**PUBLIC COMMENTS---CHRISTOPHER KENT, D.C.**

Thank you for the opportunity to submit comments to the Chiropractic
Advisory Committee. I am Christopher Kent, and have been a doctor of
chiropractic for thirty years. I formerly served as an associate
professor at Palmer College of Chiropractic-West, and on the
postgraduate faculties of several chiropractic colleges. My current
responsibilities include serving as President of the Council on
Chiropractic Practice (CCP) and on the Board of Directors of the World
Chiropractic Alliance (WCA). I am also WCA's Main Representative to the
Department of Public Information, affiliated with the United Nations,
and serve as chairperson of the NGO (non-governmental organizations)
Health Committee.

My remarks are made as a private individual, and do not necessarily
reflect the official positions of any of the aforementioned
organizations.

For each of the specific issues addressed, I shall reference the page
number(s) and lines in Draft #6, dated July 2003.

**EDUCATION REQUIREMENT** (Page 4, lines 30-46; Page 4, lines 1-44.)

The Committee recommendation for the broader educational standard
incorporating lines 38 through 43 on Page 3, should be followed.

**PRIVILEGES** (Page 8, lines 19-28.)

According to the comment regarding the inclusion of surface
electromyography and thermography on the list of minimal initial
privileges, the Committee appears to have relied on an obsolete Job
Analysis conducted by the National Board of Chiropractic Examiners
regarding surface EMG, and which did not include thermography.

The 2003 study, "How Chiropractors Think and Practice^1^," by the
Institute for Social Research of Ohio Northern University, reported that
86.9% of the chiropractors surveyed considered surface electromyography
"appropriate for the chiropractic profession's scope of practice," and
88.6% indicated that thermography was "appropriate for the chiropractic
profession's scope of practice."

Council on Chiropractic Practice Clinical Practice Guideline Number 1:
Vertebral Subluxation in Chiropractic ^2^ rated both surface
electromyography and thermography (skin temperature instrumentation) as
"established" procedures. This is the highest rating given. Council on
Chiropractic Practice Clinical Practice Guideline Number 1: Vertebral
Subluxation in Chiropractic is included in the National Guideline
Clearinghouse ([http://www.ngc.gov](http://www.ngc.gov/)), sponsored by
the [Agency for Healthcare Research and Quality
(AHRQ)](http://www.ahrq.gov/), U.S. Department of Health and Human
Services, in partnership with the [American Medical
Association](http://www.ama-assn.org/) and the [American Association of
Health Plans](http://www.aahp.org/).

Surface electromyography and thermography should be on the list of
minimal initial privileges.

# ACCESS TO CHIROPRACTIC CARE (Page 9, lines 23-46; Pages 10-11, all; Page 12, lines 1 through 36.)

Direct access to chiropractic care should be made available to eligible
veterans who request it.

The Committee has correctly acknowledged that patients should
participate in making health care decisions (Page 10, lines 44-46; Page
11, lines 1-3).

It is also desirable for doctors of chiropractic to be integrated into
the VA system, and function as members of the healthcare team.

However, in addition to the problem of bias described in the report
(Page 11, lines 29-34), a more significant issue is whether a primary
care physician (or other provider) has the education, training, and
clinical skills to determine the safety and appropriateness of
chiropractic care.

A search of medical school curricula failed to disclose any US medical
school that provides training in chiropractic analysis. Similarly, such
training does not appear to be part of the residency programs completed
by primary care physicians, or other persons providing primary care.

On page 6, lines 19-20 of Draft #6, the Committee acknowledges,
"'Subluxation complex' or 'vertebral subluxation complex (VSC)' are
terms specific to chiropractic."

Furthermore, a recent study in the *Journal of Bone and Joint
Surgery^3^* concluded: \"Current medical school training in
musculoskeletal medicine is inadequate.\"

The average score of the 85 residents tested was 59.6% (73% was
considered passing); the highest score was 86%; the lowest 35%. Only 19
residents earned a passing grade; 70 (82%) \"failed to demonstrate basic
competency.\"

The authors concluded

> \"The current study clearly documents the inadequacy of medical school
> education with regard to musculoskeletal medicine. The duration of the
> residents\' preparation in this area was inadequate. For the study
> population as a whole, the mean duration of instruction in
> orthopaedics was only 2.1 weeks. In addition, 28 residents (33%) had
> graduated from medical school with no rotation, required or elective,
> in orthopedic surgery; these residents had the lowest mean score
> (55.9%) on the examination and the highest rate of failure (93%).

Given the absence of training in determining the safety and
appropriateness of chiropractic care by primary care providers,
protocols should be designed that permit direct access to chiropractic
providers.

Contrary to the suggestion of the Committee (Page 9, lines 37-39), a
primary care provider, with few exceptions, lacks the education,
training, and experience to determine indications and contraindications
to chiropractic care.

It is important to note that chiropractic adjusting procedures are not
limited to high-velocity, low-amplitude thrust (HVLA) procedures.
Reflex, low-force, and tonal techniques are also available, many of
which may be safely applied in circumstances where HVLA techniques may
be inappropriate.

Primary care physician and non-physician primary care providers are
generally not familiar with these procedures, and could become barriers
to the provision of chiropractic care.

While direct access may be at variance with the current VA model, it
could be accommodated. An eligible veteran requesting chiropractic
evaluation would be seen by a doctor of chiropractic, who would report
the findings, recommendations, and chiropractic care plan to the primary
care provider.

This would not preclude referrals from other providers; nor need it
result in isolation of the chiropractic department. Doctors of
chiropractic would still participate as team members.

# HEALTH BENEFITS OF LONG-TERM CHIROPRACTIC CARE

Those committee members who insist that there is no convincing evidence
of the value of regular chiropractic care are incorrect. While a
comprehensive review of literature is beyond the scope of this
commentary, the following examples are illustrative:

Blanks, Schuster and Dobson^4^ published the results of a retrospective
assessment of subluxation-based chiropractic care on self-related
health, wellness and quality of life. This is, to my knowledge, the
largest study of its kind ever undertaken regarding a chiropractic
population. After surveying 2,818 respondents in 156 practices, a strong
connection was found between persons receiving Network care and
self-reported improvement in health, wellness and quality-of-life. 95%
of respondents reported that their expectations had been met, and 99%
wished to continue care.

Coulter et al^5^ performed an analysis of an insurance data base,
comparing persons receiving chiropractic care with non-chiropractic
patients. The study consisted of senior citizens over 75 years of age.
It was reported that the persons receiving chiropractic care reported
better overall health, spent fewer days in hospitals and nursing homes,
used fewer prescription drugs, and were more active than the
non-chiropractic patients.

Rupert, Manello, and Sandefur^6^ surveyed 311 chiropractic patients,
aged 65 years and older, who had received \"maintenance care\" for five
years or longer. Chiropractic patients receiving maintenance care, when
compared with US citizens of the same age, spent only 31% of the
national average for health care services. There was a 50% reduction in
medical provider visits. The health habits of patients receiving
maintenance care were better overall than the general population,
including decreased use of cigarettes and decreased use of
nonprescription drugs. Furthermore, 95.8% believed the care to be either
\"considerably\" or \"extremely\" valuable.

Rupert^7^ reports that 79% of chiropractic patients have maintenance
care recommended to them, and nearly half of those comply.

Clearly, there is a growing body of evidence that wellness care provided
by doctors of chiropractic may reduce health care costs, improve health
behaviors, and improve patient perceived quality-of-life.

**EQUIPMENT** (Page 18, lines 37-45).

Because of the need to objectively demonstrate manifestations of
vertebral subluxation, it is strongly recommended that surface
electromyography and thermography be added to the list of equipment and
supplies in Appendix C. The rationale is addressed *supra* under
"Privileges."

**APPENDIX C** (Page 28, lines 21-23).

The use of passive modalities, such as electrostimulation and
ultrasound, has been shown to prolong disability in musculoskeletal
conditions. Again, a comprehensive literature is beyond the scope of
this commentary. However, the following are illustrative:

Van den Hoogen et ^a8l^ published the results of a study involving 269
patients. The objective of these investigators was to identify
prognostic indicators of the duration of low back pain in general
practice, and the occurrence of a relapse. It was concluded that
receiving physical therapy was associated with a longer duration of low
back pain.

The authors reported, \"at every moment in time, patients receiving
physical therapy had a 61% less chance to recover in the following week
than patients not receiving physical therapy.\"

*Clinical Guidelines for the Management of Acute Low Back Pain^9^,*
produced by the Royal College of General Practitioners in Great Britain,
address the appropriateness of physical agents and modalities.

The *Guidelines* state that, \"Although commonly used for symptomatic
relief, these passive modalities do not appear to have any effect on
clinical outcomes.\" The modalities listed in the *Guidelines* include
ice, heat, short wave diathermy, massage, and ultrasound.

The *AHCPR Guideline for Acute Low Back Problems in Adults^10^* concurs:
\"The use of physical agents and modalities in the treatment of acute
low back problems is of insufficiently proven benefit to justify their
cost.

\"\...Only two studies evaluated physical agents and modalities in
patients with acute low back pain. Neither found significant differences
in self-rated pain relief or other outcome measures between patient
groups receiving physical agents and modalities (including diathermy,
ultrasound, flexion/extension exercises, massage, and electrotherapy)
and groups receiving a placebo.\"

Gam and Johannsen^11^ reviewed 293 papers published since 1950 to assess
the evidence of effect of ultrasound for musculoskeletal disorders.
Serious methodological problems existed in many of the papers. However,
in 13 cases data were presented in a way that made pooling possible. The
conclusion: \"None of the methods gave evidence that pain relief could
be achieved by ultrasound treatment.\"

### It is recommended that physical modalities be provided through the physical therapy department, where they may be incorporated into a regime of patient-active therapies.

### This will avoid unnecessary expense and duplication of services. Doctors of chiropractic could refer patients for physical therapy services.

### 

### Thank you for the opportunity to provide these comments.

### 

### Sincerely,

### 

### Christopher Kent, D.C.

### 

# References

1.  McDonald WP, Durkin K, Iseman S, Pfefer M, et al: How Chiropractors

> Think and Practice. Institute for Social Research. Ohio Northern
> University. Ada, OH. 21003. Pages 17 and 58. May be purchased online
> at
> [http://www.chiropracticsurvey.com](http://www.chiropracticsurvey.com/)

2.  Council on Chiropractic Practice Clinical Practice Guideline Number
    1.

> Vertebral Subluxation in Chiropractic Practice. Chandler, AZ. 1998.
> Pages 22-23. Available without charge online at
> [http://www.ccp-guidelines.org](http://www.ccp-guidelines.org/)
>
> 3\. Freedman KB, Bernstein J. The adequacy of medical school education
> in
>
> musculoskeletal medicine. *J Bone and Joint Surg,* 80A:1421-1427. Oct.
>
> 1998
>
> 4\. Blanks RHI, Schuster TL, Dobson M: \"A retrospective assessment of
> Network care using a survey of self-reported health, wellness and
> quality of life.\" *Journal of Vertebral Subluxation Research*
> 1997;1(4):15.
>
> 5\. Coulter ID, Hurwitz EL, Aronow HU, et al: \"Chiropractic patients
> in a comprehensive home-based geriatric assessment, follow-up and
> health promotion program.\" Topics in Clinical Chiropractic
> 1996;3(2):46.
>
> 6\. Rupert RL, Manello D, Sandefur R: \"Maintenance care: health
> promotion services administered to US chiropractic patients aged 65 or
> older, Part II.\" *Journal of Manipulative and Physiological
> Therapeutics* 2000;23(1):10.
>
> 7\. Rupert RL: \"A survey of practice patterns and the health
> promotion and prevention Attitudes of US chiropractors. Maintenance
> care: Part I.\" *Journal of Manipulative and Physiological
> Therapeutics* 2000;23(1):1.
>
> 8\. van den Hoogen HJM, Koes BW, Deville W, et al: \"The prognosis of
> low back pain in general practice.\" *Spine* 1997;22(13):1515.
>
> 9\. *Clinical Guidelines for the Management of Acute Low Back Pain.*
> Royal College of General Practitioners. September, 1996. Available at
> http://www.rcgp.org.uk
>
> 10\. \"Clinical Practice Guideline Number 14.\" *Acute Low Back
> Problems in Adults.* Agency for Health Care Policy and Research.
> December 1994.
>
> 11\. Gam AN, Johannsen F: \"Ultrasound therapy in musculoskeletal
> disorders: a meta-analysis.\" *Pain* 1995;63(1):85.