a member of the wonderful drugless profession. Thank you.
Susan Eissinger, DC
Chico, California
Kudos to Dr. Pate
Dear Editor:
Kudos to Dr. Deborah Pate on her article on Lyme disease and joint pain in children that appeared in your Sept. 22 issue. Lyme disease is a tremendous problem in several regions of the U.S. where the disease is endemic, especially here in the northeast. As front line physicians, chiropractors need to be aware of the widespread affects, both articular and constitutional, that borreliosis can cause.
I would like to clarify two important points that appeared in the article so that readers can better understand the challenges of Lyme disease. The differential diagnosis of Lyme disease can be elusive. Called the "great imitator," symptoms can vary from generalized viral complaints to neurological problems in disseminated disease.1 To further compound the problem, a significant number of patients do not have the typical erythema migrans (EM) rash. More than one patient was diagnosed in my office lying prone on the adjusting table when we discovered EM on the dorsal portion of a trunk or limb. In 1995, only 57 percent of Lyme disease cases documented at the New York State Dept. of Health reported the incidence of EM.2 This is particularly troubling considering that the majority of diagnosed cases in the U.S. continue to be reported from the sprawling suburbs of New York City.3
Serological test results in Lyme disease patients, especially in late illness and disseminated disease, remain inconclusive and controversial.4 ELISA and western blot assays test IgG and IgM antibody titers to B. burgdorferi, and often produce false positives and false negatives.5 In Gerber's study on children diagnosed with Lyme in southeastern Connecticut, only 37 percent of children with a documented EM had positive antibodies to borrelia.6 Late disease (which is not uncommon due to problems in early detection and diagnosis) may also be seronegative. Plasmid polymerase chain reaction (PCR) studies for serum cerebrospinal fluid, synovial fluid, urine and EDTA whole blood specimens show great promise, but are still inaccurate at times for definitive diagnosis. Seroconversion, recurrent EM despite extended drug therapy, and the presence of spirochetal nucleic acids in active chronic Lyme arthritis has also been documented.7,8 While peaking IgMs are common in late disease, reactivity will not aid the clinician in differentiating early from late illness: seroactivity only indicates exposure.
Finally, the ability of Borrelia burgdorferi to evade host defenses should not be underestimated. While the mechanism of bacteriostatic treatment patterns is not clear, possible scenarios include intercellular sequestration, dormant states of pathogenesis, and antigenic variation of surface proteins.9 Unfortunately, is some patients, Lyme disease may not be curable in a bacteriologic sense.
The diagnosis of Lyme disease has been and continues to be a clinical diagnosis.10 Definitive diagnosis may therefore remain elusive. As long as laboratory science does not catch up with this illness, treatment of Lyme borreliosis will remain clinically difficult, politically controversial, and the subject of great debate in health care.
References
- Brier SR. Lyme disease: a case report. JMPT, 13(6):24-26, Jul-Aug 1990.
- Schwartz I, Fish D, Daniels TJ. Prevalence of the rickettsial agent of human granulocytic ehrlichiosis on ticks from a hyperendemic focus of Lyme disease. NEJM, 337(1):49, July 3, 97.
- Dorward DW, Fischer ER, Brooks DM. Basic and clinical approaches to Lyme disease. A Lyme Disease Foundation Symposium. Clinical Infectious Disease, 25(supp 1), July 1997.
- Harris NS, Stephens BG. Antigenuria detected in 30% of patients with active symptoms without treatment and confirmed rash. J Spirochete & Tick-Borne Diseases, 2:37-41, 1995.
- Burruscano JJ. Managing Lyme Disease: Diagnostic Hints and Treatment Guidelines for Lyme Borreliosis, 11th ed., Oct. 1996, 10-12, East Hampton, New York.
- Gerber MA, Shapiro ED, Burke GS, Parcells VJ, Bell GL. Lyme disease in children. NEJM, 335(17), 1270-4.
- Liegner KB, Shapiro JR, Ramsay D, et al. Documentation of recurrent EM despite extended antibiotic therapy. J Am Acad Dermat (2 pt. 2):312-14, Feb. 28, 1993.
- Bradley JF, Johnson RC, Goodman JL. The persistence of spirochetal nucleic acids in active Lyme arthritis. Ann Intern Med, 120(6):487-9, March 15, 1994.
- Liegner KB. Chronic persistent infection in Lyme disease. VE Annual Lyme Disease Scientific Symposium, May 1993, Atlantic City, New Jersey.
- Brier SR. Primary Care Orthopaedics. Mosby Year-Book, St. Louis, 1998, in press.
Steven Brier, DC, ATC
Freeport, Maine
Medicare in the Year 2000?
Dear Editor:
First let me compliment you on the direction you have taken since you broke off from MPI. You seem to have a greater variety of articles, and they are more in-depth.
I was ecstatic when I saw your headline a couple of issues ago trumpeting the demise of the Medicare requirement for x-rays. What a great victory I thought, until the bottom line glared up at me on the continuation page: "... starting Jan. 1, 2000." What a cruel joke. Anything could happen by then, and it has (see below).
The real kicker came when I received the Nationwide Insurance revised 6/97 Medicare Ohio Policy Manual on Chiropractic Services. I cannot believe the doublespeak that is used here. Whoever wrote it must have taken classes from the novel, 1984, or possibly Joseph Goebbels, but more likely the Clinton administration.
In the first section under "Indication and Limitations of Coverage," it states: "Coverage will be denied for lack of reasonable expectation that the continuation of treatment would affect improvement or arrest or retard deterioration in the condition within a reasonable and generally predictable period of time. Continued repetitive treatment without an achievable and clearly defined goal are considered maintenance therapy and are not covered."
The manual lists the four categories of conditions that Medicare covers. One is chronic, yet the definition of chronic reads: "A patient's condition is considered chronic when it has persisted for more than 12 weeks and is not expected to result in some functional improvement. Once the functional status has remained stable (unchanged for three or four weeks) for a given condition, further manipulation is considered maintenance therapy and is not covered."
An additional definition of maintenance therapy is added in the next paragraph: "Maintenance therapy is performed to treat a chronic and stable condition, or to prevent deterioration, is not a Medicare benefit. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program."
There you have it doctors, Medicare covers chronic conditions, ... but it doesn't. So again we see dealing with government and the medical community is like taking two steps backward for every step forward. By 2000, the number of Medicare patients will be so minuscule that it won't matter that x-rays aren't required.
If anyone from Ohio would like to join me in filing a formal complaint with Medicare, contact me. I'm writing my Congress persons for assistance. I have composed a letter for my patients to send to them and Medicare.
Grant Douglas Lewis, DC
3600 Olentangy River Rd.
Suite C-3
Columbus, Ohio 43214