Chiropractic Business - What is the nature of the business

A few friends of mine sent me a great book to read by Jeff Jarvis, What would Google do. There is a chapter in the book that talks about what is the nature of your business and how most people don't know what business they are in.

Approximately 25 years ago a NYRR volunteer (non-medical) I was friendly with explained this concept to me. He worked in fleet rentals for Hertz and asked me what business is Hertz in? The obvious answer, which I said, was renting cars. He told me I was wrong. Renting cars wasn't a profitable business. The cost of advertising, reservation system, rental counters at airports, buses, lots, carrying charges on the cars and their maintenance was barely offset by the actual money received for the rentals. Thus, one can't really say that Hertz was in the car rental business.

He said that what Hertz did was the largest manufacturer and seller of used cars. That was because they sold the used car for more money than they bought the new car for but couldn't do this until it was used "enough." Those of us who rented from Hertz actually paid for the privilege of working to turn the new car into a used enough car so that Hertz could sell the used car we made back to us for a profit.

He used this as a metaphor for his belief that most companies have no idea what business they are in. This made me think about what business I, a practicing chiropractor was in.

As I said I was reminded of this by Jeff Jarvis' book WWGD. The question then is what business is a chiropractor in? Some in my profession would say that we are in the subluxation removal business. This is delusional. How many people who have never heard of chiropractic wake up and say, "gee I wish there was someone who could get rid of these darn subluxation." The obvious answer is no one. Now that could of course be because they didn't know the word. However, there isn't a vernacular term for the subluxation as is true with other medical conditions. People say that someone broke a bone, and might not know the term fracture. Or they'll know heart attack or stroke rather than myocardial infarction or cerebral infarction.

Some of my colleagues would say, but a person dying of heart disease, of cancer or diabetes or... does not know that they have these diseases until they become symptomatic. That is true. However, at this point in time my profession, chiropractic, has yet to find a valid or even reliable way to find a subluxation. Nor have we found that getting rid of them helps people or that a person with a subluxation is less healthy then a person without one.

On the other had there are valid and reliable tests for heart disease, cancers and diabetes. We also have good evidence that left untreated these diseases do kill and that with treatment patients can sometimes live much longer lives (depending on the specific disease, the stage at diagnosis).

Clearly there is good scientific evidence that spinal manipulation is a beneficial intervention. While the physical therapy profession and others have newly discovered the benefits of manipulation, after years of saying it was quackery, those benefits are found without the metaphysical aspects of the subluxation dogma some in chiropractic espouse.

Then what is a chiropractic business? Generally it is non-surgical spine care or another way to think of mainstream chiropractic is it is the non-surgical management of spinal pain disorders.

I say management because that might mean that chiropractor does all the diagnosis and treatment or it might involve an integrated approach where the doctor of chiropractic works to lead a team or be a member of a team whose goal is the improvement in a patient's spinal function.

Do chiropractors' management skills extend beyond the spine? Depending on the doctor the answer is yes. My own practice in NYC in the 1980s was mostly lower extremity conditions as most of my patients were runners. But I also treated a lot of cyclists, swimmers and triathletes so also saw a lot of upper extremity problems too. I was a sports chiropractor and thus had competency that extended beyond the spine.

Some of my peers think because I was a co-author on a paper titled: Chiropractic as spine care: a model for the profession that my co-authors and I believe that chiropractic has no place outside the spine. This is very far from the facts of our paper. We just believe that as a profession all of us need to, at minimum, be competent in non-surgical spine care and the profession needs to maintain the spine and its non-surgical care as the basic minimum competency. And come on when the public thinks of a chiropractor what do they think of? SPINE. I travel a lot and when people find out I'm a chiropractor they either grab their neck or the their back and say can you help me. No one has ever said - "oh I have a subluxation." That is despite the fact that so many chiropractors talk subluxation 24/7 even on the web.

An analogy. My family has had two occasions to consult oral surgeons. These doctors are trained as dentists. However, they do not have additional professional training at medical doctors. These dentists do not fill any cavities, or do other restorations that we ordinarily associate with dentists. Yet they are dentists. But the American Dental Association does not market dentistry as oral surgery. Still while these oral surgeons do not have training as medical doctors they do have additional training beyond what a general dentist has.

Likewise, for a chiropractor, such as myself, specializing in sports chiropractic there is the need for post-graduate training without that then the general chiropractic physician is a non-surgical spine specialist. Not a bad business to be in when over 90% of people will get back pain sometime in their life.

SMP

Foundation for Anachronistic Chiropractic Pseudo-Religion

A friend recently sent me an email from the Foundation for Vertebral Subluxation (FVS). They say that they are: "Dedicated to the Founding Principles & Tenets of the Chiropractic Profession"

This is an attempt to revise the history of chiropractic to suggest that there was stagnate set of principles the some people today are trying to change. The founder of chiropractic, D.D. Palmer changed his theory about what chiropractic was three times over the seven years he wrote about chiropractic. (1) Some outside chiropractic like to point out that D.D. wasn't an M.D. or university educated. This is absolutely true, however, the evidence is clear that D.D. was well read and up-to-date when it comes to medical knowledge of his day. (2, 3)

If D.D. could change his theory three times then why on earth would the chiropractic profession want to pick one of D.D.'s or his son's theories and etch them in stone? That is dogma that has no place in modern health care or modern chiropractic.

The Dalai Lama was once asked what Tibetan Buddhism would do if it was shown conclusively that there is no reincarnation, a central tenet of Tibetan Buddhism. His response, "Tibetan Buddhism will have to change."

Given that D.D. was "in to" the literature, (3) I am comfortable with saying I am a loyal chiropractor and will not bow to one of those four theories of chiropractic D.D. had. Today's chiropractor has the duty to follow in DD's footsteps and rethink chiropractic as the science dictates. I know that some sell to their patients that they do chiropractic as it was done in the past and actually get some people to think that practicing chiropractic as they think it was practiced 50 or 100 years ago is better than making appropriate changes when the scientific evidence suggests that there is a better way.

I'm sure expressed this way, that most people would say, "gee do I really want to go to a chiropractor whose methods are from the early 20th century?" I think not. I mean who would go to any professional and say, "please do not be up-to-date"?

The Foundation for Vertebral Subluxation wants to preserve a term, subluxation, that D.D. didn't use until after the trial of Shegatoro Morikubo for practicing medicine, surgery and osteopathy without a license in LaCrosse WI.(4) Subluxation and innate intelligence were first used by Smith et al in the first textbook on chiropractic Modernized Chiropractic .(5)

Many in chiropractic never learned the origin of the pseudo-religion or chiropractic philosophy. (6, 7, 8). It was nothing more than a legal tactic used in Morikubo's case. After Tom Morris, Morikubo's attorney got the medicine and surgery charges dropped, the tactic was to say that chiropractic and osteopathy had different philosophies and therefore Morikubo wasn't practicing osteopathy. In some ways it is unfortunate, because this was successful and then BJ etched into stone "chiropractic philosophy". (4)

The late Dr. Joe Keating wrote two articles about Morris that are available on-line
Tom Morris, Defender of Chiropractic Part I & Part II

I love the photo below. it is of BJ Palmer's rehab facility at the Palmer School of Chiropractic c1945. (BJ's signature is on each of the rugs)

What this shows is that even BJ Palmer wasn't so pure and straight as he "mixed" using rehab. The FVS wants to live today in a chiropractic past that did not actually exist. Their revised chiropractic history is a pseudo-religion that has no place in today's chiropractic beyond a class in the history of the profession. It is about as relevant to dealing with the needs of today's patient as sulfa drugs and mercury are for the medical profession.

The subluxation is dead, long live chiropractic.

SMP

1. Keating JC, Jr., D.D. Palmer's Forgotten Theories of Chiropractic
   
2. Gaucher-Peslherbe P-L. Chiropractic: Early Concepts in their historical setting. Lombard, IL: National College of Chiropractic; 1993.
3. Gaucher-Peslherbe PL, Wiese G, Donahue J. Daniel David Palmer's medical library: the founder was "into the literature.". Chiropr Hist. 1995 Dec;15(2):63-9.
4. Keating JC, Jr. B.J. of Davenport: The early years of chiropractic. Davenport, IW: Association for the History of Chiropractic; 1997.
   
5. Smith OG, Langworthy SM, Paxson MC. Modernized chiropractic. Cedar Rapids, IA: Lawrence Press Co; 1906.
   
6. Keating JC, Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. Subluxation: dogma or science? Chiropr Osteopat. 2005 Aug 10;13:17.
7. Mirtz TA. UNIVERSAL INTELLIGENCE: A Theological Entity in Conflict with Lutheran Theology. J Chiropr Humanit. 1999;9(1).
8. Mirtz TA. The question of theology for chiropractic: A theological study of chiropractic'sChiropr Humanit. 2001;10(1).
   
   
   

Surface deception - surface EMG

Although the article that stimulated this blog was published in February, I was only alerted to it by an automated Google news search, whose results that were emailed to me this week. The article is about the use of surface EMG to diagnose chiropractic subluxations. I won't go into the validity of the concept of the subluxation as I have co-authored a paper on that already, and the literature that supports or refutes our paper has not changed in any substantive way that I know of.

The article, sEMG: An overview, in my opinion, does little more than express, what I think, is a biased belief lacking any evidence that a subluxation can be demonstrated by sEMG. sEMG or surface EMG is a useful tool for certain purposes. One of those purposes doesn't happen to be diagnosis. It is really a research tool. Used to determine which muscle is active during certain movements. There are some sophisticated methods that are showing some promise in determining dysfunction that may be at the root of low back pain (1) or validating the diagnosis of low back pain. (2) but nothing I have seen suggesting that the sEMG can help find a subluxation. (3)

One fundamental problem with the use of sEMG to diagnose subluxations is that none of the methods used by my colleagues at this time involve what is called normalization. Normalization is where one converts the electricity measured during the sEMG to percent of maximum volitional movement or percent of some predetermined activity. The reason normalization is important is if one is just trying to compare the voltage from one patient to set of "normal" values inside the device one does not account for variables that change that voltage independent of muscle activity. For example, if one has an obese patient and thin one, the obese patient will have lower voltage readings on the EMG because fat is a great insulator without regard to the actual activity of the muscle. (4, 5) None of the sEMG devices that are marketed to chiropractors require normalization procedures before they produce their pretty computer graphics supposedly showing where the subluxation is.

Now most doctors of any profession lack the training that would provide them with the knowledge to evaluate the claims of the sEMG manufactures. However, if one reads the sEMG: An overview there are to simple clues to the lack of validity of these devices. The only references used are a twenty-two year old pilot study and a twenty year old book. Given the fact that approximately ten thousand papers are published weekly in the biomedical literature it is not that common that one needs to rely on such old references. Especially when professional groups both outside (6) and inside the chiropractic profession (7) have published since then noting the lack of validity of the use of these devices.(6, 7)

SMP

1. Cholewicki J, Silfies SP, Shah RA, Greene HS, Reeves NP, Alvi K, et al. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 2005 Dec 1;30(23):2614-20.
2. Geisser ME, Ranavaya M, Haig AJ, Roth RS, Zucker R, Ambroz C, et al. A meta-analytic review of surface electromyography among persons with low back pain and normal, healthy controls. J Pain. 2005 Nov;6(11):711-26.
3. Owens EF, Jr. Chiropractic subluxation assessment: what the research tells us. J Can Chiropr Assn. 2002;46(2):215-20.
   
4. Lehman GJ, McGill SM. The importance of normalization in the interpretation of surface electromyography: a proof of principle. J Manipulative Physiol Ther. 1999;22(7):444-6.
5. Ng JK, Kippers V, Parnianpour M, Richardson CA. EMG activity normalization for trunk muscles in subjects with and without back pain. Med Sci Sports Exerc. 2002 Jul;34(7):1082-6.
6. Pullman SL, Goodin DS, Marquinez AI, Tabbal S, Rubin M. Clinical utility of surface EMG: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 2000 Jul 25;55(2):171-7.
7. Position Statement of the American College of Chiropractic Consultants on sEMG 2006