Chiropractic

Brief History
Chiropractic is one of the manual healing arts whose roots go back many thousands of years. Manipulative therapies were known in China nearly 5000 years ago, and have flourished in Europe, Asia and the Americas through the ages. Over 100 years ago, chiropractic as a distinct system of care was established by Daniel David Palmer, whose theories about vertebral subluxation as the root cause of disease served as the foundation of the education and practice for many decades. As research and knowledge about all the healing arts matured and expanded in the second half of the twentieth century, the theories about why chiropractic works have also developed beyond that initial idea (see Philosophy).

The chiropractic profession in the United States experienced considerable and sustained opposition from the conventional medical system. It took 77 years for all the states to become licensed, and until an antitrust suit against the American Medical Association was won in 1991, chiropractors were systematically excluded from professional cooperation with MDs. This meant almost no access to research funding, difficulty getting third party reimbursement, problems in establishing cross-referral and co-management relationships, and fragmented care for patients. Today we can observe growing research funding, rapidly developing professional relationships and integrated care models, and expanded third party reimbursement. All states are licensed (although not uniformly), all the colleges are accredited, and the profession has substantially united around philosophy and practice. Chiropractors serve on the federal Practicing Physician's Advisory Council and Medicare Coverage Advisory Committee which advise the Secretary of the Department of Health and Human Services and the Administrator of the Health Care Financing Administration on Medicare issues. The legacy of the many decades of oppression and prejudice will continue to resolve as research further validates the care and the public demand grows.

Philosophy
Although the philosophy of chiropractic care has broadened through the years, it is still a core perspective of chiropractic that a central role in health is played by the nervous system, and that techniques which restore normal nerve flow and full function will have an impact on the health of the entire body. In fact, the interrelationship of structure and function, and the importance of whole body evaluation are both key principles in the chiropractic philosophy. Chiropractic doctors understand that the site of actual pain may not be the causal location; they believe that long-term functional adaptations to pain and loss of mobility cause the whole body to alter its normal patterns. For these reasons, they practice whole body health care, and may look to nutritional needs, exercise and psychosocial influences to help a patient re-establish and maintain health. The Council on Chiropractic Guidelines and Practice Parameters oversees the development of standardized protocols for chiropractic treatment.

Scope of Practice
Chiropractic is a manual (hands-on) natural health care discipline which functions without drugs or surgery. The chiropractic approach to care has evolved considerably since the early days of its history, and the profession today has a multifactorial view of the nature of health and disease - including not only spinal, musculoskeletal and neurological function, but vascular, biochemical and psychosocial as well. The Association of Chiropractic Colleges describes the practice of chiropractic as including the following elements: establishing a diagnosis, facilitating neurological and biomechanical integrity through appropriate chiropractic case management, and promoting health.

Although there are variations among the different state laws, all chiropractors perform manual manipulation of the spine and adjacent tissues. In most states, manipulation of the extremities is also included in the scope of practice. There are a number of techniques in current use, utilizing varying degrees of force and different methodology.

In some states, chiropractors function as family doctors, with a scope of practice broad enough to include standard diagnostic tools and modalities such as nutrition, herbal medicine and homeopathy; however, there are states where the scope does not permit this breadth (Washington state is one example). Chiropractors are trained to refer and co-manage cases with other health care practitioners and they play a vital role in the nation's health care system. Over 25 million patient visits per year occur in chiropractic offices, and Medicare, workers' compensation, and many third party payers reimburse chiropractic care for certain conditions. There is well-respected research on the effectiveness of chiropractic care for back injuries and chronic low back pain, showing earlier return to work, greater satisfaction with care, and lower costs than for conventional treatment.

Regulatory Scope
Chiropractic is licensed in all 50 states and the District of Columbia, with a significant degree of variability from the most to the least restrictive. The statutes range from authorizing spinal manipulation only (the most limited statutes) to a broad range of diagnostic and treatment approaches, equivalent to a primary care provider in natural medicine. Washington State has one of the most limited statutes and Illinois one of the most liberal. In all statutes, chiropractors do not prescribe drugs or perform surgery. Depending upon the individual state's regulatory structure, there will usually be a board or advisory committee in the State Department of Health or Department of Licensing that administers the licensing examination, issues and renews licenses, receives and investigates complaints, and administers the rules and regulations that further define the scope of practice. The National Board of Chiropractic Examiners is the principal testing agency for the chiropractic profession. Every state has a state-level professional association, and the national professional associations are the American Chiropractic Association and the International Chiropractors Association. There is a Federation of Chiropractic Licensing Boards which provides extensive regulatory information.

Education and Credentialing
Admission to chiropractic colleges typically requires at least two years of college credits with an emphasis on the health sciences (some schools now require an undergraduate degree for admission). The chiropractic curriculum is four academic years, and emphasizes all the basic health sciences and outpatient clinical training. The Council on Chiropractic Education accredits all 16 U.S. colleges. Upon graduation, the DC degree is awarded and the graduate is eligible to sit for the state licensing examination. Continuing education is normally required by state law, and is available at state and national conferences. The field has a number of professional journals, and research is also beginning to be available in the conventional medical journals as well. A consortium of chiropractic colleges was recently awarded a grant from the NIH National Center for Complementary and Alternative Medicine, and chiropractors sit on many advisory boards for integrated care. There is advanced certification available from a few specialty boards.

Typical First Office Call or Visit
If you have never visited a chiropractor before, your first visit will usually involve a discussion of any significant health history. You may be asked to sign a release for your doctor to obtain a copy of your medical records from other practitioners, so he/she can develop a comprehensive picture of your health needs. Some physical examination procedures will be done, depending on the acuteness of your condition and the scope of practice in your state. X-rays will often be done to determine the extent of any injury or condition that is causing pain or limitation of movement. Laboratory work may be indicated, and if the scope of practice allows that, your chiropractor may obtain those tests as well.

You will likely receive an "adjustment" during each visit to a chiropractor, which is a generic term describing any of a number of different techniques for manually manipulating the spine, extremities and/or soft tissues. Chiropractors have special tables for performing adjustments and your position will be selected for safety and effectiveness. Feel free to inquire about the type of technique your doctor uses, so you learn some of the terminology and understand what is being done to you.

At the end of your first visit, your doctor will likely recommend a series of visits. Chiropractic, like most manual therapies, relies on repeated interventions over time to achieve maximum effect. If you have any questions at all about the treatment plan, be sure to ask them. If you don't begin to experience improvement within a week or two, raise the question of whether the treatment is working. If you are not seeing significant improvement within a month, consider seeking another kind of care, or a second opinion. In acute situations, these time frames may need to be shortened. Never hesitate to ask for a referral to another practitioner if you feel that is indicated.

Limitations to be aware of
It is very important to understand any limitations on scope of practice that may be imposed by your state's licensing law. Any chiropractor should be able to tell you quickly and easily what s/he may and may not do. Chiropractors do not prescribe drugs or perform surgery, and will refer patients who require such treatment to other providers. If you have undergone chiropractic care for a month with no improvement in your condition, it is time to seek another opinion about effective treatment; if the condition is acute, a shorter time frame may be appropriate. Certain types of chiropractic care may be contraindicated for patients whose bony structure is susceptible to fractures (e.g., in the presence of osteoporosis) or bone tumors; for those with severe rheumatoid arthritis; and for patients with bleeding disorders (e.g., coagulation problems). Checking with your primary care provider before seeking chiropractic care is advisable if you have any serious, ongoing disease process.

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