Academy of Chiropractic’s Lawyers PI Program
From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
“Subluxation: The Proper Use in Documentation”
Pain relief is a different story because almost every patient did get pain relief with subluxation care, although it was never my goal… BUT… when I added modalities, I afforded pain relief much faster and patients could return to their normal lifestyle much faster while we continued to fix the underlying problem of vertebral subluxation. It took 2 compression fractures in my spine and laying on the floor for 3 months in agony to have a catharses (I am quite slow) that people deserve to feel better while they are getting well… but there is a price to pay.
The price is many patients start to believe that they were in my office for pain relief and prematurely terminated care once the pain abated. The pain is gone… and so are they. This was rectified though my report of findings when I strengthened my communication about “I cannot fix your problem until the pain is gone.” I was, and never will be in solely the pain business. That is what they make Advil for and I do not want to compete with analgesics. I specialize in biomechanics and prevent premature degeneration, while helping the body heal itself. As we are starting to better understand the spine-brain-organ connection, I do not need research to convince me of what I have witnessed with my own hands and eyes for over 3 decades.
Stomachs, lungs, hearts and every organ in the body is positively affected by the chiropractic adjustment. So many sick people got “miraculously well” under my care and others in chiropractic and we are just starting to see the very, very beginning of the research to verify that. Maybe in another 2-3 years we will have the scientific evidence behind all I have witnessed. However, I still needed to educate my patients that they had best be very diligent in keeping their treatment plan and getting adjusted long enough to make those biomechanical changes and the fact that their pain went away so quick verified that my recommendation for biomechanical stabilization was accurate. I then educated them during every single visit on subluxation care and most stayed under chiropractic care for lifetime evidenced by my PVA of 113.
THE PROBLEM ARISES when philosophy gets in the way of being a doctor and the DC documents that they have treated subluxation as a clinical entity. Under the objective section of the SOAP note too many of you state they you have “adjusted subluxations at C4, C5, C7, T1, T7, L4, L5.” The same holds true in the initial and re-evaluations when doctors report under the examination section “subluxations found at C4, C5, C7, T1, T7, L4, L5.”
That cannot happen at the clinical level because a chiropractic subluxation is not a clinical finding. According to Joe Flesia DC, a mentor and friend for decades until he passed away many years ago took credit for the following “opinion” that was well articulated, circulated and posted about vertebral subluxation complex and written decades ago (Len Faye DC shared with me 2 weeks ago in New York that he created this, but Joe isn’t around for that argument):
The Vertebral Subluxation Complex:
An Integrative Perspective
The Five Components
Basic to this integrative review of the components of the Vertebral Subluxation Complex is the component nomenclature involved in the model:
1. Component #1 –Spinal Kinesiopathology– spinal pathomechanics, including alignmentand motion irregularities
2. Component #2 –Neuropathophysiology/Neuropathology– compressed or facilitated nerve tissue
3. Component #3 –Myopathology– muscle spasm, muscle weakness/ atrophy
4. Component #4 –Histopathology– inflammation, edema and swelling of tissue,
usually local to the traumatized area
5. Component #5 –Pathophysiology/Pathology– pathophysiologic and pathoanatomical changesdue to the previous four components usually seen locally as degeneration, fibrous tissue and/or
erosion local and peripherally as a loss of global homeostasis.
There are many pitfalls about using the chiropractic subluxation in the wrong context. The following was published in 2011:
Reference: Reggars J. (2011) Chiropractic at the crossroads or are we just going around in circles?, Chiropractic & Manual Therapies, 19:11 (doi:10.1186/2045-709X-19-11)
Open access Link: http://www.chiromt.com/content/19/1/11
Vertebral Subluxation Complex: use and misuse
What has fuelled this diminishing market share, public distrust and numerous complaints of misconduct? The answer is the road to the VSC. However, it is not this theoretical construct itself that has created this situation and led us back to the crossroads, but rather the way it is taught, sold and promoted, to not only chiropractors but the general public.
In Australia, the "Peak Body" of the chiropractic profession, the CAA, actively promotes subluxation based chiropractic via its previously mentioned "Core Values" (Appendix 1). Based on the VSC, the CAA's "Vision Statement" envisages chiropractic as a separate and distinct alternative health system:"To achieve a fundamental paradigm shift in healthcare direction where chiropractic is recognized as the most cost efficient and effective health regime of first choice that is readily accessible to all people." In light of this "Vision Statement", it is worthwhile remembering the recommendation of the Webb Report, thirty three years ago,"The Committee recommends that chiropractic and osteopathy should not be given legal recognition in any form which would imply that they are alternative health systems."
Chiropractic trade publications and so-called educational seminar promotion material often abound with advertisements of how practitioners can effectively sell the VSC to an ignorant public. Phrases such as "double your income", "attract new patients" and "keep your patients longer in care", are common enticements for chiropractors to attend technique and practice management seminars. Selling such concepts as lifetime chiropractic care, the use contracts of care, the misuse of diagnostic equipment such as thermography and surface electromyography and the x-raying of every new patient, all contribute to our poor reputation, public distrust and official complaints.
To illustrate how the VSC dogma and ideology can be misused by some chiropractors, it is worth reviewing the case of Dr. Mark Pearson-Gills, who was disciplined by the CRBV for advocating a 60 visit, 12 month treatment plan for a 4 1/2 week old infant. The defendant later appealed the decision in the Victorian Civil and Administrative Tribunal (VCAT) and the transcript of the proceedings is on the public record. The facts of the case were that"Baby CC was approximately 4 1/2 weeks old, when her mother brought her to see Dr. Pearson-Gills, after reading an advertisement promoting the applicant's practice and offering a first session at a reduced rate of $20. Dr. Pearson-Gills explained in a clinic handout that,"The SOLE purpose of your chiropractic examination and care is to locate and correct subluxations." After examining the baby, using thermography and other means, Dr. Pearson-Gills recommended a 60-visit 12-month plan of care.
It is likely that any reasonable person presented with this scenario would find such a plan indefensible and a prima facie case of professional misconduct. However, Dr. Pearson-Gills produced expert witnesses and several of his peers to defend his actions. The defense rested not on scientific evidence but the philosophical underpinning of finding and correcting subluxations.
In summing up, the Presiding Member of the tribunal discredited the testimony of one expert witness, Dr. Matthew McCoy, from the USA:"Dr McCoy gave evidence at the request of Dr. Pearson-Gills and his solicitor and his attendance in Australia was funded by Dr Pearson-Gills. Despite his protestations that he appeared against chiropractors, the inescapable conclusion is that Dr McCoy is a partisan witness committed to defending the practices of subluxation based chiropractors against malpractice claims and registration board investigation." and ".... I will discount any evidence that Dr McCoy gave, which supported the applicant's case. I gained the impression watching him that he had flown to Australia to give evidence to VCAT as part of his job in supporting WCA (World Chiropractic Alliance) practitioners."
In my view, Smith's words of 1999 resonate today, with the same clarity:"Why do we tolerate the charlatans, hucksters, profiteers, and wild-eyed 'philosophers' who taint our profession's image, who obstruct political unity and espouse untrue science that cannot withstand the test of research; who recruit patients with gimmicks, and who mislead naive students and young practitioners with dogma and promises of great wealth? Is it because profession ethics is mostly lacking in chiropractic? Is it due to a laissez faire attitude within chiropractic where anyone can say anything under the guise of "philosophy"? Or is mainstream chiropractic simply scared to confront these fringe elements, fearful of litigation or argument? Have we become a profession ruled by a vocal minority (the Ouiji board practitioners), hellbent on keeping our profession in the past with dogma dominating over science, with leaders who espouse anti-scientific rhetoric, with practitioners who give free spinal exams and $10 office visits, all the while masquerading as "principled" chiropractors who preach unproved health gospel? Is this characterization wrong, or painfully accurate? You tell me."
For the true believer, the naive practitioner or undergraduate chiropractic student, who accepts in good faith the propaganda and pseudo-science peddled by the VSC teachers, mentors and professional organizations, the result is the same, a sense of belonging and an unshakable and unwavering faith in their ideology.
Others use the propaganda and pseudo-science as a convenient way to justify the exploitation of their patients, and diminish their social and ethical responsibilities as a registered health practitioners, and because their peers are doing the same thing, they reason that they are less accountable; "et to quoque".
I share this with you today because we have come “light years” beyond pure rhetoric and have science behind us verifying what we do. I urge you to read to articles in the US Chiropractic Directory:
Research Proves Chiropractic Adjustments Effect Multiple Areas, Not Just the Area Treated: THE BRAIN CONNECTION
Research Proves Chiropractic Adjustments Effect Emotions, Learning, Memory, Consciousness, Motivation, Homeostasis, Perception, Motor Control, Self-Awareness, Cognitive Function, Voluntary Movement, Decision Making, Touch and Pain: BRAIN CONNECTION
These are just the beginning of teaching the most recent and insightful scientific findings to date about chiropractic. In the August edition of the American Chiropractor magazine there is a fully detailed research review on explaining the spine-brain connection (as of this posting that is 2 months from now). We no longer have to speculate and philosophize about why chiropractic works, we have the evidence for pain modulation and as I shared with you initially, the adjustment-spine-brain–organ-disease connection will hopefully follow shortly.
I initially intended this to be a short 3 paragraph consultation, however this subject is far too important to not understand as many facets as possible as well as the history and pitfalls of misusing the chiropractic vertebral subluxation.
As explained by Dr.’s Flesia and Faye (yes, I now give both credit) there are multiple components of the vertebral subluxation complex and each are clinical findings. These opinions (I keep avoiding using the word research or science because his 5 components are opinions) are valuable even in the absence of hard science. They are valid guidelines for documentation purposes as they are consistent with both what is being taught in academia and the recommendations of Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS) published guidelines titled “Evaluation and Management Services Guide.” I am not suggesting that the 5 components of vertebral subluxation complex is being taught or that language is used, but what Dr.’s Flesia and Faye suggested years ago are integral parts of an accepted responsible clinical examination performed by a chiropractor.
We need to evaluate each component and based upon the clinical findings of those components, then… and only after concluding positive clinical findings for any of the components can you make the diagnosis of subluxation. THEREFORE… subluxation is not a clinical finding, it is a diagnosis.
The MEDICARE listings for Subluxation (the 739 series):
739.0 Occipital Subluxation (Nonallopathic Lesion)
739.1 Cervical Subluxation (Nonallopathic Lesion)
739.2 Thoracic Subluxation (Nonallopathic Lesion)
739.3 Lumbar Subluxation (Nonallopathic Lesion)
739.4 Sacrum or Coccyx Subluxation (Nonallopathic Lesion)
739.5 Pelvic (Ilia or SI) Subluxation (Nonallopathic Lesion)
Note: ICD refers to this as a “non-allopathic lesion” and the chiropractic profession historically has assigned subluxation to mainstream our “philosophical” conclusion. I also do not think that is a bad pathway as we are working within a system that historically has not supported our profession to convey what we do.