There is a disturbing effort afoot to rebrand chiropractors as primary care physicians, a subject both Harriet Hall and I have discussed in previous posts. Part of this effort includes convincing state legislatures to grant prescription privileges to chiropractors, an effort that succeeded in New Mexico, as reported in a post a couple of years ago. Let’s return to New Mexico and see how that is working out for everyone.
By way of background, in 2008, the New Mexico legislature created a new iteration of chiropractor called “certified advanced practice chiropractic physicians” with the authority to
prescribe, administer and dispense herbal medicine, homeopathic medicines, vitamins, minerals, enzymes, glandular products, naturally derived substances, protomorphogens, live cell products, gerovital, amino acids, dietary supplements, foods for special dietary use, bioidentical hormones, sterile water, sterile saline, sarapin or its generic, caffeine, procaine, oxygen, epinephrine and vapocoolants.
[Editor's Note: Today, we have a guest post from Sam Homola, who, as you recall, practiced as a chiropractor until he ultimately realized that there is no evidence that subluxations exist. Since then, he's discussed in various places, including, we are pleased to say, SBM, his skepticism regarding chiropractic. Enjoy!]
Much has been written (and published on this site) about the implausibility of chiropractic vertebral subluxation theory which proposes that a vertebral subluxation complex or a spinal joint dysfunction “may affect organ system function and general health.” Associated chiropractic gimmickry that might be harmful as well as a waste of time and money should be also be brought to the attention of concerned consumers. As a chiropractor (retired) who has renounced subluxation theory, it might be helpful to share my concerns about some dubious chiropractic methods that are foisted upon an unsuspecting public, unchallenged in the market place.
“Complementary and alternative medicine,” as pediatrician and fellow blogger John Snyder aptly stated in a recent journal article on CAM and children,
is a term used to describe a disparate, poorly defined set of practices and treatment modalities presumed to be distinct from so-called ‘conventional medicine’.
As we have discussed here at Science-Based Medicine, this amorphous concept facilitates a convenient fluidity in delineating the parameters of CAM. Without a clear definition, CAM (and integrative medicine) proponents are able to rebrand plausible and evidence-based practices such as diet, exercise and relaxation as CAM, a tactic we at SBM call “bait and switch.” This results in inflation in the figures of CAM use (important because CAM is all about popularity) and claims that CAM “works.”
Practitioners of so-called “complementary and alternative medicine” currently enjoy a certain measure of government largesse in the form of state laws mandating coverage of their services by private health insurance plans. The federal Patient Protection and Affordable Care Act (often referred to as the Affordable Care Act, or “ACA,” and sometimes as “Obamacare”) has the potential of putting a significant dent in this forced coverage of pseudoscientific health care.
All states require private health insurers to cover certain health care services by law. These mandates can be in the form of requirements that specific health care services or treatments be covered, that certain providers be covered, or that certain populations be covered.
Mandates are ubiquitous, inconsistent among states and costly. One insurance industry trade group calculates that there are currently 2,262 separate state mandates. Some are supported by clear evidence of benefit, such as immunizations and mammograms. Others, unfortunately, require coverage of “CAM” services, such as acupuncture and chiropractic. (In fact, acupuncture is typically not covered by small group plans unless required by state mandate.) Whether beneficial or not, all agree that these mandates increase premium costs to the consumer, most estimated to be from less than one percent to five percent of premiums, depending on the mandate. Chiropractic coverage, for example, can vary from state to state, from limiting the insured to a specific number of visits per year all the way to requiring chiropractors to be covered on par with medical doctors.
Our last look at the Council on Chiropractic Education (CCE), about 18 months ago, found the CCE deeply embroiled in a heated dispute among various chiropractic factions over new accreditation standards for chiropractic colleges. Today we offer an update on that situation.
Update: the CCE is deeply embroiled in a heated dispute among various chiropractic factions over new accreditation standards for chiropractic colleges.
As you may recall, the CCE, which accredits chiropractic colleges in the U.S., stood accused of removing the subluxation from its standards for accreditation, so that chiropractic students would no longer be required to learn how to “detect” and “correct” the putative vertebral subluxation. Of course, the chiropractic subluxation doesn’t exist, but we’ll get to that in a minute. This brouhaha was raised by the more traditional wing of the chiropractic community, called “straights,” whose practice (and livelihood) is based on convincing patients that their spines need “adjustments” to remove these subluxations under the threat of ill health should they be left unattended. The straights were also upset at the move by another faction of chiropractic seeking to rebrand chiropractors as primary care physicians who diagnose and treat a wide variety of diseases and conditions.
Legislative alchemy, as faithful SBM readers know, is the process by which state legislatures and Congress take scientifically implausible and unproven treatments and diagnostic methods and turn them into licensed health care practices and legally sold products. Previous posts have explored this phenomenon in naturopathy, chiropractic and acupuncture.
Our last report on the legislative efforts of CAM providers appeared almost six months ago, the beginning of the legislative year for many states. Now, most legislatures have shuttered the statehouse doors and gone home. So let’s see how the CAM practitioners are doing this year.
A goal of the American Association of Naturopathic Physicians (AANP) is “full scope of practice” in all 50 U.S. states. They’ve got a ways to go. Naturopaths are currently licensed to practice in only 17 states and the District of Columbia. Bills to expand licensure failed to make it out of committee again during the 2012 legislative sessions of two states, Iowa and Maryland. In Colorado and Virginia, where licensing bills failed to pass in previous years, no new legislation was introduced to license naturopaths in 2012. Bills to license naturopaths are still pending before legislative committees in Illinois, Massachusetts, Michigan, North Carolina, New York and Pennsylvania. However, in North Carolina and Pennsylvania these bills have been languishing in committee since 2011, making passage appear less likely This is especially true in North Carolina, where the legislative session ends soon.
Another strategy of the AANP is “progressive legislation.” This means that while some compromise in initial licensing legislation may be necessary to get a licensing bill passed, successive attempts can cure any initial disappointments through expansion of scope of practice and insurance coverage, for example. Nowhere was this strategy more successful in 2012 than in Vermont, where “naturopathic physicians” (as the Vermont Legislature calls them) were officially defined as “primary care providers” (PCPs) for the purpose of health insurance coverage. The new law means that naturopathic physician practices can qualify as patient “medical homes” under the state’s Blueprint for Health and that they may practice as such independently and without supervision.
In April, the Texas District Court of Appeals (Third District) affirmed a lower court ruling that chiropractors are prohibited from performing manipulation under anesthesia and needle electromyography[EMG]. The lower court also ruled that the Texas Board of Chiropractic Examiners exceeded its authority in defining the chiropractic scope of practice to include “diagnosis.” This part of the ruling was overturned by the Court of Appeals, but with some interesting language in the opinion which could turn their one win into a Pyrrhic victory for Texas chiropractors. In a separate ruling, not on appeal, a lower court held that vestibular testing is outside the scope of chiropractic practice.
First, some background. Back in 1949, the Texas Legislature defined the scope of chiropractic practice as, among other things, “the practice of adjusting the vertebrae to correct any subluxation or misalignment thereof . . .” Over the ensuing years, the legislature amended the chiropractic practice act with an eye toward modernization, resulting in the current scope of practice being “nonsurgical, nonincisive procedures, including, but not limited to, adjustment and manipulation, in order to improve the subluxation complex or the biomechanics of the musculoskeletal system.” Now that’s progress!
A recent three-part article published in ACA News advocates turning chiropractors into “conservative primary care providers” who would be the initial point of contact for patients, would serve as gatekeepers for referrals to medical doctors and specialists, and would co-manage patients with those specialists on a continuing basis: essentially, family doctors. I think that’s a terrible idea. It might benefit chiropractors by increasing their market share, but it wouldn’t benefit patients. There is no evidence to indicate that chiropractors are capable of filling that role effectively or safely.
NUHS. The article was co-authored by several chiropractors on the faculty of the National University of Health Sciences, a school noted for integrating quackery with medicine. The “sciences” this school teaches are listed at the top of its website: chiropractic medicine, naturopathic medicine, oriental medicine, acupuncture, biomedical science, and massage therapy. The only one of those that even sounds like science, “biomedical science,” offers a bachelor of science degree with an integrative medicine focus and with no required core courses whatsoever!
Their doctor of chiropractic degree program says:
National University prepares students to become first-contact, primary care physicians fully qualified to diagnose, treat and manage a wide range of conditions.
Low-back problems are one of the most common reasons for visits to doctors’ offices and the most common cause of disability among persons under the age of forty five. Most of the time, acute low-back pain is the result of simple strain and is a self-limiting condition that will resolve in four to six weeks, with or without treatment. But since back pain can be a forerunner of disability or a symptom reflecting serious pathology, every effort should be made to seek appropriate care that is based on a definitive diagnosis. Failure of physicians to ease the concerns of back-pain patients by explaining their problem and advising them in the care of back pain often results in dissatisfied patients who may be attracted by the approach of alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis. Misinformation provided by such practitioners may contribute to disability by allowing progression of disease or by exaggerating the seriousness of the problem in the mind of the patient. Thus, while back pain is rarely serious, it should always be carefully evaluated to reach an accurate diagnosis and to determine if specialized care is needed. Care should be taken to inform the patient in a positive manner─to avoid unnecessary surgery as well as inappropriate or unnecessary treatment.
Something to Consider When You have Back Pain
Almost everyone will experience acute low back pain at least once during a lifetime. Much of what must be done to care for a bad back must be done by you. It would certainly help to be well informed about the causes of back pain when seeking appropriate treatment.
It goes without saying that when incapacitating back pain occurs as a result of a serious accident or injury, you should seek emergency medical care. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, you may need the services of a specialist. Back pain that occurs for no apparent reason and does not affect movement may be a symptom referred from an internal organ. Once a diagnosis has ruled out a serious problem and it has been established that you have nonspecific or uncomplicated mechanical-type back pain, self-help measures designed to relieve your symptoms and to protect and strengthen your back may be the only treatment needed. If there is no active pathological process and your back pain lasts three months or longer, you may have a “chronic” back problem that can lead to recurring back pain, requiring ongoing vigilance and self help.
Time is the most important part of treatment for uncomplicated back pain caused by injury. It’simportant, however, to be aware of red flags indicating that back pain might be the result of something more serious that a simple strain. In the absence of red flags, imaging studies or special testing might not be indicated during the first four weeks of low back symptoms. When a red flag is present, you should not delay in reporting your symptoms to your family physician.