To the Editor in reply
I would like to thank Drs. Blanchette and Hartvigsen for their thoughtful letter with respect to the recent paper published by my colleagues Dr. Robert Jones, Anna Pauliina Korpela, BSc and me. Drs. Blanchette and Hartvigsen raise the question that unlike dental and optical (and presumably foot) care, spine care may not have clear anatomical boundaries, and perhaps the future for primary spine care may best lie within a spine care specialist or a person with broader musculoskeletal focus. The authors further suggest that many patients with spine pain may consult a number of providers for their ‘multisite MSK conditions’, a situation that would not make the most effective use of health care funds. Additionally, they suggest that the ‘real challenge’ for chiropractors is integration within mainstream primary care as MSK health providers rather than focusing exclusively on spine care. They acknowledge that chiropractors are of course not alone “claiming the role of primary care MSK care providers” and conclude with an opinion that continued focus on research and education along with the integration within the multidisciplinary collaborative approach ‘will’ ultimately determine the fate of the profession in this arena.
First, the title of our paper is “Chiropractors as Primary Spine Care Providers”. It is not “Chiropractors as ONLY Primary Spine Care Providers”. The purpose of our manuscript was to raise the question whether a chiropractor ought to be the preferred provider of spine care. A chiropractor’s education is primarily spine-based (although of course also contains a rich education in differential diagnosis with good training in other MSK-related conditions). DCs of course treat a myriad of diverse MSK problems and at no time did we suggest anything to the contrary; rather our focus was whether the DC might be the suitable ‘go to’ clinician for spinal pain. In order to address the specific question whether the DC ought to be the Primary Spine Care Provider we contrasted the evolution of optometry and other health professions that have filled such a ‘niche’ within the provision of specific healthcare needs. I think “anatomical boundaries” have nothing to do with the provision of spine care akin to the example of dental or optical care. The question posed by Blanchette and Hartvigsen; “[whether] the future for primary spine pain care lies with a spine care specialist or with a person who has a broader musculoskeletal focus across pain sites and conditions” fails to advance the notion that the appropriately trained DC could be the preferred spine care provider…or does it? Is the suitably trained DC not qualified in all of these areas? This was precisely the point of our manuscript; a chiropractor who is scientifically trained, evidence-based, and who practices within an integrated model with other disciplines could well be the ideal provider of spine care...but not only spine care. The discussion regarding the 90.6% of chiropractors who do not limit their practice to spine care muddies the water, as does the development of the new discipline of ‘musculoskeletal health care provider’. It seems that such a discussion devolves into one of semantics.
Professional Identity: The World Federation of Chiropractic (WFC), the Canadian and Ontario Chiropractic Associations (and many others) clearly state the chiropractor should fulfill the role of the spinal pain expert. None of these associations makes identity statements regarding broader MSK issues although MSK is often included in various definitions of chiropractic and rightly so. One definition of chiropractic listed on the WFC website (American Association of Chiropractic Colleges-1996) states; “Chiropractic is a healthcare discipline that emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery. The practice of chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health. In addition, doctors of chiropractic recognize the value and responsibility of working in cooperation with other health care practitioners when in the best interest of the patient”. Clearly, this definition emphasizes the spine within the context of the practice of chiropractic.
We chose to focus our paper with respect to the clearly stated identity statements of a host of chiropractic societies, institutions and associations. In particular, at the conclusion of the June 2005 World Federation of Chiropractic’s 8th Biennial Congress held in Sydney, Australia, the WFC adopted the identity statement that DCs should become “The spinal health care experts in the health care system”. This conclusion reached 9-years ago, was the product of deliberation of over 100 delegates and observers from national associations in 36 countries, including both the ACA and the ICA and involved an “identity task force” and followed the recommendations of a 40-person WFC Task Force. Additionally, the most recent submission to the World Health Organization by the WFC (January 2013) suggests that the primary reasons for consulting a chiropractor are back pain (60%) and other MSK ailments such as neck pain (is this not also a form of spinal pain?), shoulder, extremity and “arthritic pain” (20%). Therefore, close to 80% of the reasons people consult chiropractors relate to some form of spinal (and related) complaint. Furthermore, this report discusses evidence and clinical trials, practice guidelines and Bone and Joint Taskforce reports concerning neck pain and related disorders. There is no discussion of other ‘broad’ MSK complaints. Again, and at the risk of appearing repetitive, we do not suggest that chiropractic only treat spinal complaints-but it appears that this is very much, where the profession’s emphasis appears to be. Furthermore, it is obvious that a host of MSK-related ailments are relevant to spinal pain and that DCs can and do treat such things.
(Please see attached link from the WFC website under “identity of the profession”) http://www.wfc.org/website/
However and of particular relevance to Blanchette and Hartvigsen’s letter, despite this WFC identity statement, the chiropractic profession continues to present various professional identities. For example, the Danish Chiropractic Association (DCA) web page states that the aims of the association are (amongst others): “To unite chiropractors aimed at representing and protecting the professional, financial and social interests of the chiropractic profession”. There are further statements with respect to the mandate of the DCA such as:
To establish guidelines for chiropractic business.
To determine wages and working conditions for graduates in internships.
To co-operate with other organizations and associations on issues of mutual interest.
What is missing is any specific ‘identity’ statement. On the other hand, the American Chiropractic Association states that; “Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic care is used most often to treat neuromusculoskeletal complaints, including but not limited to back pain, neck pain, and pain in the joints of the arms or legs, and headaches”.
It is plainly evident from these various identity statements and definitions that the chiropractic profession does not present a unified voice to the public, government, third party payers…or to itself; and this speaks to the central premise of our paper.
We agree that chiropractic ought to seek to achieve improved integration into the contemporary healthcare system and to this end, it is vital that the profession continue to invest in enhanced research and education: we make these points quite clearly and succinctly within our manuscript (pages 288–290). We specifically illustrate the success of the CCRF in Canada with the development of Chiropractic Research Chairs, the developing collaboration between the Canadian Memorial Chiropractic College and the University of Ontario Institute of Technology. In fact, we specifically state, “Increased collaboration, an emphasis on evidence based treatment and continued efforts to broadly expand the research base will resolve many lingering obstacles” (page 289).
As illustrated by Drs. Blanchette and Hartvigsen there are hosts of other well-trained, experienced health care providers who are quite capable at the provision of broad MSK therapy-and within this context, the chiropractor is just one more.
Within the context of our manuscript and the letter by Blanchette and Hartvigsen, perhaps the most poignant question is whether the chiropractic profession ought to be a jack-of-all-trades or master of at least one (that is by definition, connected above, down inside and out)?
