Chiropractic’s Current State:
Impacts for the Future
By Robert D Mootz DC. Editor, JMPT Vol-30, Num-1.

Abstract
The chiropractic profession is currently facing a shift in practice and health care environments. This editorial reflects on the current state of the profession and suggests that the profession should move from the thinking and practice styles of the past that primarily attempted to prove patient care and practice to a more productive approach that strives to improve patient care and practice. The following primary areas that require attention are discussed: (1) evidence-based and best practices-oriented research priorities; (2) constructive engagement of the greater health care system; and (3) successful ethical business models. (J Manipulative Physiol Ther 2007;30:1-3)

More than one third of Americans report that they used alternative therapies within the previous year, with back pain and neck pain representing 2 of the top 3 reasons for doing so.¹ At first glance, this might seem rather promising for doctors of chiropractic; however, the use of chiropractic care actually may have peaked at only less than 10% of the United States population in the 1990s.² Chiropractic now appears to lead the alternative care pack for having the largest decline in use, with a full 2.5% drop in its use in recent years.³

This can be superimposed on an ever-increasing competition for health care dollars, greater interest by conventional and alternative care providers in being go-to resources for musculoskeletal disorders, substantial evolution of health care systems and infrastructure, and the chiropractic profession’s apparent comfort level with isolation from conventional and collaborative education and delivery settings. Innovative ways to select studies and perform regression for meta-analyses are even appearing to cast manipulation (and thus by association chiropractors) in a less favorable light.^4,5 Consider the American Physical Therapy Association’s vision statement for physical therapists (www.apta.org/aboutapta):

By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.

In my humble opinion, this environment is ripe for greater irrelevance if not atrophy or extinction. Meanwhile, what are our professional priorities?

Professional Debates and Priorities
It is worthwhile for chiropractors to reflect on several business-as-usual approaches and their juxtaposition with what is happening in health care to remain as meaningful contributors to health care delivery and ideally enhance our ability to constructively engage in this delivery. The role that chiropractors play in the care of patients tomorrow will be a reflection of the changes we set in motion today.

The Institute for Alternative Futures recently published a report that summarized the status of the chiropractic profession and delineated key challenges to be confronted.⁶ The report offered a best guess scenario for how the future is likely to play out (muddling along with the status quo) along with a worst case scenario (increasing competition and decreased use of chiropractic) and two best case scenarios (one along a musculoskeletal specialist direction and another along a primary/alternative care direction).

Two key observations from the report about our current state warrant comments: (1) other professions are increasingly embracing physical medicine, including the incorporation of manipulation into their care regimens, and, perhaps of greater concern, (2) the increasing effectiveness of nonmanipulative regimens. In the past, chiropractic-as-usual approaches compared better than medicine-as-usual approaches, which typically centered on poor patient selection for surgery, palliation modalities, bed rest, and riskier steroidal drugs. Recent studies imply that the improvements made in many medical and physical therapy approaches (eg, nonsteroidal drugs, early activation, and activity combined with pain control modalities) have improved outcomes and reduced length as well as cost of care; thus, recent trial and cost analyses reflect much greater similarity in outcomes between alternatives.^7,8 Although manipulation may still be a preferred approach in terms of value, the magnitude of advantages that manipulation has held appears to be diminishing in comparison with other methods.

Conventional wisdom about the science of chiropractic has revolved around demonstrating the effectiveness (ie, proving) of our interventions to confront pundits. What has been lacking is harnessing science to determine and refine best practices (ie, improving). It seems that there is a fear that if we somehow report what the science actually says, and not all of which is 100% to our advantage, then we will be banned from the field of health care. It is my belief that we will be embraced if we harness the science and use it to refine and improve what we do. The importance of the society’s comfort level with our objectivity and our ability to self-correct cannot be understated. Sure, bias has and does exist, but isolation and blind promotion of doctorcentered approaches will only reinforce it. If we choose to live in a state of denial, taking only studies whose results we like into account, we will be choosing our own irrelevance.

Dramatic changes are underway throughout the health care system, including more explicit adoption of evidencebased practice and technology assessment into care pathways, practice guidelines, coverage policy, and regulatory policy. Perhaps of even greater interest is how the focus of these approaches has evolved from the prescriptive practices of managed care into outcomes and performance-based measurement at the individual practice level. Instead of the adoption of strategies designed only to exclude actuarial outliers, the development of resources and incentives to achieve meaningful outcome goals is increasingly being tested.^9,10

How are chiropractors engaging the system as it evolves? Unfortunately, except for individual success stories (and there are many), for the most part, chiropractic institutions, such as clinics, trade associations, and academic settings, are focused on preserving the status quo (eg, practice rights, reimbursement, and wallowing in our unsolvable internal philosophical and professional identity debates). They should instead be shaping the future through research and development of successful and efficient practice niches, collaborating with conventional and alternative care settings for care strategies, and refining chiropractic best practices to improve patient outcomes.

Chiropractic’s never-ending identity debates¹¹ frequently distract us from other critical self-improvement tasks. This is not to say that introspection and vigorous discussion of what we believe are not valuable and stimulating; however, the idea that we must choose identity sides (eg, subluxation based vs musculoskeletal based) and have a worldwide consensus statement on our identity to get on with the business of doing a better job for our patients diverts attention away from other important tasks at hand. Chiropractic identity debates are summarized in Figure 1.

Condition-care orientation	vs	Wellness-care orientation
''Primary'' (whole-patient) care	vs	Spine/neuromusculoskeletal care
Conventional health care practice	vs	Complementary and alternative practice
Philosophical dualism (attenuating vitalism/beliefs against materialism/science)	vs	Philosophical monism (taking sides as only a vitalist or a materialist)
Fig 1. Debate issues regarding the identity of chiropractic.

Despite my personal viewpoint, I am certain that no amount of ranting by proponents of any particular viewpoint will convince others to abandon lifelong convictions and change their worldview. Among the planet’s chiropractors, one can find a broad range of all of these identities engaging the system, with successful practice examples for any of them. Pragmatically, however, uncomplicated spine care represents most of what the population engages doctors of chiropractic for.¹² Despite our respective practice preferences, musculoskeletal spine care for people whose spines hurt is what 90% of the public are interested in. Pontification to the contrary will not change this reality, and achieving credibility into other areas will require a generation or two of competence development. In fact, competence development and credibility attainment are still needed for our core spine care approaches.

Regardless of one’s practice or identity preference and of the fact that studies continue to show the value, benefit, or equivalency of manipulation for neck pain and back pain, most health care providers are embracing evidence-based practice and quality improvement as well as adopting an attitude of innovation and problem solving to position themselves as a resource to improve outcomes, reduce inefficiency and unnecessary care, and control costs. The aim is to improve the status quo. Altruistic reasons aside, the self-interest of remaining viable and relevant in the rapidly evolving health care system is enough motivation for others to get better at what they do.

Primary Areas of Development
The moral of the story is that resting on one’s laurels is a recipe for being eaten alive by the competition. I believe that chiropractic institutions and organizations need to develop a much greater sense of urgency in the following 3 areas:

1. Evidence-based and best practices–oriented research priorities-We need to emphasize proactive applied research that helps figure out how to help patients get better quicker and at a lower cost as compared with what we do now and to develop effective strategies to disseminate and enhance the adoption of such research by a significant proportion of practices.
2. Constructive engagement of the greater health care system-Collaboration (not necessarily integration) with a multitude of conventional health care institutions is necessary for the purpose of piloting approaches to improve patient outcomes, reduce errors and inefficiencies, promote strategic payments for best practices, and develop seamless integrated care pathways for services that we offer for condition care as well as elective care.
3. Successful ethical business models-Implementing best practices that reduce treatment dependence, foster faster results, and promote self-reliance also means fewer units of billable services for doctors. Strategic reimbursement (eg, paying more for doing less) needs better exploration and development. Partnerships with enlightened systems and payers need to be sought. Mature residency and fellowship opportunities are urgently needed in virtually any area outside of chiropractic’s perceived core nonsurgical spine care competencies if fields such as sports chiropractic, geriatric care, and pediatric care are to ever achieve sustainable credibility. Even complementary and alternative medicine as well as spine care practices could benefit from more fleshed-out economically viable practice models. Like much of health care, the traditional business model for chiropractic has been getting paid more for doing more, a perverse incentive if doing more is not directly related to a better meaningful patient outcome. Best practices can only be sustainable when they are economically viable, making this angle a critical health services research priority.

The recommendations of the Institute for Alternative Futures for the chiropractic profession include accelerating our research activity, striving for high standards of practice, engaging integration and collaboration with mainstream health care, engaging in consumer-driven health care models, achieving greater professional unity, meaningfully contributing to the public health agenda, and better preparing for niche markets such as geriatric care and alternative care.⁶ Substantive development of improvement research priorities, real residency programs, and aggressive promotion of successful ethical practice models must occur to effectively implement such recommendations.

Conclusion
There is no magic legislation, no ultimate clinical trial, no absolute research study, and no perfect guideline that will endorse the status quo to turn back reimbursement to the good old days. Neither will the supreme enlightenment of the loyal opposition on the horizon permit us the luxury of procrastination or abdication of the hard work that is needed now.

References

1. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004;1-19.
2. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280:1569-75.
3. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med 2005;11:42-9.
4. Ernst E, Canter PH. A systematic review of systematic reviews of spinal manipulation. J R Soc Med 2006;99:192-6.
5. Bronfort G, Haas M, Moher D, Bouter L, van Tulder M, Triano J, Assendelft WJ, Evans R, Dagenais S, Rosner A. Review conclusions by Ernst and Canter regarding spinal manipulation refuted. Chiropr Osteopat 2006;14:14.
6. Institute for Alternative Futures: the future of chiropractic revisited: 2005-2015. Alexandria (VA): Institute for Alternative Futures; 2005. 117 pgs.
7. UK BEAM Trial Team. United Kingdom Back Pain Exercise and Manipulation (UK BEAM) randomized trial. Effectiveness of physical treatments for back pain in primary care. BMJ 2004;329:1377.
8. UK BEAM Trial Team. United Kingdom Back Pain Exercise and Manipulation (UK BEAM) randomized trial. Cost effectiveness of physical treatments for back pain in primary care. BMJ 2004;329(7479)1381.
9. Wickizer TM, Franklin GM, Mootz RD, Fulton-Kehoe D, Plaeger-Brockway R, Drylie D, Turner JA, Smith-Weller T. A communitywide intervention to improve outcomes and reduce disability among injured workers in Washington State. Milbank Q 2004;82:547-67.
10. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Ann Intern Med 2006;145:265-72.
11. Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T. Chiropractic as spine care: a model for the profession. Chiropr Osteopat 2005;13:9.
12. Mootz RD, Cherkin DC, Odegard CE, Eisenberg DM, Barassi RA, Deyo RA. Characteristics of chiropractic practitioners, patients, and encounters in Massachusetts and Arizona. J Manipulative Physiol Ther 2005;28:645-53.

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