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Chiropractic in the United States:
Training, Practice, and Research

Chapter VIII: Content of Practice
Robert D. Mootz, DC; Paul G. Shekelle, MD, PhD

**Comments in red by Stephen Barrett, M.D.

A. Presenting Problems and Diagnoses

Two studies of national scope have tried to describe what chiropractors actually do in practice. The first was a national survey of over 5,000 practicing chiropractors (Christensen, 1993), which asked what conditions patients presented with or had concurrently. The second, using data collected from the office records of a cluster sample of chiropractors, looked at the presenting symptoms the chiropractors recorded in charts and at diagnoses recorded for insurance purposes (Hurwitz, 1998). Both studies collected data in the early 1990s. These studies allow for a comparison between what chiropractors indicate they do in response to a survey and what they actually record for specific patients in their office records.

The patient conditions that chiropractors indicated they routinely, often, or sometimes see in their practice are listed in Table 19 (Christensen, 1993). Symptoms for which 1,916 patients sought chiropractic care in the United States and Canada, as recorded in the office record of the initial visit, are listed in Figure 2. About two-thirds of patients were seeking care for low back pain.

**Figure 2 (not reproduced here to avoid an unnecessary graphic, is a pie chart stating that 68% of the patients sought care for low back pain and 32% came for other reasons (13% for neck face pain or injury, 5% for mid-back pain or injury, 3% for arm pain or injury, 3% for arm or leg sprain or strain, 2% for headaches, and 5% for all other reasons). One percent of the charts did not indicate the reason.

The diagnoses made by chiropractors (either in the office record or on the claim form) for 477 U.S. patients who sought care for non-low back pain complaints are listed in Table 20. While musculoskeletal conditions dominate all three lists, some obvious discrepancies exist. When asked, chiropractors say they routinely see patients with headaches, often see patients with blood pressure problems, allergies, or obesity, and sometimes see patients with nutritional disorders, menstrual disorders, asthma or emphysema, various infections, diabetes, and a variety of other non-musculoskeletal disorders. Examination of office records for patients' symptoms and diagnoses, however, reveals a near-absence of non-musculoskeletal conditions. No nonmusculoskeletal symptom accounted for more than 1 percent of patients' symptoms, and the three most frequently diagnosed nonmusculoskeletal conditions, asthma, otitis media, and migraine headaches, were noted for only about 1 in 200 patients (Hurwitz, 1998).

Table 19. Frequency of Presenting and Concurrent Patient Conditions Chiropractors Indicated They See in Their Practices

ROUTINELY SEEN Spinal subluxation/joint dysfunction
Headaches
OFTEN SEEN Muscular strain/tear
Osteoarthritis/degenerative joint disease
Peripheral neuritis or neuralgia
Tendonitis/tenosynovitis
Radiculitis or radiculopathy
Vertebral facet syndrome
Intervertebral disc syndrome
Sprain or dislocation of any joint
Extremity subluxation/joint dysfunction
Hyperlordosis of cervical or lumbar spine
Scoliosis
Bursitis or synovitis
High or low blood pressure
Allergies
Obesity
SOMETIMES SEEN Kyphosis of thoracic spine
Osteoporosis/osteomalacia
Carpal or tarsal tunnel syndrome
Skeletal congenital/developmental anomaly
Articular joint congenital/developmental anomaly TMJ syndrome
Thoracic outlet syndrome
Systemic rheumatoid arthritis or gout
Occupational or environmental disorder
Muscular atrophy
Nutritional disorders
Menstrual disorders
Asthma, emphysema, or COPD
Upper respiratory or ear infection
Pregnancy
Respiratory viral or bacterial infection
Acne, dermatitis, or psoriasis
Loss of equilibrium
Diabetes
Psychological disorders
Eating disorders
Ear or hearing disorders
Eye or vision disorders
Hiatus or inguinal hernia
Gastrointestinal bacterial or viral infection
Infection of kidney or urinary tract
Colitis or diverticulitis
Thyroid or parathyroid disorder
Hemorrhoids

Source: Christensen M, Morgan D (eds). Job Analysis of Chiropractic: A Project Report, Survey Analysis and Summary of the Practice of Chiropractic within the United States, Greely, CO: NBCE, 1993.

Table 20. Most Frequent and Selected Diagnoses of Patients Seeking Care for Non-Low Back Pain Reasons From Chiropractors in the U.S.

ICD CODE DESCRIPTION

% OF ALL NON-LBP DIAGNOSES (N=477)

•••
Missing

23.7

847.0
Sprains and strains, neck

13.7

847.1
Sprains and strains, thoracic

5.4

723.1
Cervicalgia

3.7

839.0
Dislocation, cervical vertebra

3.7

729.1
Myalgia and myositis, unspecified

3.4

739.1
Nonallopathic lesion, cervical region

3.2

784.0
Headache

2.7

723.2
Cervicocranial syndrome

2.1

723.3
Cervicobrachial syndrome (diffuse)

1.8

346.0
Migraine

0.5

382.9
Unspecified otitis media

0.3

493.9
Asthma, unspecified

0.2

•••
(130 other diagnoses)

(35.6)
   

100%

Adapted from Hurwitz EL et al. Utilization of chiropractic services in the United States and Canada: 1985-1991. Am J Publ Hlth 1998;88:771-776.

The different messages conveyed by the two sources of data might be accounted for in a variety of ways, including how the information was collected. The conditions patients presented with, or had concurrently reported, in the Christensen survey (1993) may not be the same as the presenting symptoms the chiropractor recorded in the chart or as the diagnoses the chiropractors recorded for insurance purposes. Given reimbursement policies, coding restrictions, and utilization reviews that may occur, some chiropractors may feel an incentive to only report those symptoms and diagnoses that facilitate reimbursement. Reimbursement incentives may strongly influence the records chiropractors keep and the diagnoses that are reported. In many plans, e.g., Medicare, chiropractors are required to report a musculoskeletal diagnosis (and sometimes the diagnosis of "vertebral subluxation" is mandatory) in order to be paid for services.

**Chiropractic coverage under Medicare, which began in 1973, was limited to manual manipulation of the spine for the treatment of "subluxations demonstrated by x-rays to exist." To enable payment, federal officials accepted an elaborate chiropractic "definition" of subluxations for which payment could be made. During the mid-1980s, the U.S. Department of Health and Human Services' Office of the Inspector General (OIG) surveyed 145 chiropractors by telephone about their billing practices. Eighty-four percent said that some subluxations do not show on x-rays. Nearly half responded that when billing Medicare, they "could always find something" (by x-ray or physical examination) to justify the diagnosis, or they actually tailored the diagnosis to obtain reimbursement. The Balanced Budget Act of 1997 eliminates the x-ray the requirement as of January 1, 2000, and requires the Secretary of Health and Human Services to develop and implement utilization guidelines for chiropractic coverage when a subluxation has not been demonstrated by X-ray.

Secondly, almost a quarter of the non-low back complaint patients had no diagnosis, and this group might contain some of the "missing" nonmusculoskeletal diagnoses. However, given that few patients presented with nonmusculoskeletal complaints, this is probably not an important factor. Finally, this may reflect vagaries of memory and that the large number of "routine" musculoskeletal pain patients the chiropractor sees recedes somewhat compared to the unusual cases, which seem to stand out.

**The Christensen survey, done in 1991, contain a design flaw that makes some of its data uninterpretable. To survey the types of conditions seen, participants were asked to check off how frequently they saw more than 100 "presenting or concurrent problems." The highest score was for "spinal subluxation/joint dysfunction," which the vast majority reported seeing daily. Chiropractors disagree about the meaning of the word "subluxations"

Some find subluxations in all of their patients. Many advise patients who have no symptoms to undergo periodic "maintenance care" in which their alleged subluxations are located and corrected, typically on a monthly or weekly basis. The Christensen data do not indicate what percentage of patients with "spinal subluxation/joint dysfunction" had nothing physically wrong with them.

B. Diagnostic Methods

Chiropractic training and literature approach clinical diagnosis in a similar fashion to that of all health care disciplines in that history, physical and regional examination, special studies, and specialty-specific evaluation procedures are routinely incorporated into patient work-ups (Gatterman, 1990; Haldeman, 1993). All accredited chiropractic teaching institutions incorporate history and physical examination into their curricula. Standard history and physical examination methods are basic chiropractic clinical competencies (Council on Chiropractic Education, 1991). Using standard historical, diagnostic, and assessment procedures, chiropractors attempt to differentiate problems of mechanical versus visceral origin (Souza, 1994a).

**The above statements are true but incomplete. Large percentages of chiropractors use one or more quack diagnostic procedures in addition to (or even instead of) standard tests.

The chiropractic literature is also paying increased attention to the role pain behavior and psychosocial issues play in conditions such as back pain and to evaluation and management strategies in these areas (Milus, 1994; Skogsbergh, 1994).

While chiropractors claim to document case progress in standard SOAP (i.e., Subjective, Objective, Assessment, Plan) notation format (Christensen, 1993), several chart abstraction studies have noted that chiropractors often maintain inadequate patient records (Nyiendo, 1991; Hurwitz,1998). Although quality record keeping may be a problem in all health professions, it appears to be a greater problem for chiropractors, who typically practice outside of group clinic and practice settings. It is expected that the increased emphasis on record keeping in the chiropractic literature and, more importantly, the quality assurance processes associated with participation in accredited managed care organizations will lead to improvements in record keeping over time (Mootz, 1994; McElheran, 1994).

**Table 20 shows that 23.7% of the patients seeking chiropractic care for reasons other than low back pain had no diagnosis recorded in their chart. I wonder what percentage had nothing physically wrong with them.

Table 20. Most Frequent and Selected Diagnoses of Patients Seeking Care for Non-Low Back Pain Reasons From Chiropractors in the U.S.

ICD CODE DESCRIPTION

% of all non-LBP Diagnoses (N=477)

•••
Missing

23.7

847.0
Sprains and strains, neck

13.7

847.1
Sprains and strains, thoracic

5.4

723.1
Cervicalgia

3.7

839.0
Dislocation, cervical vertebra

3.7

729.1
Myalgia and myositis, unspecified

3.4

739.1
Nonallopathic lesion, cervical region

3.2

784.0
Headache

2.7

723.2
Cervicocranial syndrome

2.1

723.3
Cervicobrachial syndrome (diffuse)

1.8

346.0
Migraine

0.5

382.9
Unspecified otitis media

0.3

493.9
Asthma, unspecified

0.2

•••
(130 other diagnoses)

(35.6)
   

100%

Adapted from Hurwitz EL, et al. Utilization of chiropractic services in the U.S. and Canada: 1985-91
Am J Publ Hlth 1998;88:771-776.

1. History and Physical Examination

Two North American chiropractic practice parameter commissions recently rated history taking as a "necessary" component of a chiropractic patient evaluation (Haldeman, 1993; Henderson, 1994). Exploration of presenting complaint, family history, past health history, psychosocial history, and review of systems were considered necessary components of an adequate history (Haldeman, 1993). Standard procedures have been recommended for history taking that emphasize active listening and directed questioning related to the mechanisms of a problem's onset (Bowers, 1995a). The extent to which practicing chiropractors actually follow these guidelines is unknown. However, a recent survey of more than 6,500 chiropractors by the National Board of Chiropractic Examiners (Christensen, 1993) suggested that case histories are "routinely" performed and that chiropractors place "substantial" importance on the information gleaned from this process.

**The quality of history-taking is far more important than the frequency. I know of no study showing how well chiropractors can do this.

Performance of a physical examination is considered essential for establishing a diagnosis and determining a treatment plan (Haldeman, 1993; Henderson, 1994; Gatterman, 1990). Chiropractors receive extensive training and appear well prepared to perform orthopedic and neurological assessments (McCarthy, 1994; Evans, 1994) and the Christensen survey (1993) found that chiropractors report that they "routinely" perform these assessments. Assessment of general health status and performance of regional examinations were also considered important by chiropractors but are performed less frequently than physical examinations (Christensen, 1993).

**It is not clear how much the information chiropractors collect is used to make rational diagnoses and/or treatment plans. My 1993 visit to a "straight" chiropractor illustrates what can happen.

Periodic updating of the physical examination is emphasized in chiropractic education and clinical internships (Gatterman, 1990; Mootz, 1988), and its use is reported by chiropractors to be "frequent" (Christensen, 1993). Reassessment and monitoring of patient progress received special attention by chiropractic practice parameters commissions (Haldeman, 1993; Henderson, 1994). Table 21 lists attributes of chiropractic reassessment considered "necessary" by one of the commissions (Haldeman, 1993). Functional outcomes assessment is increasingly being incorporated into overall clinical strategies for monitoring patient progress (Yeomans, 1996).

Table 21. Necessary Principles of Chiropractic Reassessment

  • Reassessments are integral to case management and should be made following an appropriate period of care.
  • Necessity and content of reassessments are determined by patient response.
  • Reassessment shall be made if the patient's status worsens.
  • Reassessment shall be made if a patient manifests signs or symptoms in an area not previously evaluated.
  • Reassessment should be performed only after it is reasonably expected that measurable change in a patient's condition would have occurred.
  • Reassessment should be made in all areas where there were prior positive clinical findings.

Adapted from Haldeman S, et al. (eds). Guidelines for Chiropractic Quality Assurance and Practice Parameters. Gaithersburg, MD: Aspen Publishers, 1993; pp 135-6.

2. Mechanical Assessment Procedures

In addition to the routine clinical evaluation procedures standard to any patient workup (i.e., history, physical and regional examination, and special studies) chiropractors have developed assessment methods for determination of the mechanical status of a patient. Some mechanical assessment strategies are common to physical medicine procedures (Henninger, 1993, 1994; Hammer, 1991) and others are unique to chiropractic (Haas, 1995; Faye, 1992; Youngquist, 1989). Table 22 provides a listing of mechanical assessment procedures that may be used by chiropractors to identify joint dysfunction.

Table 22. Examples of Mechanical Assessment Procedures
Used by Chiropractors to Identify Joint Dysfunction

  • Pain provocation
  • Static palpation
  • Motion palpation
  • Range of motion measurement
  • Postural symmetry
  • Dynamic spinal loading
  • Tissue compliance
  • Reactive leg length discrepancy
  • Gait analysis
  • Function capacity and physical performance evaluation

Chiropractors typically approach mechanical assessment in a comprehensive fashion, routinely incorporating a number of hands-on evaluation methods (McMillin, 1995; Henninger, 1994). Osterbauer (1996) reviewed the evidence for reliability and utility of several chiropractic approaches to mechanical assessment procedures for detection of joint dysfunction or subluxation. Procedures with reasonable ("fair to good") reliability included assessments of osseous and soft tissue pain or tenderness (Mootz, 1989; Boline, 1993). Procedures for determining mobility, cutaneous temperature differences, and joint position have not fared well in reliability studies.

**The significance of this paragraph may not be obvious. The Osterbauer paper looked at the methods chiropractors use to assess "subluxations." It notes that chiropractors do not agree among themselves about what subluxations are or how they should be identified. It contains a table reporting on the reliability of six "chiropractic methods" of "subluxation assessment." The table states that bone pain has "fair to excellent" reliability, soft tissue pain has "fair to good" reliability, but that leg-length testing, use of heat-sensing devices, and two methods in which the chiropractor detects subluxations by hand are either "poor to moderate" or "poor." Other data (Christensen, 1993) show that the majority of chiropractors use at least one method that is "poor to moderately" reliable. Would you like your medical doctor to use poorly reliable diagnostic tests?

3. Special studies

Chiropractic training includes the use of clinical laboratory studies. Details on the application of these tests have long been described in the chiropractic diagnostic literature and in practice parameters (Jaquet, 1971; Adams, 1990; Vear, 1992; Triano, 1992; Haldeman, 1993). However, clinical laboratory testing appears to be only "rarely" or "infrequently" used in chiropractic practice (Hurwitz, 1998; Christensen, 1993). For example, blood tests are ordered for fewer than 1 percent of patients (Hurwitz, 1998). The infrequent ordering of lab tests may be due to legal restrictions on chiropractors performing phlebotomy in some jurisdictions as well as to the types of patients typically seen by chiropractors.

**It may also be related to inadequacies in chiropractic education.

Radiology and imaging is used with far greater frequency than laboratory studies. In the NBCE survey (Christensen, 1993), chiropractors indicated that radiographs were "frequently" ordered and special imaging studies such as CT or MR were "sometimes" ordered. In the analysis of office records of patients who sought care for low back pain, 54 percent of patients had lumbosacral radiography, about 2 percent of patients had CT, and 2 percent had MR imaging during their "episode of care" (Hurwitz, 1998). Thus, except for plain film radiography, special imaging and other special diagnostic tests are rarely used by chiropractors.

Radiology is a significant component of chiropractic education. A specialty society devoted to radiology, The American Chiropractic College of Radiology, serves in an advisory role for radiology residency programs at chiropractic colleges and certifies specialty-level competency in radiology. Yochum and Rowe (1996), chiropractic radiologists, authored a skeletal radiology text that is used in both chiropractic and medical radiology training. In a study comparing the abilities of chiropractic and medical radiologists, orthopedists, general practitioners, and chiropractic students to interpret radiographs, chiropractic and medical skeletal radiologists scored highest followed by chiropractic students, orthopedists, and general medical and chiropractic practitioners (Taylor, 1995).

**Perhaps it should be mentioned that the study pertained to the ability to interpret abnormal films of the lumbosacral spine and not to overall ability to read xrays.

Other special studies sometimes used or ordered by chiropractors include nerve conduction studies, bone scans, and electromyography. Appropriate use of these procedures is incorporated into the curriculum of chiropractic colleges and is addressed in chiropractic practice parameters (Haldeman, 1993). Chiropractic utilization of advanced diagnostics is quite low. In the past, chiropractors have been excluded from medical referral loops and have been forced either to care for patients without such studies or to obtain their own equipment and perform the tests themselves. Hence, either by design or circumstance, chiropractors often rely on low tech patient assessment procedures of historytaking, physical, regional, mechanical examinations, and plain film radiography while monitoring progress using a "therapeutic trial" approach to patient management.

C. Treatment Methods

Chiropractic treatments, as well as diagnostic practices, vary by geographic region due to differences in State laws governing scope of practice and due to differences in practitioner philosophy. The therapeutic procedure most closely associated with chiropractic is spinal manipulation. However, chiropractic patient management often includes lifestyle counseling, nutritional management, rehabilitation, various physiotherapeutic modalities, and a variety of other interventions (Gatterman, 1990; Haldeman, 1992, 1993). Physiologic therapeutics, taught in all chiropractic schools, are included in the chiropractic scopes of practice in most jurisdictions. Detailed protocols for the use of physiologic therapeutics have been published in the chiropractic literature (Hooper, 1996; Jascoviak, 1986) and are emphasized in the leading chiropractic research publication, the Journal of Manipulative and Physiologic Therapeutics.

The NBCE survey (Christensen, 1993) reported that chiropractors "routinely" performed chiropractic adjustive techniques. Overall, 96 percent of chiropractors reported having recommended corrective or therapeutic exercise at least once in the 2 years prior to the survey, and 84 percent of doctors recommended nutritional counseling, supportive techniques, or supplements during the same time period. No data are available in the Christensen survey (1993) about the proportion of individual patients who receive specific types of care. The office record data indicated that of 920 patients who presented with low back pain, 84 percent received spinal manipulation (or adjustment), 79 percent received nonthrust manual therapies such as mobilization, massage, and heat packs, 31 percent received education, and 5 percent received other forms of therapy such as acupuncture (Hurwitz, 1998).

**There are good reasons to believe that the majority of chiropractors involved in nutrition-related activities" are doing them improperly, and that most chiropractors who "practice nutrition" are prescribing unnecessary of irrationally formulated supplement products. See Quackwatch's article Steer Clear of "Chiropractic Nutrition." One of the most important nutrition-related areas is the management of abnormal blood cholesterol levels. As far as I know, the percentage of chiropractors who counsel patients about this (whether properly or not) has never been determined. The Christensen survey's finding that chiropractors order blood tests on fewer than 1% of their patients suggests that very few chiropractors are doing appropriate cholesterol counseling.

1. Manual Methods

The syntax surrounding the mechanical intervention of spinal manipulation is the source of some controversy within the chiropractic profession. Most chiropractors prefer the term chiropractic "adjustment" to manipulation because it is believed to imply a more specific or precise maneuver and distinguishes it from other forms of manipulation. There are at least 100 distinct chiropractic, osteopathic, and physical therapy manipulation techniques, a large array of highly specialized adjusting tables and equipment, and a great deal of variation in the specific techniques used by individual practitioners (Haldeman, 1993; Greenman, 1996; Bergmann, 1993).

There are four terms with distinct definitions that are frequently used to characterize manual manipulative methods (Haldeman, 1993). The general umbrella term of spinal manipulative therapy is often used to encompass all types of manual techniques regardless of their precise anatomic and physiologic focus or their discipline of origin. Mobilization is defined as passive movement of a joint within its physiologic range of motion. This roughly equates to the range of motion a joint can typically be taken through by its intrinsic musculature. Manipulation is passive joint movement, which takes the joint beyond its physiologic range into the paraphysiologic space. Intrinsic muscle contraction alone does not usually move joints this far. When a joint is moved into this "para-physiologic" range, cavitation can occur, which, in a synovial joint, is typified by an audible release or "pop." A gaseous bubble may appear within the synovial fluid for several minutes after manipulation (Greenman, 1996).

Both mobilization and manipulation are used to facilitate joint motion. When applied in manual medicine and physical therapy, assessment and manipulative treatment tend to focus exclusively on joint pain and restriction. However, even though the execution of high velocity manipulative thrusts by chiropractors and nonchiropractors may appear similar, chiropractic techniques focus on a more global clinical picture to characterize and apply adjustments. Chiropractors typically consider the nature and mode of condition onset, muscle spasm, pain radiation patterns, static and dynamic postures, and/or gaits as well as joint pain in determining whether or not a mechanical intervention should be applied (Mootz, 1995a). For example, the spinal areas manipulated using typical manual medicine and physical therapy assessment approaches are often based on which joints or regions have restricted motion. In contrast, the decision as to which area to manipulate using various chiropractic techniques may be based upon pain radiation patterns, which paraspinal muscle regions are taut and how they are enervated, the biomechanical function of affected joints compared to that of adjacent areas, and the mechanics involved in initial onset (Grice, 1992; Gitelman, 1992). Thus the regions manipulated by chiropractors may not directly correspond to the symptomatic region or to the area that a nonchiropractor may feel is the site of the manipulable lesion.

In addition, there are many unique features associated with chiropractic techniques including patient positioning, equipment, characteristics of prestressing joints, and thrust. Decisions about the frequency and duration of chiropractic manipulative treatment may not be much influenced by its effect on range of motion. Rather, progress indicators such as function, coordination, and endurance often influence when and how chiropractic manipulation is provided. Some of the syntax in chiropractic reflects this with many drawing a distinction between the terms manipulation and adjusting. Table 23 provides definitions for manipulation, mobilization, and adjusting that illustrate these conceptual differences (Haldeman, 1993).

Table 23. Distinctions Between Adjustment, Manipulation, and Mobilization

Chiropractic Adjustment: This term refers to a wide variety of manual and mechanical interventions that may be high or low velocity; short or long lever; high or low amplitude; with or without recoil. Procedures are usually directed at specific joints or anatomic regions. An adjustment may or may not involve the cavitation or gapping of a joint (opening of a joint within its paraphysiologic zone usually producing a characteristic audible "click" or "pop"). The common denominator for the various adjustive interventions is the concept of removing structural dysfunctions of joints and muscles that are associated with neurologic alterations. The chiropractic profession refers to this concept as a "subluxation." This use of the word subluxation should not be confused with the term's precise anatomic usage, which considers only the anatomical relationships.

Manipulation and Mobilization: During joint motion, three barriers or end ranges to movement can be identified. The first is the active end range, which occurs when the patient has maximally contracted muscles controlling a joint in a particular directional vector. At this point, the clinician can passively move the joint toward a second barrier called the passive end range. Movement up to this barrier is termed physiologic joint space. Beyond this point, the practitioner can move the joint into its paraphysiologic space. The third barrier encountered is the anatomic end range. Movement beyond this will result in rupture of the joint's ligaments.

Manipulation: Passive movement of short amplitude and high velocity, which moves the joint into the paraphysiologic range. This is accompanied by cavitation or gapping of the joint, which results in an intrasynovial, vacuum phenomenon thought to involve gas separating from fluid. Usually accompanied by an audible pop or click, manipulation has been shown to result in increased joint motion compared to mobilization alone. This increase in motion lasts for a 20 to 30 minute refractory period during which an additional cavitation of the same joint will not occur. Manipulation is a passive dynamic thrust that causes cavitation and attempts to increase the manipulated joint's range of motion.

Mobilization: Passive movement within the physiologic joint space administered by a clinician for the purpose of increasing overall range of joint motion.

Source: Haldeman S, Chapman-Smith D, Petersen D (eds). Guidelines for Chiropractic Quality Assurance and Practice Parameters. Gaithersburg, MD: Aspen Publishers, 1993.

Bartol (1991) categorized chiropractic adjustive techniques according to their mechanical characteristics. Table 24 lists a classification scheme used by American and Canadian chiropractic practice parameter commissions to categorize types of chiropractic manual interventions. Table 25 provides examples of some better known chiropractic adjustive techniques. The Christensen survey (1993) reported that chiropractors "routinely" perform specific chiropractic adjustive techniques, "frequently" employ supportive or other non-adjustive techniques, but only "sometimes" use instruments (e.g., Activator) in the application of adjustments.

Regarding specific forms of manipulation and adjusting used by chiropractors, the job analysis by Christensen (1993) reported that Diversified, Gonstead, Flexion-Distraction, Activator, and Thompson techniques were the most frequently used procedures. All other techniques were used by fewer than 43 percent of practitioners. Over 93 percent of chiropractors reported using such full-spine adjusting procedures as their primary approach to patient care. Fewer than 2 percent indicated a primary emphasis on upper cervical procedures. Although roughly one-third of chiropractors indicated that they used other techniques (such as cranial work), the number reporting them as a primary emphasis was too small to warrant an individual listing in the Christensen job analysis (1993).

Table 24. Generic Chiropractic Manipulative and Adjustive Categorization System

A. Manual, Articular Manipulative, and Adjustive Procedures

1. Specific Contact Thrust Procedures
a. high velocity thrust
b. high velocity thrust with recoil
c. low velocity thrust
2. Nonspecific Contact Thrust Procedures
3. Manual Force, Mechanically Assisted Procedures
a. drop-tables and terminal point adjustive thrust
b. flexion-distraction table adjustment
c. pelvic block adjusting
4. Mechanical Force, Manually Assisted Procedures
a. fixed stylus, compression wave adjustment
b. moving stylus instrument adjustment

B. Manual, Nonarticular Manipulative, and Adjustive Procedures

1. Manual Reflex and Muscle Relaxation Procedures
a. muscle energy techniques
b. neurologic reflex techniques
c. myofascial ischemic compression procedures
d. miscellaneous soft tissue techniques
2. Miscellaneous Procedures
a. neural retraining techniques
b. conceptual approaches

Adapted from Haldeman S, et al. (eds). Guidelines for Chiropractic Quality Assurance and Practice Parameters. Gaithersburg, MD: Aspen Publishers, 1993.

Table 25. Examples of Specific Chiropractic Techniques

Full-spine, high-velocity techniques
Diversified
Gonstead
Thompson Terminal Point
Pierce-Stillwagon
Pettibon
Chiropractic Biophysics
Lumbo-pelvic techniques
Cox Flexion-distraction
Logan Basic
Upper cervical techniques
Upper Cervical Specific
NUCCA
Grostic
Orthogonal
Miscellaneous/Instrument Adjusting
Sacro-Occipital Technique
Applied Kinesiology
Activator
Toftness

2. Exercise and Rehabilitation

According to Christensen (1993), 96 percent of chiropractors reported that they used corrective and therapeutic exercises. Evidence-based guidelines published by AHCPR stress the importance of early activation of acute low back pain patients in order to optimize recovery (Bigos, 1994). Chiropractors have incorporated patient activation and exercise into their management strategies since the early part of the 20th century (Cook, 1994; Liebenson, 1995). Chiropractors have also become involved in the treatment of athletes, gaining substantial recognition in the sports medicine specialties. The American College of Sports Medicine was one of the first multidisciplinary organizations to allow chiropractors membership status. Chiropractors also have been included by many countries as Olympic team physicians and leading chiropractic colleges have recently sponsored postgraduate certification programs in sports chiropractic and rehabilitation. A clinical journal devoted to sports chiropractic and rehabilitation has been published for the better part of a decade and chiropractic authors have increasingly emphasized rehabilitation and activation strategies (Liebenson, 1995; Cook, 1994; Nelson, 1994; Souza, 1994b).

Chiropractic rehabilitation protocols appear very similar to standard rehabilitation practices (Nelson, 1994; Cook, 1994; Liebenson, 1996).

**One very important difference exists, however. Many chiropractors encourage patients to enroll in lifelong "preventative maintenance" programs.

With the increased popularity of fitness and conditioning in recent decades, exercise and rehabilitation have developed their own sub-specialty identity within medicine and physical therapy as well as in chiropractic. Chiropractic approaches to exercise range from the low-tech in-office conditioning and stabilization programs (Cook, 1994; Nelson, 1994; Liebenson, 1996) to more extravagant high-tech conditioning equipment (Christiensen, 1992). The Chiropractic Rehabilitation Association (CRA) publishes rehabilitation guidelines for chiropractic (CRA, 1992). Exercise and rehabilitation have been classified as "promising" to "established" for increasing functional capacity in chiropractic practice parameters (Haldeman, 1993; Henderson, 1994).

3. Lifestyle and Activities of Daily Living

Promotion of wellness and lifestyle strategies is also a significant, if underexplored, aspect of chiropractic practice. More than two-thirds of chiropractors report using nutritional and exercise counseling in practice (Christensen, 1993), and chiropractic college curricula include courses on the subject. Health promotion strategies for chiropractors exist in the literature (Jameson, 1991; Hawk, 1995; Bowers, 1995b); however, data on application in practice is scant.

**Chiropractors typically claim that they use a preventive approach. However, detailed look at what they do and don't do would probably prove very embarrassing to the profession. For example, chiropractic surveys show that fewer than half promote immunization. I also believe that most of their nutritional counseling is quacky.

4. Ancillary and Complementary Procedures

Chiropractors also use a variety of complementary and ancillary procedures. The most frequently used procedures include cryotherapy, bracing, and nutritional counseling (Christensen, 1993). The majority of practitioners also use rest, heat, orthotics, traction, and physiotherapeutic modalities. Acupressure and meridian therapy are used by about 65 percent of practitioners with fewer than 12 percent reporting that they use acupuncture (Christensen, 1993).

**I find it puzzling that the use of meridian therapy is mentioned here without noting that it is a form of quackery.

D. Chiropractic Management of Specific Health Care Problems

1. Considerations in Management of Neuromusculoskeletal Problems

In recent years manipulation has been the subject of substantial scientific inquiry (Bronfort, 1992; Shekelle, 1991a, 1991b, 1992a, 1992b, 1995) and its role in the management of at least some musculoskeletal conditions appears promising (see Chapter XI for more details on evidence for efficacy of manipulation). However, more study is needed, especially given the current emphasis on cost containment in health care. As previously indicated, the majority of conditions for which patients seek chiropractic are musculoskeletal problems (Hurwitz, 1998; Goertz, 1996; Christensen, 1993) with low back pain and head/neck pain accounting for the great majority.

Low Back Pain

Chiropractic management of low back pain depends on the characteristics of the patient and the condition. Management of acute low back pain usually entails initial pain and inflammation control, with emphasis on return to normal activity (Mootz, 1991, 1993a; Cox, 1996). Depending on the clinical presentation, manual interventions such as manipulation and adjusting may be directed at restoring joint motion and stretching tight musculature. Other manual procedures including soft tissue work, passive and active movements, and therapeutic exercise may be used based on severity of condition, patient tolerance, and demands of activities of daily living (Cox, 1996; Nelson, 1994). Additionally some chiropractors may use supportive modalities (e.g., thermal or electric physiotherapeutics) to enhance muscle relaxation and tissue metabolism. Treatment frequency and duration depends on the nature and extent of the condition (Hansen, 1994a). Back pain that appears to be associated only with uncomplicated simple joint dysfunction generally resolves within a few days or weeks (Hansen, 1994a; Mootz, 1993a). Acute low back conditions with more substantial soft tissue injury and/or radicular involvement typically involve more intensive and prolonged management (on the order of a few months) (Mootz, 1993a; Cox, 1996).

Chronic and recurrent low back conditions often require greater emphasis on modification of daily activities and conditioning (Liebenson, 1996; Skogsbergh, 1994). Manipulation may be combined with rehabilitation protocols for such cases (Mootz, 1993a). Somatization and other types of pain behavior are also frequently considered in treating chronic pain patients as are the impact of the condition on the patient's lifestyle and the extent of the patient's motivation. Collaborative care and/or referral for counseling may be sought in such cases.

Cervical and Thoracic Spine Conditions

As with low back pain, chiropractic management of cervical and thoracic conditions is based on the nature and extent of the problem as well as on the patient's psychological, social, and physical circumstances. Two of the more common cervical spine complaints seen by chiropractors are neck pain and cervicogenic headache (Hurwitz, 1998). Uncomplicated neck pain that may be related to simple joint dysfunction can be cared for with a combination of manipulation and myofascial work, and should respond quickly to such interventions. Neck pain involving discogenic or radicular complications is also something chiropractors feel comfortable managing (Coulter, 1995). However, this requires careful monitoring that demonstrates improvement under care and manipulative treatment may need to be modified from that used on patients without radiculopathy to avoid possible compression of inflamed tissues within the cervical foramen (Mootz, 1996).

Post-traumatic cervical sprain and strain, often associated with whiplash type injury, is another condition frequently managed by chiropractors (Foreman, 1995). This is usually treated with pain control (e.g., cryotherapy, rest, compression, elevation), bracing, rehabilitation, and manual interventions (including manipulation) during the course of care as patient response and tolerance permit (Mootz, 1996). Soft tissue injuries, especially some of the more extensive ones, can heal slowly and develop fibrosis which may prolong response time and increase treatment duration (Foreman, 1995).

Extremity Conditions

Sports injuries and extremity conditions are also addressed by chiropractors (Souza, 1994b, 1994c; Turchin, 1995) and have been the subject of preliminary chiropractic practice guideline efforts (Chiropractic Rehabilitation Association, 1992). Management methods may include typical nonpharmaceutical pain control, exercise and extremity manipulation or mobilization.

2. Management of Other Conditions

Little is known about how frequently chiropractors diagnose and treat non-neuromusculoskeletal problems, and no studies have described how such problems are actually managed. A 1995 survey by the American Chiropractic Association (ACA) found that chiropractors estimated that, on average, 16 percent of their practices were devoted to the treatment of nonneuromusculoskeletal conditions (Goertz, 1996). However, as noted earlier, a study using data from chiropractors' office records found that fewer than 5 percent of patients were seen for nonneuromusculoskeletal conditions (Hurwitz, 1998).

Chiropractors may often see patients who smoke, are overweight, or who have previously undiagnosed conditions such as hypertension or rheumatoid arthritis. Depending on the extent of the problem, the chiropractor's training and experience, and the scope of practice for which the chiropractor is licensed, specific monitoring strategies and lifestyle modifications may be recommended (Jameson, 1991; Milus, 1994; Bowers, 1995a; Frischer, 1995; Evans, 1995). Disease screening, nutritional counseling, and lifestyle modification are part of chiropractic training (Jameson, 1991, Bowers, 1995a).

**How well chiropractic training actually prepares chiropractors to do these things would be an interesting question to research. My guess is that most of the schools don't do it very well.

Since the profession's inception, many chiropractors have believed that chiropractic adjusting techniques enhance general health and wellness, and facilitate healing in patients with nonmusculoskeletal disorders. Although some chiropractors promote these beliefs, others are cautious about making such claims for which there is little scientific support. Thus, at this time, these beliefs are based on conceptual biologic models and anecdotal clinical experience but not on scientific evidence.

**I believe that the majority promote beliefs that adjustments enhance general health and wellness. Some of the "conceptual biological models" are delusionally based.

The most controversy surrounding chiropractic management of non-NMS conditions derives from vestiges of early chiropractic and osteopathic models regarding how spinal manipulation might impact a disease process.

**My dictionary defines vestiage as "a visible trace, evidence, or sign of something that once existed but exists or appears no more." The "early models" included such concepts as subluxations, nerve impingement, nerve energy, and Innate Intelligence. Many chiropractors still cling to them.

There are a number of models regarding the physiological effects of manipulation and an overview of research on the topic can be found in Chapter X. The most sophisticated models speculate on the reflex effects spinal manipulation might have on autonomic function (Gatterman, 1995). However, autonomic nervous system function remains poorly understood and specific responses to stimuli are dependent on so many confounding factors as to make predictable and workable models a significant challenge.

Many practitioners have anecdotally reported remissions of diagnosed systemic or visceral disease while a patient is under chiropractic care. Although a cause-effect relationship may be apparent to those affected, other explanations must be considered. For example, chest and arm pain may result from cardiac ischemia or mechanical dysfunction in the chest wall or rib cage. Manual methods may relieve a patient with the latter cause, leading to an inaccurate assumption that manipulation influenced heart disease. Natural progression, concurrent interventions, and placebo responses may also provide rival explanations to a direct neurologically mediated response. More research is needed in this area.

**The paragraph would be made more meaningful by replacing the word "rival" with "logical."

E. Practice Guidelines, Clinical Pathways, and Technology Assessments in Chiropractic

The first evidence- and consensus-based practice parameters on chiropractic in the U.S. were developed through a large-scale professionwide effort (Haldeman, 1993). This effort, called the "Mercy Conference" (after the conference center where the formal nominal group consensus meeting was held) used a formal consensus approach, with input from a broad cross-section of the profession. The recommendations, developed using a standardized and evidence-based approach, address the broad range of chiropractic practices. After a 3-year process, final recommendations were agreed upon (Haldeman, 1993). The guidelines delineate general clinical parameters and lack specificity for approaches to the management of patients with specific conditions. An infrastructure to evaluate and oversee future revisions has been established by the Congress of Chiropractic State Associations.

**The Commission for the Establishment of Guidelines for Chiropractic Quality Assurance and Practice was composed of 35 prominent chiropractors. After chapters were drafted and underwent review by outside consultants, the commission met for several days to reach a consensus on the many recommendations that had been proposed. The final report was completed in 1992 and commercially published in 1993 as a 263-page book.

The guidelines address more than 300 aspects of the history and physical examination, diagnostic imaging, instrumentation, laboratory testing, record-keeping and patient consent, clinical impression, modes of care, frequency and duration of care, clinical reassessment, outcome assessment, collaborative care, contraindications and complications, preventive/maintenance care, public health, and professional development. Each clinical procedure was rated as established, promising, equivocal, investigational, doubtful, or inappropriate. ("Equivocal" meant that a procedure's value "can neither be confirmed or denied.") The first three ratings were considered "positive" and appropriate for clinical use and insurance reimbursement. Procedural and administrative items were rated as necessary, recommended, discretionary, or unnecessary, while contraindications were rated as none, relative, relative to absolute, or absolute.

Although the Mercy Guidelines were a much-needed step in the right direction, some of the ratings were overly positive and many of chiropractic's quacky practices were called "investigational" or even "equivocal." For example. use of chiropractic adjustments for "preventive maintenance was rated "equivocal" because "the clinical experience of the profession developed over a period of nearly 100 years suggests . . . merit"

Unlike what the medical profession does with prominent medical guidelines, few chiropractors will actually use the Mercy report for guidance. And, as noted below, subluxation-based practitioners rejected it and produced a report of their own.

One other chiropractic practice inventory has been developed in the United States (WCA, 1993). It was a narrow scope ("straight") practice parameter project, which lacked an explicit process and involvement of different viewpoints. The recommendations promoted lengthy periods of treatment and did not consider evidence contrary to the sponsor's beliefs. The proceedings quickly went out of print and have not been reissued although a second effort has been undertaken.

Two more recent efforts have occurred in Canada and Australia (Henderson, 1994; Ebrall, in press). Like Mercy, both used explicit processes to evaluate the literature and synthesize expert opinion on which the recommendations are based. These efforts update Mercy by incorporating new information. Their recommendations were generally similar to those of Mercy.

In addition to the efforts to produce practice parameters, a number of condition-specific guidelines and critical care pathways (Table 26) have recently appeared in the chiropractic literature (Hansen, 1994b). Chiropractors also participated in a multidisciplinary panel that produced national guidelines for the management of acute low back pain in adults (Bigos, 1994).

Finally, chiropractors have undertaken a number of technology assessments (Hansen, 1996; Mannello, 1996) such as those listed in Table 26. In addition, formal efforts to examine approaches to evaluating and validating chiropractic methods have been undertaken (Kaminski, 1987; Hansen, 1996; Osterbauer, 1996). These efforts have relied on explicit processes to evaluate the literature and expert clinical opinion on individual procedures.

Table 26. Examples of Recent Chiropractic Practice Parameters,
Clinical Pathways, Algorithms, and Technology Assessments

Chiropractic Practice Parameters Using Explicit Processes

  • Guidelines for Chiropractic Quality Assurance and Practice Parameters (Haldeman, 1993).
  • Clinical Guidelines for Chiropractic Practice in Canada (Henderson, 1994).
  • Clinical Parameters of Australian Chiropractic Practice (Ebrall, in press).

Clinical Pathways and Algorithms

  • A consensus on the assessment and treatment of headache (Nelson, 1991).
  • Fatigue: narrowing the differential (Bowers, 1994).
  • Improving the clinician's use of orthopedic testing: application to low back pain (McCarthy, 1994).
  • Fever in the adult patient (Evans, 1995).
  • Conservative management of hypertension (Mootz, 1995b).
  • Clinical considerations in the mechanical assessment of the cervical spine (McMillan, 1995).
  • Evaluation and management of an adult patient presenting with cough (Frischer, 1995).
  • Determining how much care to give and reporting patient progress (Hansen, 1994a).
  • Low back pain pathogenesis, diagnosis, and management (Aker, 1990).
  • Psychological considerations in chiropractic practice (Milus, 1994).
  • Chiropractic care parameters for common industrial low back conditions (Mootz, 1993a).

Technology Assessments

  • Proceedings of the First Consensus Conference on Validation of Chiropractic Methods (Bergmann, 1990).
  • Focus on Health Policy and Technology Assessment in Chiropractic: Proceedings of the 7th Annual Conference on Research and Education (Hansen, 1992).
  • The value of leg length inequality and specific contact short lever adjusting in chiropractic: results of a consensus process by chiropractic expert panels (Mootz, 1993b)

F. Quality Management and Medicolegal Issues

1. Quality Management Efforts in Chiropractic

Although chiropractic was not included in early attempts to address quality in health care delivery, quality management and quality assurance are now being addressed in the chiropractic literature (Hansen, 1997; Iannelli, 1995; McElheran, 1994). Chiropractic involvement in managed care programs has served as a catalyst for this interest due to credentialling requirements, accreditation of preferred provider organizations, and an increasing need for competitive advantages in the marketplace. Although a number of different definitions of "quality" have been proposed, several consistently mentioned dimensions of chiropractic quality include effectiveness of care, appropriateness of care, availability of providers, access, patient satisfaction, adequacy and completeness of medical information and record keeping systems, office environment, and continuity of care (McElheran, 1994; Iannelli, 1995).

These components of quality can be roughly categorized into those that focus on clinical services, and those that focus on the delivery of care. The technology assessment and practice guidelines efforts undertaken by the chiropractic profession have served as a springboard for documenting clinical attributes of quality. Table 26 listed several of these efforts. For example, the "Mercy" Guidelines for Chiropractic Quality Assurance and Practice Parameters described more than 300 recommended attributes of chiropractic practice in performing history and examination, special studies, diagnostic considerations, modes of care, clinical documentation, and continuing education (Haldeman, 1993). Relatively few recommendations involved condition- and patient-specific issues. Many clinical issues were dealt with in generalities and were given "equivocal" ratings, reflecting the current state of uncertainty in the scientific literature. On the delivery and administrative side, however, more specific guidelines were stated concerning such issues as record-keeping and patient confidentiality.

An example of a practitioner performance audit form used at the National College of Chiropractic Clinics to monitor quality attributes through chart audits is included as Figure 3 (Iannelli, 1995). An example of chart record content guideline currently used by a chiropractic IPA as a guideline for minimum chart requirements for its network members (McElheran, 1994) is included as Figure 4.



Figure 3. Practitioner performance audit form
National College Chiropractic Clinics Practitioner Performance Audit

Center_______ Chart # _______ Date of Visit _______ Practitioner ______________

ACUTE / CHRONIC PROBLEM CARE

 YES

 NO

 N/A
COMMENTS
Problem/#Title _____________
1. Was the subjective data adequate?

 ____

 ____

 ____
 ________________
2. Was the objective data adequate?

  ____

 ____

 ____
________________
3. Was the assessment adequate?

 ____

 ____

 ____
 ________________
4. Were the diagnostic procedures adequate?

  ____

 ____

 ____
 ________________
5. Was recommended therapy indicated and appropriate for the stated condition?

 ____

 ____

 ____
 ________________
6. Does the plan contain appropriate initial short and long term goals?

 ____

 ____

 ____
 ________________
7. Are treatment goals reviewed/revised according to their expiration dates?

 ____

 ____

 ____
 ________________
8. Was a consultation requested if indicated?

 ____

 ____

 ____
 ________________
9. Was the patient referred to the nutritionist if indicated?

 ____

 ____

 ____
 ________________
10. Was the patient referred to rehabilitation if indicated?

 ____

 ____

 ____
 ________________
11. Was the patient referred to electrodiagnosis if indicated?

 ____

 ____

 ____
 ________________
12. Was the patient referred to ergonomics if indicated?

 ____

 ____

 ____
 ________________
13. Was the patient referred to orthopedics if indicated?

 ____

 ____

 ____
 ________________
14. Was the patient referred to family practice if indicated?

 ____

 ____

 ____
 ________________
15. If appropriate, was the patient placed on elective care?

 ____

 ____

 ____
 ________________
16. Does a progress note indicate the patient received patient education, including explanation of diagnosis?

 ____

 ____

 ____
 ________________
17. If the patient received a new therapy, does SOAP note indicate specific pt. ed. was given about therapy?

 ____

 ____

 ____
 ________________
18. MECHANICAL LOW BACK PAIN: Has the initial treatment goal been achieved within 3 weeks?

 ____

 ____

 ____
 ________________
19. MECHANICAL NECK PAIN: Has the initial treatment goal been achieved within 3 weeks?

 ____

 ____ 

 ____
 ________________
20. SHOULDER IMPINGEMENT: Has the initial treatment goal been achieved within 6 weeks?

 ____

 ____

 ____
 ________________
       
MEDICAL RECORDS  
21. Does the Problem List contain all significant clinical impressions?

 ____

 ____

 ____
 ________________
22. Does the Problem List accurately indicate if problems are active or resolved?

 ____

 ____

 ____
 ________________
23. Were all entries in the record legible?

 ____

 ____

 ____
 
24. Does the progress note follow SOAP format?

 ____

 ____

 ____
 
25. Do all therapy/plan orders bear the clinician's signature and date?

 ____

 ____

 ____
 ________________
     
CONTINUITY OF CARE  
26. If ordered, was consultation/referral carried out?

 ____

 ____

 ____
 ________________
27. Are all abnormal laboratory, imaging, and specialty procedure results adequately followed up?

 ____

 ____

 ____
 ________________
28. Are test results available for tests ordered on previous visit? (NA if 1 wk since last visit)

 ____

 ____

 ____
 ________________
29. Was the patient seen by the same provider/group on 8 out of the 10 most recent visits (within 6 months)?

 ____

 ____

 ____
 ________________

Source: Iannelli GC. Principles of quality management in chiropractic practice. In Lawrence D, et al. (eds). Advances in Chiropractic, Vol. 2. St. Louis, MO: Mosby, 1995. Reprinted with permission.



Figure 4. Guidelines for Chart Records Content

Chiropractors have the legal and ethical responsibility to maintain complete and accurate records for each patient. Patient files should be stored neatly and organized to facilitate tracking and retrieval, with a system in place to maintain patient confidentiality. The following guidelines are adapted from the 1994 NCQA Guidelines for Medical Record Review.

To be considered complete, chiropractic chart records should include the following features:

Medical Record Overview

Exam / Intake Records

Daily Chart Records

12. Relevant history / subjective findings of the presenting problem noted for each visit.
13. Pertinent objective findings noted when there is significant change.
14. Assessment / diagnosis noted in encounter entries, corresponding to subjective / objective findings.
15. Treatment plan / recommendations noted, corresponding to the patient problem / diagnosis. Return time is noted as weeks, months, or PRN.
16. Notation of care prescribed or provided, corresponding to the problem being treated.
17. The care provided appears to be "medically" appropriate.
18. Reports (lab, imaging, second opinion, etc) and correspondence are signed or initialed as reviewed by the provider, significant findings are noted in the record.
19. Notation of patient's response to care.
20. Notation of home exercises /activities / ADLs given.
21. Appropriate diagnostic testing or referral is noted.
22. Notation of review / discussion of specialist findings and further recommendations.
23. All S.O.A.P. areas are updated for each PRN follow-up visit.
Source: McElheran L, Sollecito P. Delivering quality chiropractic care in a managed care setting. Top Clin Chiropr 1994;1(4):78.


Standardized systems for quality assurance and management have been successfully implemented in chiropractic settings. Iannelli (1995) reported that the National College of Chiropractic was able to implement the AmbuQual system charting the Program Quality Index (PQI) of facilities. Over a 3-year period, parameters including staff performance, continuity of care, record keeping, patient risk minimization, satisfaction, compliance, and accessibility were tracked. Ianelli concluded that tracking such data and using them in organizational decisionmaking led to increased PQI scores.

As chiropractors become more involved in interdisciplinary settings and networks, pressures for and experience with quality assurance and quality management efforts will increase. In addition, wider use of these technologies in teaching clinics should help establish practice habits that incorporate patient- and consumer-oriented performance measures making chiropractic services more accountable and appealing to consumers.

2. Malpractice Experience

Chiropractors have among the lowest malpractice insurance premiums of all physician specialties, and the percentage of chiropractic physicians who have been sued for malpractice is lower than the percentages of medical and legal professionals (Brady, 1994; Medical Liability Monitor, 1996). Based on premium rate data provided by the National Chiropractic Mutual Insurance Company (the largest chiropractic malpractice carrier in the U.S.), average annual premium costs for chiropractic malpractice coverage in 1996 ranged from a low of $611 in Indiana to a high of $4,107 in Connecticut with a national average of $2,177. This compares to average annual internal medicine premium costs ranging from a low of $1,308 in Arkansas to over $20,000 in Florida, Illinois, and New York (Medical Liability Monitor, 1996).

Although malpractice premiums do not provide an accurate measure of risk, they do reflect the relative number and severity of complications and problems arising from care. Overall, chiropractic procedures appear to be comparatively safe, although potential side effects, complications, and contraindications to adjusting have been identified (Haldeman, 1993; McGregor, 1995).

**Malpractice premiums reflect the amounts paid out to plaintiffs and the extent to which the insurance company is able to set its profit margins. It is true that premiums reflect relative number and severity of complications and problems. But they are also influenced by the severity of the original illness (suits and ultimate payouts are more likely to arise when patients are very sick or die) and the willingness of attorneys to file suit. Attorneys are generally less interested in suing chiropractors because they tend to carry less insurance (and therefore the case may not be worth pursuing) and because it is often difficult to find a chiropractor willing to testify against fellow chiropractors.

Claims data from Canada revealed that between January 1986 and December 1990, there were a total of 159 claims made against chiropractors with the most common complaints being for lumbar spine injury, rib fracture, soft tissue injury, and cervical spine injury. Cerebrovascular accidents accounted for 8 percent of the claims (Henderson, 1994). According to claims data from the National Chiropractic Mutual Insurance Company for 1990, the most common causes of malpractice claims were for disc problems, failure to diagnose, fracture, and soft tissue injury. Cerebrovascular accidents accounted for 6 percent of claims made (Haldeman, 1993). Estimates of the risk of specific complications from lumbar and cervical spine manipulation are presented in Chapter XI.

**As far as I know, chiropractic malpractice insurance companies have not made full public disclosure of the number of claims they have encountered for cerebrovascular accidents (strokes). I believe this is a deliberate strategy to make it impossible to estimate how often such incidents occur. The estimates in Chapter XI are based on incomplete data and should not be considered reliable.

In part due to concerns about the risk of adverse events and malpractice claims, guidelines for clinical management, minimization of risks, and informed consent have been published in the chiropractic literature (Haldeman, 1993; Henderson, 1994). Table 27 lists some conditions identified in the Guidelines for Chiropractic Quality Assurance and Practice Parameters that may require modification of high velocity thrust procedures due to possible risks of complications (Haldeman, 1993). Because of the limitations in data quality and availability, the type of evidence available for making these ratings was primarily expert opinion of participating panelists and/or case reports.

Table 27. Examples of Conditions (or Concurrent Conditions) That May Necessitate Modification of High Velocity Thrust Procedures on a Patient

Absolute contraindication to high velocity thrust procedures

  • region with acute episode of rheumatoid arthropathy
  • acute fracture/dislocation
  • osodontoideum
  • active juvenile avascular necrosis
  • area with malignancy
  • bone or joint infection
  • acute myelopathy or cauda equina syndrome

Relative to absolute contraindication to high-velocity thrust procedures

  • joint instability
  • benign bone tumors
  • clinical manifestations of vertebrobasilar arteriole insufficiency (to cervical manipulation)
  • congenital or acquired skeletal deformities

Relative contraindication to high-velocity thrust procedures

  • spondylolisthesis with progressive slippage
  • articular hypermobility
  • bone demineralization
  • patient with bleeding disorders

No contraindication

  • uncomplicated degenerative joint disease
  • subacute or chronic ankylosing spondylitis
  • nonprogressive spondylolysis or spondylolisthesis
  • scoliosis
  • acute soft tissue injury

Source: Haldeman S, et al. (eds). Guidelines for Chiropractic Quality Assurance and Practice Parameters.
Gaithersburg, MD: Aspen Publishers, 1993.

**The extent to which chiropractors follow any of the guidelines mentioned in this chapter or even are aware of them is unknown and may be rather low.

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