Dual model in chiropractic: A scope of practice issue
In countries where chiropractic is regulated by law, it is generally accepted as a profession that deals deals with musculoskeletal conditions [
1]. Therefore, chiropractors working in such jurisdictions, who also claim to prevent or treat non-musculoskeletal conditions, may break the law.
Chiropractors practice in several ways but one distinction relating to this issue is the separation between chiropractors who focus mainly on musculoskeletal disorders and those who state that they are unconcerned about patients’ presenting complaints, because they detect and remove ‘subluxations’ of the spine through chiropractic ‘adjustments’ [
2]. These subluxations, it was claimed already a century ago, may have a detrimental effect on health [
3] and their removal may, according to those beliefs, positively impact the prevention or recovery from many types of diseases, in addition to those of the musculoskeletal system [
3]. Some chiropractors still adhere to this model [
4,
5]. In this article, we shall call the first group of interest ‘musculoskeletal’ and the second group ‘conservative’. According to the Oxford dictionary, ‘conservatism’ is a commitment to traditional values and ideas with opposition to change or innovation [
6]. This term does, therefore, in this article, not refer to a political conviction, it merely describes an approach to traditional chiropractic values. Although many ‘conservatives’ claim they are not treating illnesses directly, they will by definition be accepting patients who either wish to preserve good health or receive treatment for various non-musculoskeletal disorders. It is therefore fair to state that this group of chiropractors may deal with patients with a broader scope of conditions than the musculoskeletal group.
With regard to the subluxation (also called by a variety of other labels such as ‘fixation’) has not been shown to measurably exist and to our knowledge, there is no objective method to detect it before a spinal problem arises. In addition, according to a recent systematic critical review of the chiropractic literature which reviewed some research on the topic, there is no acceptable evidence supporting the concept that chiropractic adjustments can
prevent the development of non-musculoskeletal disorders [
7]. In fact, according to this systematic review, the only two articles of acceptable standard showed that this was not possible. Similarly, another review concluded that there is no evidence in favour of the successful
treatment of non-musculoskeletal conditions using chiropractic methods [
8]. The ‘conservatives’ are therefore pretending to treat something that is not easily captured and claiming to have an effect that has not been shown to occur.
This conservative approach was commonly accepted in the early years of chiropractic but it is not officially approved in modern chiropractic education standards. However, chiropractors have traditionally had a rather generous approach to whether the ‘conservatives’ should be allowed to practice in this way by accepting ‘fuzzy’ definitions and texts in order to accommodate both approaches. It is worth noting that the Standards for the Council on Chiropractic Education-International in 2010 [
9], used a rather ‘generous’ definition of chiropractic, which reads: “The chiropractor, as a practitioner of the healing arts, […] must be well educated to diagnose, to care for the human body in health and disease and to consult with, or refer to, other health care providers when appropriate for best interest of the patient.”
However, in its latest revision, the World Federation of Chiropractic definition was used, which puts more emphasis on the musculoskeletal system by defining chiropractic as “a health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health” [
10].
Triage of patients: The understanding of contra-indications, non-indications and indications
For patients, it would likely matter if they consulted a musculoskeletal or a conservative practitioner, as these groups would manage their patients differently. Thus, we assume that these groups may not agree on non-indications for treatment. Examples of non-indications could be eczema, asthma, bedwetting, diabetes, ear infections and autism; conditions without an apparent biological rationale for chiropractic treatment but which normally would not likely worsen because of the chiropractic treatment. We postulate that chiropractors who are convinced that the subluxation model is correct are likely to assume that chiropractic treatment is inherently valuable and are therefore willing to accept patients with a multitude of disorders, on the understanding that they are entitled to do this because they are treating only the spine. The musculoskeletal practitioner, on the other hand, is less likely to accept patients with non-musculoskeletal diseases. Therefore, most types of non-musculoskeletal disorders can be classified as non-indications for chiropractic prevention or treatment by musculoskeletal practitioners. Consequently, the list of indications is likely to differ for these two types of chiropractors.
However, because of their training in differential diagnosis it is our opinion that both groups of chiropractors are likely to identify correctly contra-indications to treatment. Contra-indications can be defined as conditions that could worsen with spinal adjustments (such as severe osteoporosis or an aortic aneurysm).
Prevention aspects of the dichotomous chiropractic approach
Primary prevention is defined as prevention of a condition before it has occurred [
11]. According to a recent systematic review of the literature, chiropractors are generally interested in providing primary prevention to their patients, both in relation to non-musculoskeletal and musculoskeletal disorders. An example is advising their patients to have a healthy lifestyle [
12]. This model of care is, in our opinion, both reasonable and logical. However, there is no evidence that chiropractic adjustments per se can prevent non-musculoskeletal conditions, as in primary prevention, and there is no evidence that they can prevent future diseases [
7]. Therefore, to offer chiropractic treatment/adjustments to primarily prevent either musculoskeletal or non-musculoskeletal problems, idealistic as it may be, is based only on aspiration and personal opinion.
Secondary prevention is defined as early treatment of disease so as to prevent its continuation, and tertiary prevention is described as treatment of the chronically ill, to maintain their status at a reasonable level or to prevent further deterioration [
11]. Both secondary and tertiary prevention of back pain should be relevant to the chiropractic profession, as musculoskeletal problems often are episodic or chronic [
13]. Chiropractors have long believed this and have attempted to improve the quality of life for patients with recurring back problems, by means of so-called ‘maintenance care’. The percentage of chiropractors using this approach has been shown to vary greatly, such as between 2 and 95% of Swedish chiropractors’ patients belonging to this category [
14] and between 0 and 100% of Danish chiropractors’ patients [
15]. But a closer look at how it is used reveals that there is reasonable consensus among chiropractors that its indications are i) a certain number of previous episodes of low back pain (LBP) ii) in patients who respond well to chiropractic treatment [
15]. Not only does maintenance care in a recurring musculoskeletal disorder seem logical, but it has also been shown in a large randomized controlled multicentre clinical trial, using the above inclusion criteria that this type of patients, had a considerably better outcome if they received maintenance care than those who received care only when they felt they needed it [
16]. Thus, this type of treatment approach, so far, seems to have the best documented effect in chiropractic practice as compared to the usual treatment.
In other words, primary prevention of both musculoskeletal and non-musculoskeletal conditions through chiropractic adjustments could be considered non-indications, whereas maintenance care in patients with a history of episodic low back pain and good outcomes with chiropractic treatment would be an indication. On the other hand, maintenance care should not be offered to all patients who happen to consult a chiropractor as there is no obvious rationale for such an approach and no evidence for a general effect.
Chiropractic students and their ability to recognize contra-indications, non-indications and indications to treatment
A recent study of chiropractic students in Australia [
17] revealed that they generally found it more challenging to detect
non-indications than
contra-indicated and
indicated cases. Interestingly, studies have shown that also present-day chiropractic students may cling to the subluxation model and that this can also occur in institutions that do not adhere to that type of approach. Thus, approximately half of the students in this Australian study (from Murdoch University and Macquarie University) erroneously thought that chiropractic spinal adjustments can help the immune system or improve the health of infants. Further, approximately three quarters of students were of the opinion that chiropractic spinal adjustments can prevent degeneration of the spine and also help the body to function at 100% of its capacity [
18].
The question arises, do chiropractic students with such attitudes have a different approach to
contra-indications,
non-indications and
indications to chiropractic treatment versus those who do not have this strong confidence in the power of the chiropractic adjustment? To answer this question and obtain more information on this topic, a survey was carried out on chiropractic students in years 3 to 6 at the
Institut Franco Européen de Chiropraxie (at its two campuses in Toulouse and Paris, France)
. This is a European Council on Chiropractic Education-accredited undergraduate institution with a musculoskeletal approach, as regulated by the French Government [
19], existing in a country where chiropractic has been legally recognized since 2002 [
20].
The main goal of this cross-sectional survey on French chiropractic students was to investigate if students’ attitudes and opinions on various chiropractic concepts and their psychological profile could help explain their future clinical approach. The present report deals with chiropractic students’ ability to relate logically to the concept of triage and the potential influence that various degrees of chiropractic conservatism in relation to the subluxation model can have on this ability.
Our research questions were
1-
What is the ability of chiropractic students to determine contra-indications, non-indications, and indications to chiropractic care in relation to
b)
initial course of treatment?
2-
Do these triage abilities differ with academic year of study?
3-
Is there a link between students’ attitudes to the ‘subluxation model’ and their ability to determine contra-indications, non-indications and indications to treatment?