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Dynamic Chiropractic Canada – August 1, 2008, Vol. 01, Issue 01
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The Establishment of Cultural Authority for Spinal Disorders

By Scott Haldeman, DC, MD, PhD

There are many ways of looking at the future. One can look at the past to try to determine what can be expected in the future. Alternatively, one can look at the problems evident today and try to find solutions that need to be considered to improve the future.

My preference is to look at the changes currently taking place within health care, chiropractic science and clinical practice, and extrapolate these changes to determine their impact on the future. Hopefully, this can provide some insight as to the steps that must be taken by chiropractors and their leaders to ensure the profession achieves its maximum potential. It is my position that this allows one to develop an idealistic but realistic future vision for the profession.

The future can be visualized if one looks at the changes in the opportunities practicing chiropractors are seeing and the increased role researchers with chiropractic training are assuming. These changes are significantly altering the perception of chiropractic as a profession and its position within the spinal care delivery community. The following are a few of the recent developments that are greatly influencing our understanding of chiropractic theory and the delivery of chiropractic health care.

Scientific Leadership

Thirty years ago, it was possible to count the number of chiropractors with PhDs in the clinical and basic sciences on one finger. Ten years later, one could use one hand. It was virtually impossible to find a scientist with chiropractic qualifications at a university or chiropractic institution, or read a peer-reviewed and citable research paper that looked at chiropractic theory or practice. Today, it is becoming increasingly impossible to keep up with the number of chiropractors who have completed advanced scientific and professional degrees. Best estimates suggest there are more than 50 chiropractors with PhDs and many more graduate students in PhD programs. This does not count the chiropractors with MS, MPH, law or other advanced degrees. It is now common to see papers by chiropractic researchers accepted and presented at major national and international scientific meetings on spinal disorders. For example, most meetings of the North American Spine Society and the International Society for the Study of the Lumbar Spine include peer-reviewed research papers and posters presented by researchers with chiropractic qualifications.

Academic Presence

Less than 20 years ago, there were only a couple of faculty members at major universities who had any formal training in chiropractic. Any discussion of chiropractic theory and practice with medical or other students in the health sciences was provided by faculty members with limited understanding of the field. This is changing quite rapidly, particularly in Canada. Research chairs or professorships have been established at seven universities in Canada and are being organized at three additional universities. A number of the recipients of these positions have accumulated sufficient seniority to be promoted to senior departmental positions. The funding for these endowed chairs has come from donations by the chiropractic profession and political action to ensure government funding.

This same process is now happening in the United States. An endowed research chair for a researcher with chiropractic training (the Lincoln Chair) has been established at Florida State University through contributions and political action by the Florida Chiropractic Association. The presence of chiropractic researchers at major universities is also increasing and chiropractic scientists are receiving NIH/NCCAM grants. One recent example is a grant given to a chiropractic scientist who has been appointed to the position of assistant professor at the University of Pittsburgh. In addition, a number of researchers with chiropractic degrees have received academic appointments at major universities based solely on their academic and research records. It is likely this will continue in the future and reach the point that most universities have an academic presence by scientists with chiropractic training. These faculty members will assume a greater role in research and teaching in the field of spinal disorders.

Evidence-Based Practice Principles

The past two decades have seen a major change in health care. The movement has been from experience- and education-based health care to evidence-based health care. The chiropractic profession was one of the first fields that treat spinal disorders to recognize these changes were taking place and take steps to develop standards of practice. Although controversial at the time, the development of the 1992 Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy Guidelines) presented evidence-based consensus guidelines on what could be expected from a practicing chiropractor and placed the profession in the vanguard of this movement.

Shortly after the publication of the Mercy Guidelines, the Agency for Health Care Policy and Research published its clinical practice guideline for the management of acute low back problems in adults. This landmark guideline committee had two members with chiropractic qualifications. The result was an unbiased look at the literature and the inclusion of manipulation in the short list of treatments with demonstrated value in the treatment of low back pain. Since then, multiple other practice guidelines have been published internationally, most of which have reached similar conclusions. One of the most important of these is the guidelines published by the European Union that set standards to be considered in most countries in Europe. This committee included a member with chiropractic qualifications and also included positive positions on spinal manipulation.

There is no indication there will be any change in the insistence that spine care be governed by evidence-based principles. The chiropractic profession has committees in many countries reviewing the scientific literature to be sure guidelines that govern the practice of chiropractors are based on the best available evidence and clinical experience. Chiropractors are also being included on most multidisciplinary committees that are developing guidelines for the management of spinal disorders. This includes the guidelines currently being developed by the American College of Occupational and Environmental Medicine and the California Department of Industrial Relations, Division of Workers' Compensation. This process will continue to have a major impact on the manner in which chiropractic care is delivered.

Integration of Chiropractic

There was a time when chiropractors had no choice but to practice independently and were ostracized by other health care professionals. For the past two decades, research has established a role for manipulation in the management of spinal disorders, and there has been increasing recognition that chiropractic training has focused on spinal disorders more than other clinical training programs. This has resulted in marked changes in the opportunities available to chiropractors. There is increasing demand for chiropractors who are willing to work with interdisciplinary teams that focus on the management of back and neck pain.

Major clinics such as the Texas Back Institute and a number of university spine centers now include chiropractors within the treatment team. They are often considered the clinician of first choice for patients with back and neck pain. They are expected to not only treat patients, but also to screen for red flags of serious disease and determine which treatment is most likely to benefit a patient, as well as make an appropriate referral. A similar process has been included within the armed services and Veterans Administration health care delivery systems, with very positive acceptance. The successful integration of chiropractors into these systems has gone a long way toward developing a practice model in which chiropractors are part of the health care delivery system for patients with spinal disorders.

Cultural Authority

In order to assume cultural authority or the right to assume a leadership role in a specific field, it is necessary to show that a profession or group of clinicians and scientists has the ability to critically look at its theory and practice, and understand the concepts better than any other profession. It is also necessary for the profession to question concepts and develop theories most consistent with current research and improve the manner in which their services are delivered. Cultural authority is also enhanced if members of the profession understand the broader topic. In the case of chiropractic, knowledge of the broad field of spinal disorders is necessary, along with the ability to place theories in the context of other professions and treatment approaches.

The focus on high-quality research, the assumption of an academic leadership role, the development of guidelines and the integration of chiropractic into mainstream health care has done much to establish a level of cultural authority by the chiropractic profession within the field of spine care. In the past few years, scientists with chiropractic training have assumed leadership roles in major spine care initiatives.

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders published its findings in the January 2008 supplement of Spine, the highest-impact journal in the field of spinal disorders. This report was republished in the European Spine Journal and has been widely distributed internationally. The task force included a number of scientists on its scientific secretariat with chiropractic professional degrees, including the president and one of its scientific secretaries.

In February 2008, a special issue of The Spine Journal, the official journal of the North American Spine Society, was titled "Evidence-Informed Management of Chronic Low Back Pain Without Surgery." The issue was edited by two scientists with chiropractic degrees and included articles on medication, injection therapies and surgery, as well as manipulation and MUA. This issue has been widely quoted in both public and professional forums. The articles from this special issue are on the list of the most frequently downloaded articles from The Spine Journal. It is this type of committee leadership by chiropractors with scientific qualifications that has increased the cultural authority of the chiropractic profession in the field of spinal disorders.

The One Obstacle

There remains one obstacle to the establishment of full integration and leadership of chiropractic within the health care community: participation. The numbers of practicing chiropractors who are members of the national societies, routinely read scientific journals and attend scientific conferences (especially in the United States) is relatively small. By not participating in the national dialogue on the future of the profession, knowledge of findings or the debates that take place at these scientific meetings, many chiropractors are slowing down the process of developing cultural authority. This reduces the likelihood the chiropractic profession will reach its full potential as a leader in the field. It would be unfortunate if the scientific progress being made in understanding the role of chiropractic theory and practice in spinal disorders were not communicated and incorporated into the practice of the average chiropractor.

There is growing participation by practicing chiropractors in countries other than the United States. In most countries outside of North America, chiropractic education is included in the state-supported university systems. In many countries, 80 percent to 100 percent of practicing chiropractors are members of their national societies and thereby contribute to the financial and political strength of the profession. Attendance at national meetings is increasing and associations in many countries insist speakers have a strong scientific background, as well as a clinical message to deliver. There is also insistence that the speakers debate any disagreements with each other or with the practitioners in attendance.

A major leadership for this process has been assumed by the World Federation of Chiropractic (WFC), the European Chiropractors' Union and, in recent years, an increasing number of national chiropractic associations. The WFC, for example, has insisted on a strong scientific program and discussion of current theoretical and clinical problems since its inception. For the past few years, the congresses sponsored by the WFC have had more than 100 scientific papers accepted through a peer-review system for presentation in either platform or poster format. Every meeting has prominent medical speakers who present keynote addresses on new developments in the field of spine care and usually give seminars on the examination or management of spinal disorders. The WFC meetings are being attended by increasing numbers of chiropractors from around the world, and the next meeting is expected to have more than 1,000 chiropractors in attendance and participating in the discussion.

I believe, however, that the future role of chiropractic will not be determined primarily by its researchers. They are important in providing the scientific and academic leadership necessary to advance the field, but the future of the profession lies with every practicing chiropractor. The full potential of the profession will become evident when essentially every chiropractor is a member of their state and national societies and thereby forces the leadership of those organizations to stay abreast of scientific and political change; when every chiropractor reads a number of scientific journals to maintain the highest level of knowledge and most up-to-date care of patients; and when the major chiropractic scientific meetings have thousands of chiropractors in attendance discussing and debating the latest development in their field.

I believe this is possible and look forward to that day. When this happens, chiropractors will become the leaders in the field of spine research and the clinicians of first choice when patients are seeking information for care of the spine and associated problems. People who have spinal problems or are at risk of developing symptoms and disability from such disorders will benefit most from this process. That is the sole reason for our existence. This is my vision for the future of the profession.

Dr. Scott Haldeman is chairman of the research council of the World Federation of Chiropractic and presided over the Bone and Joint Decade 2000-2010 Task Force on the Neck Pain and Its Associated Disorders. He is a fellow of the Royal College of Physicians of Canada and the College of Chiropractic Science of Canada; past president of the North American Spine Society, the American Back Society and the North American Academy of Manipulative Medicine; and serves on the editorial board of six journals including Spine, The Spine Journal and JMPT.

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