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Chiropractors gaining new respect across the U.S.

Q. My mother is super-active for a woman past 80. She insists on cutting her lawn and regularly runs errands for neighbors, who largely are shut-ins. Still, she complains of “achy legs” and plans now on seeing some local chiropractor. Is this wise? A. The day has long past when chiropractors were regarded solely as “bone crackers” and shunned as pariahs, to be held outside the bounds of scientific medicine. There are many hospitals today with chiropractors on staff. Moreover, Medicare reimburses for “spinal manipulation” therapy. In effect, this places the federal government’s approval seal on both manipulator and his or her treatment. Now, having said this, I quickly add that a conservative, even deliberate, approach to most matters of health and medicine strikes me as appropriate. For example, let’s together examine the matter of chronic pain in the back, which could in fact also cause someone to suffer “achy legs.” First, accept that more than 70 percent of American adults, at some point in their lives experience what medicine labels “significant lower-back pain.” (Aside: the first rule for treatment of back pain: the pain almost always goes away, with or without treatment.) Next, know that the rush to treatment for back pain is good business. Indeed, the current estimate for this medical care is more than $26 billion annually. Disabling back pain commonly occurs between the ages of 45 and 64, when many people are anxious to return to work to prove they’re still fit. The result: a rush to surgery, in particular the lower-lumbar spinal fusion. There were more than 150,000 such operations performed last year, and while critics of medicine acknowledge this surgery is excellent for patients with fractured spines or spinal cancers, no one is absolutely sure how effective it is for lower back pain. Yet, these fusions continue-and no one steps up to suggest we call a temporary halt, at least until we have persuasive proof. Plainly, faith in medicine runs very deep in today’s America. Now, before someone yells “Doctor hater” or insinuates a bias exists in favor of chiropractors, let me state: 1) no relatives, or close friends, practice chiropractic medicine; 2) however, a beloved son, Paul R. Lindeman, is a board-certified internist. Further, I once worked inside the House of Medicine, referring to the headquarters building of the American Medical Association (AMA) in Chicago. During these years, there was an aggressive committee whose full-time mission was to uncover failings, mishaps and errors committed by chiropractors. In my role as editor-in-chief of Today’s Health, the AMA’s consumer magazine, I understood the subject represented trouble, editorially speaking. Chiropractors were considered imposters, or “fakes.” (Aside: this was just 30 years ago.) Thus, the lessons for today: Back pain is common, it’s expensive and there oftentimes is a rush to treat it “now!” Meanwhile, medical science knows not nearly enough about the origin and/or cause of this trauma. “We know more about the surface of the moon than we do how to treat the bad back,” continues as popular wisdom. For too long, chiropractors have worked under a shadow, in a dark place where bias holds currency. At a time when all science is moving faster and faster, why not invite these professionals to the main banquet: challenge the supposed newcomers (the discovery of chiropractic dates to September, 1895) to “show us what you got!” And please publish all findings in the accepted medical literature. Consider, our compelling need to do better: the United States spends more than $4,500 per person per year on health care. Costa Rica, with half as many doctors per capita, spends just $300 per person every year. Yet life expectancy at birth is all but identical in both countries? Here then are a number of reason why we’re “sick:” an estimated 127 million Americans, of all ages, are obese or overweight, while 47 million still smoke, risking any number of cancers. Additionally, 14 million abuse alcohol, and 16 million use addictive drugs. Plainly, we need a serious, continuing national campaign promoting good health habits, so how about this for a first proposal: a cut in Medicare premiums and taxes for those older adults who demonstrate they’re avoiding the leading risks to a healthful lifestyle? In summary, they’re living right. Finally, this free advice to chiropractors: join the good health practices campaign. Tell your senior patients to exercise (nearly everyone can walk), eat smart, be sociable, volunteer, read and learn. Too few medical doctors, pressured for time, follow this common sense regimen. Bard Lindeman welcomes questions from readers. Although he cannot respond to each one individually, he will answer those of general interest in his column. Write to Bard at 5428 Oxbow Rd., Stone Mountain, GA 30087-1228; fax to 404-815-5787; or send e-mail to [email protected] Reprinted with permission of Bard Lindeman, article in the Gwinnett Daily Post. Bard Lindeman covers issues faced by seniors, including family, health, retirement, elder care and aging. He has received the American Society on Aging National Media Award.

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Self-treatment of benign paroxysmal positional vertigo

Semont maneuver vs Epley procedure ABSTRACT The authors compared the efficacy of a self-applied modified Semont maneuver (MSM) with self-treatment with a modified Epley procedure (MEP) in 70 patients with posterior canal benign paroxysmal positional vertigo. The response rate after 1 week, defined as absence of positional vertigo and torsional/upbeating nystagmus on positional testing, was 95% in the MEP group (n = 37) vs 58% in the MSM group (n = 33; p < 0.001). Treatment failure was related to incorrect performance of the maneuver in the MSM group, whereas treatment-related side effects did not differ significantly between the groups. View the procedure on videos © 2004 American Academy of Neurology NEUROLOGY 2004;63:150-152 To read the FULL TEXT click on the link below:

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Chiropractic Care: Is It Substitution Care or Add-on Care in Corporate Medical Plans?

Metz, R Douglas DC; Nelson, Craig F. DC, MS; LaBrot, Thomas DC; Pelletier, Kenneth R. PhD, MD(hc) Abstract: An analysis of claims data from a managed care health plan was performed to evaluate whether patients use chiropractic care as a substitution for medical care or in addition to medical care. Rates of neuromusculoskeletal complaints in 9e diagnostic categories were compared between groups with and without chiropractic coverage. For the 4-year study period, there were 3,129,752 insured member years in the groups with chiropractic coverage and 5,197,686 insured member years in the groups without chiropractic coverage. Expressed in terms of unique patients with neuromusculoskeletal complaints, the cohort with chiropractic coverage experienced a rate of 162.0 complaints per 1000 member years compared with 171.3 complaints in the cohort without chiropractic coverage. These results indicate that patients use chiropractic care as a direct substitution for medical care. (C)2004The American College of Occupational and Environmental Medicine Journal of Occupational & Environmental Medicine. 46(8):847-855, August 2004.

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A Randomized Clinical Trial Comparing Chiropractic Adjustments to Muscle Relaxants for Subacute Low Back Pain

ABSTRACT Background: The adult lifetime incidence for low back pain is 75% to 85% in the United States. Investigating appropriate care has proven difficult, since, in general, acute pain subsides spontaneously and chronic pain is resistant to intervention. Subacute back pain has been rarely studied. Objective: To compare the relative efficacy of chiropractic adjustments with muscle relaxants and placebo/sham for subacute low back pain. Design: A randomized, double-blind clinical trial. Methods: Subjects (N = 192) experiencing low back pain of 2 to 6 weeks' duration were randomly allocated to 3 groups with interventions applied over 2 weeks. Interventions were either chiropractic adjustments with placebo medicine, muscle relaxants with sham adjustments, or placebo medicine with sham adjustments. Visual Analog Scale for Pain, Oswestry Disability Questionnaire, and Modified Zung Depression Scale were assessed at baseline, 2 weeks, and 4 weeks. Schober's flexibility test, acetaminophen usage, and Global Impression of Severity Scale (GIS), a physician's clinical impression used as a secondary outcome, were assessed at baseline and 2 weeks. Results: Baseline values, except GIS, were similar for all groups. When all subjects completing the protocol were combined (N = 146), the data revealed pain, disability, depression, and GIS decreased significantly (P < .0001); lumbar flexibility did not change. Statistical differences across groups were seen for pain, a primary outcome, (chiropractic group improved more than control group) and GIS (chiropractic group improved more than other groups). No significant differences were seen for disability, depression, flexibility, or acetaminophen usage across groups. Conclusion: Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing GIS. Hoiriis KT, et al. Journal of Manipulative and Physiological Therapeutics. July/August 2004; Vol. 27, No. 6. Read the complete study by clicking on the JMPT Online link in the "Members' Only" section. Not a member? Than join NYSCA today to access this and other regularly updated information.

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Two Doctors of Chiropractic Join Elite Team of Olympic Health Care Providers

ARLINGTON, Va., Aug. 12 -- For the first time in the history of the Olympic Games two doctors of chiropractic will serve on the official U.S. Olympic Team medical staff, an elite group of health care providers selected by the U.S. Olympic Committee (USOC) to treat U.S. Olympiads. Drs. Marc Jaffe of Summit, N.J., and Ira Shapiro of Old Bridge, N.J., will join 44 other medical professionals serving the U.S. Olympic Team at the Summer Games in Athens, Greece. Since 1980, there has been only one doctor of chiropractic (DC) included on the medical staff of each U.S. Summer Olympic Team, and 2002 was the first year that a DC served on the U.S. Winter Olympic Team's medical staff. However, increasing athlete demand for chiropractic care has persuaded the USOC to boost the amount of available care at the 2004 Summer Games. "It is a true testament to the value of chiropractic care to be recognized by the U.S. Olympic Committee. It is with great pleasure that ACA's members have served athletes in past Olympics, and with two doctors of chiropractic on staff for this summer's games, we can be assured that our athletes have the best health care available," said American Chiropractic Association (ACA) President Donald J. Krippendorf, DC. During the games, medical staff will be available to the athletes at practice and during competition. Some of the staff will also work with athletes at the USOC's medical clinic in the Athlete's Village. "It's the athlete who realizes the benefit [of chiropractic care]. That's why we're in the Olympic movement," explained Dr. Shapiro. "We fit in perfectly with everything that goes on there." Athletes have long understood the value of chiropractic care as a means to maintain their health and improve their competitiveness. In the past, U.S. athletes sought out chiropractic care on the side because they strongly believed in its effectiveness to alleviate pain at the source and to condition their bodies for peak performance. Additionally, with increased scrutiny surrounding the use of performance-enhancing drugs, athletes are turning to safe, drug-free health care whenever possible. Athletes outside of the Olympics rely on chiropractic care, too. Both Drs. Jaffe and Shapiro have dedicated much of their professional lives to treating the nation's finest athletes. Dr. Jaffe has served as an attending chiropractor for events such as the U.S. Track and Field Championships, the U.S. Weightlifting Championships, the U.S. Triathlon Championships and the New York City Marathon. Furthermore, he is a consultant to the Rutgers University football team and is listed as a treating chiropractor in a manual distributed by the NFL to players for the New York Giants and New York Jets. Dr. Shapiro has an equally illustrious list of credentials that include service as an attending physician at the Gatorade Ironman Triathlon World Championship, the U.S. Figure Skating Championships and the World Championship of Freestyle Wrestling. However, previous experience does not ensure a berth on the U.S. Olympic medical staff. Both doctors were required to complete a rigorous evaluation of their clinical skills and of their abilities to work as a team with Olympic athletes and other medical staff. With the growing popularity of complementary and alternative medicine, chiropractic care has become increasingly integrated with other, more traditional medical treatments. The USOC medical team uses a similar approach by creating a group of providers who work cooperatively to maximize the athletes' health and well-being. "We have a tremendous collaborative working relationship with the other health care professionals," observed Dr. Shapiro -- who adds that there is a saying that the chiropractor is the busiest person around at USOC medical facilities. Chiropractic has been practiced in the United States for more than 100 years, and each year, millions of Americans trust their health to one of the nation's 60,000 doctors of chiropractic. To read research studies about the effectiveness of chiropractic care, visit ACA's website at:

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HUDEC BECOMES FIRST DOCTOR OF CHIROPRACTIC EVER TO GRADUATE FROM MILITARY RESIDENCY PROGRAM

Arlington, VA – For the first time in history, a doctor of chiropractic graduated from a military hospital residency program -- when Joanna Hudec, DC, completed a fellowship in integrative medicine at the National Naval Medical Center (NNMC) in Bethesda, MD on June 18, 2004. Hudec’s history-making graduation is seen by many as one of the clearest signs to date that the chiropractic profession works well with the medical community. Known as “the President’s hospital” because it is the site at which sitting U.S. presidents and other dignitaries receive care, NNMC is considered the “flagship of naval medicine.” The hospital also is the National Capital Region Resource for homeland defense. Most importantly, NNMC keeps the uniformed services mission ready and provides care to their families. “For chiropractic care to be integrated into a program within the most hallowed halls of medicine is an unparalleled step for this profession,” said American Chiropractic Association (ACA) President Donald J. Krippendorf, DC. “The ACA sincerely thanks Dr. Hudec for the shining example she has set for chiropractic.” U.S. Surgeon General Dr. Richard Carmona not only attended the graduation ceremony -- which included about 355 medical interns, residents and fellows -- but also congratulated Dr. Hudec for her efforts and thanked NNMC attending physician William Morgan, DC for the time he spent as the program director of this residency. Additionally, the commanding officers of both NNMC and Walter Reed Army Medical Center thanked Dr. Hudec for her outstanding work. At a dinner following the ceremony, Texas Chiropractic College (TCC) President Richard Brassard, DC, presented Dr. Hudec with a diploma certifying her completion of TCC’s Postdoctoral Fellowship in Integrative Medicine. Dr. Hudec began her 12-month fellowship at NNMC in April of 2003. Recognizing the need for doctors of chiropractic to be trained to work in an integrative hospital environment, TCC Director of Research James Giordano, PhD, and Dr. Morgan envisioned and then implemented the fellowship program, which is expected to become an ongoing, annual program. Dr. Hudec, an ACA member, called the founding of the fellowship program “just the beginning of the advancement of chiropractic into the military.” “In establishing this fellowship program, Texas Chiropractic College has made a very real contribution to our profession’s ongoing efforts toward integration into both the military health care system and our nation’s hospital system,” said Dr. Krippendorf. During her fellowship program, Dr. Hudec established a chiropractic clinic for the medical students at the Uniformed Services University of the Health Sciences (USUHS), also located in Bethesda, MD. That clinic is believed to be the only chiropractic clinic ever established within a medical school. A major goal of the military hospital chiropractic fellowship program is to provide a qualified pool of doctors of chiropractic to serve the needs of civilian, Department of Veterans Affairs (DVA) and Department of Defense (DOD) hospital-based chiropractic clinics.

An investigation into the validity of cervical spine motion palpation using subjects with congenital block vertebrae as a 'gold standard'

Abstract Background: Although the effectiveness of manipulative therapy for treating back and neck pain has been demonstrated, the validity of many of the procedures used to detect joint dysfunction has not been confirmed. Practitioners of manual medicine frequently employ motion palpation as a diagnostic tool, despite conflicting evidence regarding its utility and reliability. The introduction of various spinal models with artificially introduced 'fixations' as an attempt to introduce a 'gold standard' has met with frustration and frequent mechanical failure. Because direct comparison against a 'gold standard' allows the validity, specificity and sensitivity of a test to be calculated, the identification of a realistic 'gold standard' against which motion palpation can be evaluated is essential. The objective of this study was to introduce a new, realistic, 'gold standard', the congenital block vertebra (CBV) to assess the validity of motion palpation in detecting a true fixation. Methods: Twenty fourth year chiropractic students examined the cervical spines of three subjects with single level congenital block vertebrae, using two commonly employed motion palpation tests. The examiners, who were blinded to the presence of congenital block vertebrae, were asked to identify the most hypomobile segment(s). The congenital block segments included two subjects with fusion at the C2– 3 level and one with fusion at C5-6. Exclusion criteria included subjects who were frankly symptomatic, had moderate or severe degenerative changes in their cervical spines, or displayed signs of cervical instability. Spinal levels were marked on the subject's skin overlying the facet joints from C1 to C7 bilaterally and the motion segments were then marked alphabetically with 'A' corresponding to C1-2. Kappa coefficients (K) were calculated to determine the validity of motion palpation to detect the congenitally fused segments as the 'most hypomobile' segments. Sensitivity and specificity of the diagnostic procedure were also calculated. Results: Kappa coefficients (K) showed substantial overall agreement for identification of the segment of greatest hypomobility (K = 0.65), with substantial (K = 0.76) and moderate (K = 0.46) agreement for hypomobility at C2-3 and C5-6 respectively. Sensitivity ranged from 55% at the C5-6 CBV to 78% at the C2-3 level. Specificity of the procedure was high (91 – 98%). Conclusion: This study indicates that relatively inexperienced examiners are capable of correctly identifying inter-segmental fixations (CBV) in the cervical spine using 2 commonly employed motion palpation tests. The use of a 'gold standard' (CBV) in this study and the substantial agreement achieved lends support to the validity of motion palpation in detecting major spinal fixations in the cervical spine. BMC Musculoskeletal Disorders 2004, 5:19 - Published: 15 June 2004

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Clinical and Cost Outcomes of an Integrative Medicine IPA

ABSTRACT Objective: We hypothesized that primary care physicians (PCPs) specializing in a nonpharmaceutical/nonsurgical approach as their primary modality and utilizing a variety of complementary/alternative medicine (CAM) techniques integrated with allopathic medicine would have superior clinical and cost outcomes compared with PCPs utilizing conventional medicine alone. Design: Incurred claims and stratified randomized patient surveys were analyzed for clinical outcomes, cost offsets, and member satisfaction compared with normative values. Comparative blinded data, using nonrandomized matched comparison groups, was analyzed for age/sex demographics and disease profiles to examine sample bias. Setting: An integrative medicine independent provider association (IPA) contracted with a National Committee for Quality Assurance (NCQA)-accredited health maintenance organization (HMO) in metropolitan Chicago. Subjects: All members enrolled with the integrative medicine IPA from January 1, 1999 through December 31, 2002. Results: Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions per 1000, 58.4% hospital days per 1000, 43.2% outpatient surgeries and procedures per 1000, and 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame. Conclusion: In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone. While certainly promising, these initial results may not be consistent on a larger and more diverse population. Sarnat RL, Winterstein J. Journal of Manipulative and Physiological Therapeutics. June 2004; Vol. 27, No. 5.

VA to Begin Chiropractic Care

WASHINGTON -- Veterans can receive chiropractic care at 26 selected Department of Veterans Affairs (VA) facilities beginning this fall, Secretary of Veterans Affairs Anthony J. Principi announced today. VA will hire or contract with doctors of chiropractic to provide the care. In consultation with VA primary care providers, doctors of chiropractic will offer patient evaluations and chiropractic care for neuromusculoskeletal conditions. "Today, VA makes another significant improvement to the world-class health care we provide for eligible veterans," said Principi. "Veterans who will benefit from chiropractic services will now have the opportunity to receive chiropractic care to restore them to good health." Locations where chiropractic care will be provided include Togus, Maine; West Haven and Newington, Conn.; Buffalo and the Bronx, N.Y.; Butler, Pa.; Martinsburg, W.Va.; Columbia, S.C.; Augusta, Ga.; Tampa and Miami, Fla.; Mountain Home, Tenn.; Columbus, Ohio; Danville, Ill.; Iron Mountain, Mich.; Kansas City, Kan.; Jackson, Miss.; San Antonio, Temple, and Dallas, Texas; Albuquerque, N.M.; Fort Harrison, Mont.; Seattle, Wash.; Sacramento and Los Angeles, Calif.; and Sioux Falls, S.D. Eligible veterans in areas distant from these locations will also be able to receive chiropractic care through VA's outpatient fee-basis program after a referral by their primary care provider, and prior authorization by the department. VA was authorized to offer chiropractic care and services under the provisions of section 204 of Public Law 107-135, the Department of Veterans Affairs Health Care Programs Enhancement Act of 2001. Chiropractors seeking employment or to provide contract services to veterans should call the Human Resources office of any of the above facilities. Some VA positions may be advertised at:

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NEW BILL WOULD GIVE VETERANS DIRECT ACCESS TO DOCTORS OF CHIROPRACTIC

ARLINGTON, VA -- The American Chiropractic Association (ACA) today applauded Congressman Bob Filner (D-CA) for introducing legislation to provide veterans with direct access to a doctor of chiropractic through the Department of Veterans Affairs (DVA) health care system. The ACA, the nation's largest chiropractic organization, worked closely with Congressman Filner on the direct access bill now before Congress and on other ongoing efforts to ensure unimpeded access to chiropractic care. In the past, segments of the federal bureaucracy have been reluctant to implement directives from Congress regarding chiropractic care. This new bill (HR 4051) seeks to send a message to opponents of chiropractic - inside and outside of the government - that America's veterans will not be denied the chiropractic care they need and deserve. "Congressman Filner is a powerful and effective leader on health care issues and a well-known fighter for America's veterans," said ACA President and U.S. Navy veteran Donald J. Krippendorf, DC. "He has shown time and again that he is committed to protecting the rights of doctors of chiropractic and chiropractic patients. Introduction in the U.S. House of Representatives of the "Better Access to Chiropractors to Keep our Veterans Healthy Act" by Congressman Filner is a strong statement of support for chiropractic care and its positive benefits for veterans and other patients." The Filner bill (HR 4051) seeks to amend Title 38 of the United States Code to permit eligible veterans to receive direct access to chiropractic care at Department of Veterans Affairs hospitals and clinics. Section 3 of HR 4051 states that "The Secretary [of Veterans Affairs] shall permit eligible veterans to receive needed [health care] services, rehabilitative services, and preventative health services from a licensed doctor of chiropractic on a direct access basis at the election of the eligible veteran, if such services are within the state scope of practice of such doctor of chiropractic." The measure goes on to directly prohibit discrimination among licensed health care providers by the DVA when determining which services a patient needs. Congressman Filner is a senior member of the Committee on Veterans Affairs. He represents California's 51st Congressional District, including Imperial County and a portion of San Diego County and the communities of Bonita, Brawley, Calexico, Calipatria, Chula Vista, El Centro, Heber, Holtville, Imperial, La Presa, National City, San Diego, Seeley and Westmoreland. In 2004, the ACA presented Congressman Filner with its Veterans Health Care Leadership Award.

DVA SECRETARY PRINCIPI GREEN-LIGHTS CHIROPRACTIC CARE FOR AMERICA’S VETERANS

Washington, DC - The American Chiropractic Association (ACA) and the Association of Chiropractic Colleges (ACC) commended Department of Veterans Affairs (DVA) Secretary Anthony Principi for issuing an historic and far-reaching blueprint for formalizing the full inclusion of chiropractic care into the massive veterans health care system in the United States. Secretary Principi’s decision today to implement more than three dozen recommendations made by a multi-disciplinary health care advisory panel will dramatically improve the quality of care available to millions of veterans in the U.S. and increase access to chiropractic care for every veteran who wants or needs to see a doctor of chiropractic. The Secretary’s bold action originated with legislative directives from Congress in 2002 and 2003 - passed at the urging of the ACA, the ACC and America’s veterans - to establish a permanent chiropractic benefit through the DVA system and authorize the DVA to hire and employ doctors of chiropractic as care providers. “This is a great victory for veterans and an historic new opportunity for doctors of chiropractic across America,” said ACA President and U.S. Navy veteran Donald Krippendorf, DC. “Secretary Principi always makes certain that veterans come first. He’s done so today by acting decisively to bring chiropractic care into veterans hospitals from coast-to-coast and to make doctors of chiropractic full partners in providing care to all those who answered our country’s call to serve.” Since the creation of the DVA health system, the nation’s doctors of chiropractic (DCs) have been kept outside the system and all but prevented from providing proven, cost-effective and much-needed care to veterans, including those among the most vulnerable and in need of the range of the health care services DCs are licensed to provide. In 2002, 4.5 million patients received care in DVA health facilities, including 75% of all disabled and low-income veterans. Although the DVA health care budget is roughly $26 billion, in 2002, less than $370,000 went toward chiropractic services for veterans. In issuing today’s order to his department to begin inclusion of chiropractic care, Secretary Principi specifically acknowledged that the goal is “to ensure that chiropractic care is ultimately available and accessible to veterans who need it throughout the DVA system.” Several key elements of Secretary Principi’s blueprint were strongly supported by the ACA and the ACC, including: · DVA’s endorsement of the integration of full-scope chiropractic care (under applicable state law) into all missions of the DVA health care system, including patient care, education, research and response to disasters and national emergencies, and DVA facilities across the country. · DVA’s endorsement of a successful and patient-friendly model - essentially based on the operations of Bethesda National Naval Medical Center - of full integration of doctors of chiropractic as partners in health care teams. · Inclusion of chiropractic care into the VA's funding of research into treatment of service-connected conditions. · Inclusion of chiropractic colleges and students in training programs at VA facilities. · Establishment of a goal to ensure continuity of chiropractic care for newly discharged veterans who have been receiving chiropractic care through the Defense Department health care system. Jean Moss, DC, President of the ACC, commended Principi’s decision to integrate chiropractic care into the DVA health system, saying, “The administration, faculty and students of chiropractic colleges across America are delighted that Secretary Principi has taken steps to ensure that DCs can now directly contribute to the health and well-being of veterans. I am pleased, too, that chiropractic college students will become eligible to participate in internship programs at DVA hospitals and that a fair share of federal research funding will be directed to further documenting the efficacy and cost-effectiveness of chiropractic care.” Dr. Krippendorf added, “The ACA is a membership organization that is comprised of thousands of hard-working health professionals who are pillars of their communities in all 50 states. Our advocacy for full inclusion of chiropractic care in the DVA system is part of our broader campaign to ensure that DCs and their patients are treated fairly in all of the Federal government’s health care programs and initiatives. We’ve made great progress across the board, but the fight for fairness continues and the ACA is ever vigilant.” In addition to legislation authorizing the DVA to employ chiropractors (Public Law 108-170), ACA-backed bills to test expanded access to chiropractic services under Medicare (Public Law 108-173) and to accelerate the implementation of chiropractic care in the military (Public Law 108-136) were also signed into law by President Bush in 2003. In 2004, the ACA will make it a priority to ensure that Secretary Principi’s recommendations are speedily implemented, and work with Congress on new legislation to ensure that chiropractic patients are never wrongly denied access to care. There are about 60,000 DCs in the U.S. and an estimated 25 million chiropractic patients. “Today’s historic action involved the hard work and determined efforts of several members of the DVA’s Chiropractic Advisory Committee, including Drs. Reed Phillips, Cynthia Vaughn and Rick McMichael,” said ACA Chairman and Army veteran George McClelland, DC. “These outstanding leaders have helped improve America’s veterans health care system, eliminated discriminatory practices against their fellow DCs and won meaningful protections for a most deserving group of chiropractic patients.”

Six Leading Presidential Candidates Endorse Chiropractic

ARLINGTON, Va -- With just one week remaining before the beginning of the Iowa caucuses, the American Chiropractic Association (ACA) has secured official statements on chiropractic care from each of the six leading Democratic presidential candidates. ACA secured these statements through close cooperative efforts with the Iowa Chiropractic Society and politically active doctors of chiropractic across the country. "Though they may often disagree on other issues, the leading presidential candidates for the Democratic presidential nomination appear to completely agree on the value and benefits of chiropractic care," said ACA President Donald Krippendorf, DC. "The ACA is encouraged by this enthusiastic support and more determined than ever to ensure that it is maintained by our elected leaders long after Election Day." Governor Howard Dean, Congressman Dick Gephardt, Senator John Kerry, Senator John Edwards, General Wesley Clark and Senator Joe Lieberman round out the list of candidates who have submitted statements. To view these statements, visit: http://www.acatoday.com/government/other/candidates_endorse.shtml The ACA, the largest national organization representing doctors of chiropractic, has taken an active role in the months leading up to the January 19, 2004 Iowa precinct caucuses in evaluating the health care policy positions of each of the announced presidential contenders. This effort has included meetings with major candidates and senior campaign officials, and the use of ACA's specially designed issues questionnaire. "The candidates are recognizing the political clout of Iowa's chiropractic constituency," said F. Dow Bates, DC, ACA Iowa Delegate. "The numbers speak for themselves. Iowa is home to thousands of doctors of chiropractic and chiropractic assistants, tens of thousands of chiropractic patients and the largest chiropractic college in the world. The road to victory in the Iowa caucuses goes straight through the offices of the state's doctors of chiropractic." Providing additional outreach were Keith Overland, DC, ACA Connecticut delegate, who serves as a health care policy adviser to the Lieberman campaign, and Dan Redwood, DC, of Virginia, who helped secure General Clark's statement. Source: American Chiropractic Association

Advisory panel nixes VA patient self-referral to chiropractors

Chiropractic care at the Dept. of Veterans Affairs could expand dramatically, if the final recommendations of the VA chiropractic advisory committee are followed. "Any provider of care in the VA would be able to refer a patient for chiropractic services," said Warren Jones, MD, a member of the advisory committee and immediate past president of the American Academy of Family Physicians. This would mean that nurse practitioners and rehabilitation therapists could be making referrals as well as orthopedic surgeons and primary care physicians.

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Study debunking the long- held belief firm mattresses are beneficial for low-back pain

A new study debunking the long- held belief by many that firm mattresses are beneficial for low-back pain should prompt some consumers to re-think their choices in mattresses, according to the American Chiropractic Association (ACA). A study published in the November 15 issue of The Lancet found that people who slept on mattresses of medium firmness were twice as likely to report improvement in low-back pain symptoms than those who slept on firm mattresses. Doctors of chiropractic have long counseled patients that "comfortably supportive" mattresses are superior to very firm "table board" mattresses, said George McClelland, DC, chairman of the board of the American Chiropractic Association. "A medium-firm mattress will more readily adapt to the natural curvatures in a person's spine," he explained. Dr. McClelland and the ACA recommend the following tips for choosing mattresses: If you're not in the market for a new mattress, and your current mattress is too firm, you can soften it up by putting a 1- to 2-inch-thick padding on top of it -- usually available at mattress and bedding stores. A mattress should provide uniform support from head to toe. If there are gaps between your body and your mattress (such as at the waist), you're not getting the full support that you need. Every few months, turn your mattress clockwise, or upside down, so that body indentations are kept to a minimum. It's also good to rotate the mattress frame every so often to reduce wear and tear. If you're waking up uncomfortable, it might be time for a new mattress. There is no standard life span for a mattress; it all depends on the kind of usage it gets. Be aware that changes in your life can signal the need for a new mattress. For example, if you've lost or gained a lot of weight, if a medical condition has changed the way you sleep, or even if you have changed partners, it could mean that it's time to find a new mattress that will accommodate those changes and help you sleep more soundly. When you're purchasing a mattress, don't be embarrassed to actually lie down on it at the store to check its fit and comfort. Don't just sit on it to test it.

Chiropractic Can Help Reduce the Toll of Pain and Prescription Drugs on Nation's Health Care System, Says ACA

New studies showing the staggering costs of headaches, back pain and other musculoskeletal conditions on the country's economy and the skyrocketing effect prescription drugs have on insurance premiums should convince the nation's employers and insurers to more fully integrate chiropractic care into employee health plans, according to the American Chiropractic Association (ACA). A November 12 study in the Journal of the American Medical Association found that headaches and back pain are leading reasons for lost productivity and absenteeism in the workforce -- costing more than $61 billion each year. And the 2003 Annual Employer Health Benefits Survey, conducted by the Kaiser Family Foundation and Health Research and Educational Trust, found that higher prescription drug costs are a major factor contributing to increases in health insurance premiums. "Over the years, studies have shown that chiropractic care is effective at treating headaches and back pain and can get workers back on the job more quickly than traditional forms of care," said ACA President Donald J. Krippendorf, DC. "At the same time, chiropractic also helps workers avoid expensive prescription drugs -- making it a perfect fit for employers looking to control health care costs." Back pain and headaches, in particular, are two conditions that doctors of chiropractic have successfully treated for decades -- and several studies have demonstrated chiropractic's effectiveness. Most recently, a study published in the July 15, 2003 issue of the medical journal Spine found that manual manipulation -- the primary form of treatment performed by doctors of chiropractic -- provides better short-term relief of chronic back pain than medication. In 2001, researchers at Duke University found cervical -- or neck -- manipulation appropriate for both tension type headache and cervicogenic headache and noted that "cervical spinal manipulation has a very low risk of serious complications" which may be "one of its appeals over drug treatment." Just a sampling of other studies include: A 1997 study published in Spine found "strong evidence that manipulation is more effective than a placebo treatment for chronic low-back pain or than usual care by the general practitioner, bed rest, analgesics and massage." A 1996 study published in the journal Medical Care found that first contact chiropractic care for common low back conditions costs substantially less than traditional medical treatment and "deserves careful consideration" by managed care executives concerned with controlling health care spending. In 1994, the U.S. Agency for Health Care Policy and Research found that "spinal manipulation is effective in reducing pain and perhaps speeding recovery" within the first month of acute low-back pain symptoms. A 1993 study conducted in Canada and funded by the Ontario Ministry of Health found that "the overwhelming body of evidence" shows that chiropractic management of low-back pain is more cost-effective than medical management, and that "many medical therapies are of questionable validity or are clearly inadequate." For more information on chiropractic care and research on its effectiveness, visit ACA's Web site at www.acatoday.com. The ACA, based in Arlington, VA, is the largest chiropractic organization in the country. The ACA promotes the highest standards of ethics and patient care, contributing to the health and well being of millions of chiropractic patients.

Legislation to Establish Chiropractic Care Parity for Military Retirees, Dependents and Survivors through TRICARE

Attached is a copy of a Congressional "Dear Colleague" letter from Rep. Ed Schrock (R-VA) and Rep. Lane Evans (D-IL) being circulated in today's afternoon mail on Capitol Hill. It asks Members of the U.S. House of Representatives to join as original co-sponsors of an ACA-backed legislative proposal to extend chiropractic health parity to U.S. military retirees, dependents and survivors through the TRICARE program. In recent years, Congress has passed, and the President has signed into law, legislation establishing a permanent chiropractic care benefit for both active duty military personnel and veterans. The Schrock-Evans Chiropractic Parity in TRICARE Bill represents the next step toward ensuring that all of America’s current and former military service personnel, and their families, have access to the chiropractic services they need and deserve. ACA and the Association of Chiropractic Colleges have been involved in discussions concerning this issue since earlier this year and have committed to working closely with Reps. Schrock and Evans to build strong support for the legislation among pro-chiropractic Members of Congress. Accordingly, ACA urges all concerned DCs, CAs, chiropractic students and patients and friends of the chiropractic profession to immediately contact their representatives in the U.S. House to request that they join as original co-sponsors of the soon-to-be-introduced Schrock-Evans Chiropractic Parity in TRICARE Bill. As a chiropractic supporter, it is essential that you take immediate action on this matter by calling your Congressman or Congresswoman at his/her local office or through the U.S. Capitol switchboard at (202) 225-3121. Please urge co-sponsorship of the Schrock-Evans Chiropractic Parity in TRICARE Bill.

ACC STATEMENT ON DIAGNOSIS ENDORSED BY ACA's HOD

At its annual meeting, the ACA House of Delegates passed the following resolution endorsing the Association of Chiropractic College's clarification of the ACC paradigm related to diagnosis as follows: "A diagnosis is an expert opinion identifying the nature and cause of a patient's concern or complaint, and/or abnormal finding(s). It is essential to the ongoing process of reasoning used by the doctor of chiropractic in cooperation with the patient to direct, manage, and optimize the patient's health and well-being. "The process of arriving at a diagnosis by a doctor of chiropractic includes: obtaining pertinent patient history; conducting physical, neurological, orthopedic, and other appropriate examination procedures; ordering and interpreting specialized diagnostic imaging and/or laboratory tests as indicated by symptoms and/or clinical findings; and performing postural and functional biomechanical analysis to determine the presence of articular dysfunction and/or subluxation. "The Association of Chiropractic Colleges continues to foster a unique, distinct chiropractic profession that generates, develops, and utilizes the highest level of evidence possible in the provision of effective, prudent, and cost-conscious patient evaluation and care." (Note: This does not replace the current definition of diagnosis as found in the ACA Master Plan and other policy statements of the ACA. Motion Carried.)

MCH Offering Chiropractic

At a luncheon in late July at Monroe Community Hospital, Paul Dougherty took a seat at the table with a group of doctors. The symbolism wasn’t lost on anyone. A chiropractor by trade, Dougherty would have been viewed as a quack by this crowd just 20 years ago, but now he’s helping to blaze a trail that is pushing chiropractic medicine into the mainstream. Dougherty heads a newly created chiropractic clinic at Monroe Community Hospital that is believed to be the first of its kind in the country, one that offers chiropractic therapy in the setting of a long-term care institution. Here at the county’s largest nursing home, Dougherty works side by side with doctors to relieve the back and neck pain of elderly residents with chronic illnesses. When pain medications don’t do the job, Dougherty goes to work stretching and cracking the spinal columns of residents like 52-year-old Pat Gribb, who suffers from multiple sclerosis and spends all day in a wheelchair. “ It’s not a comfortable position to be in,” said Gribb, whose back pain was relieved last month when Dougherty stretched her back to unlock several compressed vertebrae. “ I immediately felt the difference.” As late as 1983, the American Medical Association considered it unethical for doctors to refer patients to chiropractors. Today, though, those guidelines encourage chiropractic treatment when doctors think it is in the best interest of their patients. About 500 hospitals in the U.S. now have chiropractors on their staffs, according to the American Chiropractic Association in Arlington, Va. “ That sounds like a pretty good number, but when you consider that there are 6,000 hospitals in the country, we still have a long way to go,” said Jerome F. McAndrews, spokesman for the group. McAndrews said he is not aware of another experiment like the one at Monroe Community Hospital: a chiropractic clinic within the halls of a nursing home. The clinic, jointly operated by the New York Chiropractic College in Seneca Falls, also is a teaching site for students and offers outpatient services. “ We’re not trying to be physicians. That’s not what we do,” said Dougherty, an associate professor at the college. “ But we do think that we have a role to play in pain management.” The clinic began as a demonstration project last year, treating 48 elderly residents with back pain, headaches, neck pains and shoulder stiffness. Monroe Community Hospital officials liked the way that these patients responded to the chiropractic treatments, so they decided to open it to the rest of the resident population. The treatment is not considered appropriate, though, for extremely frail patients. “ The goal is to reduce pain, and however you do it, I don’t care as long as it’s safe and effective,” said Dr. Paul Katz, medical director at Monroe Community Hospital. “ I admit it that when I was in medical school in the ‘70s, chiropractic had a very negative connotation to it,” Katz said. “ But there’s a lot more science behind what they do now, and it’s really given me a greater appreciation for their role.” Chiropractic medicine involves manipulating joints and muscles to improve their function. It is not known why this causes pain to subside, but it may have to do with a relaxing effect on the central nervous system, Dougherty said. Dougherty is the first to argue that more scientific research is needed. In fact, he and Monroe Community Hospital officials have applied for a $750,000 grant from the U.S. Department of Health and Human Services to conduct a three-year study on how elderly patients react to chiropractic therapy. If approved — the government’s decision is due in late August — Monroe Community Hospital will have two study groups: those who get traditional medical treatments for back pain (steroid injections, pain medications), vs. those who get medical treatment plus chiropractic. Outcomes will be measured by using a standard of patient satisfaction and cost effectiveness. “ I think there’s a future in integrating chiropractic with traditional medicine, and it’s exciting to be on the front-end of it,” Dougherty said. Courtesy of The Democrat and Chronicle

MANUAL THERAPY IS EFFECTIVE TREATMENT FOR NECK PAIN

Manual therapy is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner, claim researchers in this week's BMJ. The study involved 183 patients recruited by 42 general practitioners in the Netherlands. All patients were aged 18-70 years and had suffered neck pain for at least two weeks. Sixty patients received manual therapy (spinal mobilisation), 59 received physiotherapy (mainly exercise), and 64 received standard care from a general practitioner (counselling, education, and drugs). After 26 weeks, patients in the manual therapy group recovered more quickly than the physiotherapy group and the general practitioner care group, but differences were negligible by 52 weeks. The total costs of manual therapy were around one third of the costs in the other two groups. "Our findings showed manual therapy to be more cost effective than physiotherapy and continued care provided by a general practitioner in the treatment of non-specific neck pain," conclude the authors.

Source

Update of the VA Chiropractic Advisory Committee

DEPARTMENT OF VETERANS AFFAIRS RECOMMENDATIONS OF THE CHIROPRACTIC ADVISORY COMMITTEE Draft #6 July 2003 INTRODUCTION: Public Law 107-135, Section 204 established the Department of Veterans Affairs (VA) Chiropractic Advisory Committee “to provide direct assistance and advice to the Secretary in the development and implementation of the chiropractic health program” within Veterans Health Administration (VHA). The Committee is charged to advise the Secretary on protocols governing referrals to doctors of chiropractic, protocols governing direct access to chiropractic care, protocols governing scope of practice of chiropractic practitioners, and definitions of service to be provided, as well as to provide advice in the development and implementation of the chiropractic health program. Secretary Principi appointed Committee members in August 2002. The Committee has met ___ times to discuss the specific charges to the Committee. The Committee also has extensively discussed how chiropractic care can effectively be integrated into the existing VA healthcare system, and this document includes recommendations regarding implementation of the chiropractic health program. The Committee will, in a later report, provide input on other matters including the educational training and material required by P.L. 107-135 as well as evaluation and quality measures for the chiropractic care program. This document reflects all opinions as expressed by the members of the Committee. When the Committee did not reach complete consensus on a recommendation or Committee members expressed concerns regarding the recommendation, a Comment section following the rationale for the recommendation presents the other opinions expressed. In instances where Committee members strongly disagreed, a dissenting recommendation follows the recommendation endorsed by the majority of the Committee. A summary of the public comments received and reviewed by the Committee is attached as Appendix D. This document relates only to the provision of chiropractic care and is not intended to restrict other qualified healthcare providers from the use of manipulation in the care of patients when licensed and privileged to provide such care. BACKGROUND: Doctors of chiropractic in private practice are responsible for providing appropriate care within the scope of their licensure, education and competency and for making appropriate referral to other health care providers when necessary. Coverage of chiropractic care by health insurance plans varies as do access requirements. Many health insurance plans require referral by a primary care provider, others require only that the patient use a doctor of chiropractic within the plan, and some permit self-referral to chiropractic care. Individuals who pay for the care themselves may directly access chiropractic care. Collaborative professional relationships between doctors of chiropractic and allopathic and osteopathic physicians exist and continue to increase in the private sector as more patients become interested in chiropractic care and more insurance plans provide coverage. In 1995, the Department of Defense (DoD) initiated chiropractic care through the Chiropractic Health Care Demonstration Project (CHCDP). CHCDP demonstrated that chiropractic care was accepted best when the doctors of chiropractic were incorporated within a traditional medical team housed within the main medical facility, rather than functioning as a separate entity. As in VHA, organizational structures in DoD vary among facilities and thus several different organizational models have been used to integrate chiropractic care into its healthcare delivery system on a permanent basis. The Committee visited the National Naval Medical Center, Bethesda, where chiropractic was organizationally placed within a musculoskeletal service line that also included Rheumatology, Orthopedics, Physical Medicine and Rehabilitation, Physical Therapy, Occupational Therapy, and Podiatry. This arrangement has provided an organizational structure that reflects functional working relationships in the care of patients with neuromusculoskeletal conditions. Within DoD, the Navy’s experience indicated that hiring and placement by local commanders coupled with a strong, visible commitment to success from senior leadership resulted in a smoother integration of chiropractic care into an established traditional medical setting. The DoD experience may be instructive as VHA determines how to integrate doctors of chiropractic into its system. VHA is a comprehensive, integrated care system encompassing 163 hospitals, 850 ambulatory care and community-based outpatient clinics, 137 nursing homes, 43 domiciliaries and 73 comprehensive home-care programs. VHA endorses a primary care model of healthcare delivery, in which each patient has an assigned primary care provider who is accountable for addressing a large majority of the patient’s personal healthcare needs, with referrals to specialists when needed. While complete implementation of the model has not yet been achieved, in part due to the large influx of new patients that VHA has experienced in recent years, it remains VHA’s goal. VHA’s health care system encourages an integrated, interdisciplinary, interdependent and collaborative team approach. The composition of health care teams in VHA varies among sites as a result of differences in the size and configuration of VHA facilities, staffing patterns, and local business and medical practices, but the team approach to care serves veteran patients well, as many have multiple health care needs that overlap and influence each other. The Committee has discussed extensively how doctors of chiropractic can be integrated successfully into the VHA health care system. While local variations in services and organizational structures will play a role in this, the Committee believes the key to successful implementation is a collaborative, cooperative approach to the integration of care. Doctors of chiropractic should be an integral part of an integrated team of providers. The composition of such an integrated team may vary between sites, and members of the Committee have provided several descriptions of integrated settings that may assist VHA in its decision-making process (Appendix B). The goals for VHA’s new chiropractic care program should include: • Patients have appropriate access to chiropractic care. • Doctors of chiropractic, physician providers and other clinicians develop collaborative relationships in order to provide the concurrent patient care necessary to meet the needs of veterans. • Chiropractic care is fully integrated into all of VHA’s missions – patient care, education, research and response to disasters and national emergencies – in an appropriate manner. RECOMMENDATIONS AND RATIONALE: A. Qualifications for Employment Recommendation 1: Education requirement. Degree of doctor of chiropractic resulting from a course of education in chiropractic. The degree must have been obtained from one of the schools approved by the Secretary of Veterans Affairs for the year in which the course of study was completed. Approved schools should be: (1) Schools of chiropractic accredited by the Council on Chiropractic Education Commission on Accreditation or equivalent agency recognized by the U.S. Secretary of Education, or (2) Schools (including foreign schools) accepted by the licensing body of a State, Territory, Commonwealth, or the District of Columbia as qualifying for full or unrestricted licensure. Rationale: The Council on Chiropractic Education Commission on Accreditation (CCE) is currently the accrediting body recognized by the U.S. Secretary of Education for Doctor of Chiropractic programs and single-purpose institutions offering the Doctor of Chiropractic program. CCE has been recognized by the Department of Education since 1974 and P.L. 106-117 (the Veterans’ Millennium Health Care Act), Section 303, defines the term chiropractor as an individual who “holds the degree of doctor of chiropractic from a chiropractic college accredited by the Council on Chiropractic Education.” However, prior to 1993, a second organization, the Straight Chiropractic Academic Standards Association (SCASA) was also recognized by the Department of Education and 13 state licensing boards. Limiting recognition to CCE accredited schools excludes from VA employment licensed doctors of chiropractic who graduated from SCASA accredited schools, those who graduated from chiropractic school prior to the creation of CCE, those who graduated from a school of chiropractic before it achieved full CCE accreditation status, and those who, in the future, might graduate from a school accredited by a new chiropractic accrediting organization recognized by the U.S. Secretary of Education. H.R. 2414, introduced June 10, 2003 to amend title 38, United States Code, to provide for the full-time permanent appointment of chiropractors in VHA, states the educational qualification of chiropractors as “hold the degree of doctor of chiropractic, or its equivalent, from a college of chiropractic approved by the Secretary.” This language, which models that used for other professions in Title 38, if passed, will override the current limitation to CCE accredited schools contained in P.L. 106-117. The language of H.R. 2414 was incorporated into H.R. 2357 and passed by the House of Representatives on July 21, 2003 VA currently accepts graduation from an accredited school or a school accepted by a state licensure board for several health care professions (physician, dentist, optometrist), while the qualification standards for other professions permit education from a school accepted by a state licensing board only for graduates of foreign schools. Given the history of accreditation of chiropractic educational programs, and the existence of a second accrediting body that was recognized by the US Department of Education until 1993, the Committee recommends the acceptance of the broader education standard that will not exclude experienced doctors of chiropractic because of variations in the accreditation of chiropractic schools in the past. Comment: Chiropractic state licensure criteria is not standardized across all states nor has the same examination always been used by all states. As a result, some members of the Committee expressed concerns that licensure may not be adequate to assure the same level of training as those programs meeting the standards of a recognized accrediting body. Recommendation 2: Licensure requirement. Current, full and unrestricted license to practice chiropractic in a State, Territory, or Commonwealth of the United States, or in the District of Columbia. A doctor of chiropractic who has, or has ever had, any license(s) revoked, suspended, denied, restricted, limited, or issued/placed in a probationary status should be appointed only in accordance with existing VA provisions applicable to other independent licensed practitioners. Rationale: Doctors of Chiropractic are licensed as independent practitioners in all US jurisdictions. While some variation in licensure law exists among U.S. jurisdictions, doctors of chiropractic are responsible for providing appropriate care within the scope of their licensure, education and competency and making appropriate referral to other health care providers if necessary. P. L. 106-117 (the Veterans’ Millennium Health Care Act), Section 303 defines the term “chiropractor” as an individual who is “licensed to practice chiropractic in the state in which the individual performs chiropractic service.” H.R. 2414, introduced June 10, 2003, to amend title 38, United States Code, defines the licensure qualification of chiropractors as “be licensed to practice chiropractic in a State.” This language, which models that used in Title 38 for other professions, if passed, will override the current in language in P.L. 106-117 and allow VA to use the same criteria as used for other Title 38 professions, i.e., licensure in any US jurisdiction. The language of H.R. 2414 was incorporated into H.R. 2357 and passed by the House of Representatives on July 21, 2003. Recommendation 3: Other requirements Doctors of chiropractic should be expected to meet the other employment requirements, such as citizenship, English language proficiency and physical requirements, established by VA for all other Title 38 employees. Rationale: Doctors of chiropractic should meet the general employment criteria expected of all other Title 38 employees. B. Scope of Practice Recommendation 4: Scope of Practice Doctors of chiropractic shall provide patient evaluation and care for neuro-musculoskeletal conditions including the subluxation complex within the boundaries set by state licensure, VHA privileging and the doctor’s ability to demonstrate educational training and clinical competency in the areas necessary to provide appropriate patient care. Rationale: P.L. 107-135 states: “The chiropractic care and services available under the program shall include a variety of chiropractic care and services for neuromusculoskeletal conditions including subluxation complex.” VHA Handbook 1100.9, Credentialing and Privileging, states: “The term independent practitioner is an individual permitted by law (the statute which defines the terms and conditions of the practitioner’s license) and the facility to provide patient care services independently, i.e., without supervision or direction.” The VHA privileging process includes verification of educational training and clinical competency. Examples of neuromusculoskeletal conditions appropriate for chiropractic care include, but are not limited to, subluxation, back pain, neck pain, headache, and joint sprains and strains. A more comprehensive but not all-inclusive condition list routinely used in chiropractic education is included in Appendix A. Comment: The term “subluxation” as used by allopathic practitioners refers to the slippage of one bone on another, (i.e., a partial or complete dislocation) which is measurable on a radiograph. “Subluxation complex” or “vertebral subluxation complex (VSC)” are terms specific to chiropractic. These terms are used by doctors of chiropractic to describe a joint that they judge is no longer in proper position and/or is not functioning properly and the adjacent tissues associated with the malposition or altered motion of the joint. Subluxation complex may or may not be visible radiographically and may or may not have specific symptoms associated with it. Not all practitioners agree that the subluxation complex is a clinically definable entity. C. Services to be Provided (Privileges): Recommendation 5: Minimum Initial Privileges Minimum initial privileges, based on the state licensure of the doctor of chiropractic, should include: 1. History taking 2. Neuromusculoskeletal examination and associated physical examination 3. Ordering of standard diagnostic plain film radiologic examinations to include spine, pelvic, skull, and rib series and chest (PA and lateral) 4. Determine appropriateness of chiropractic care for the problem(s) for which the patient is being managed. 5. Provide chiropractic care a. Adjustment b. Manipulation/mobilization c. Manual therapy 6. Manage neuromusculoskeletal care 7. Referral to appropriate provider when chiropractic care is deemed inappropriate or when patient conditions outside the scope of chiropractic care are suspected or detected through examination or as a result of diagnostic testing. Recommendation 6: Other Initial Privileges When permitted by the state licensure of the doctor of chiropractic and the privileging process for the VA facility, additional initial privileges may include: 1. Ordering of additional diagnostic studies a. Imaging studies (e.g., CT, MRI, ultrasound, bone scan) b. Clinical laboratory (e.g., Urinalysis, SMA 24, Arthritis Panel, CBC) c. Other appropriate tests (e.g., EMG, nerve conduction) 2. Order or provide other treatment modalities: a. Physical modalities (e.g., heat, cold, electrical, ultrasound) b. Ergonomic evaluation, posture management c. Orthotics, supportive bracing, taping d. Counseling/education on body mechanics, nutrition, lifestyle, exercise, hygiene. Rationale: There is some variation in licensure law among the U.S. jurisdictions, and a doctor of chiropractic may not practice beyond the scope of his/her individual licensure. The Committee, in Recommendation 5, has identified privileges that all doctors of chiropractic are licensed to provide and recommends that these be permitted throughout VHA in order to provide baseline consistency in practice as chiropractic care is integrated into VHA. In Recommendation 6, the Committee has identified additional privileges that some doctors of chiropractic are licensed to provide, and recommends that these be included in initial privileges when permitted by the licensure of the doctor of chiropractic and the employing facility. The Committee understands that having different privileges for the same category of practitioner within a facility may be confusing, but believes that when consistency in practice within a facility is not an issue, doctors of chiropractic should be used to their fullest legal capability in providing care for neuromusculoskeletal conditions in order to reduce the degree to which patients are inconvenienced by having to see multiple providers for ordering of necessary diagnostic tests or treatments. The Committee also understands that some VA facilities require prior authorization for some diagnostic tests, such as MRIs, and believes prior authorizations required of doctors of chiropractic should be consistent with, but not exceed, existing facility policies. Comment: One member of the Committee recommended that appropriate use of laboratory tests by doctors of chiropractic be monitored to insure that no critical values exist which do not also reach the primary care physician and/or do not receive appropriate follow-up. VHA does not privilege individual practitioners to order diagnostic tests unless they are competent to manage the results appropriately. VHA policy requires that all emergent test results must be immediately communicated to the ordering practitioner by telephone, face-to-face conversation or hand carried report. Abnormal test results that are not emergent but require attention by the ordering practitioner may be transmitted by direct or electronic communication to the ordering practitioner or to a designated surrogate if the ordering practitioner is not available to review results in a timely manner. Electronic communication includes e-mail, fax, or view alerts transmitted to the ordering practitioner. Although notification of the primary care provider is not required by VHA policy, view alerts in the VA electronic medical record system are a mechanism by which emergent values are automatically forwarded to the patient’s primary care provider, as identified in the computer system, as well as to the ordering provider. The primary care provider also may elect to have all abnormal, non-emergent values automatically forwarded. The DoD Chiropractic Health Demonstration Project initially monitored laboratory results for over-utilization and follow-up of abnormal results, but discontinued such monitoring due to lack of positive findings, i.e., no failure to follow-up or refer for abnormal results. Comment: Two members of the Committee wished to have surface electromyography and thermography added to the list of privileges. Respondents to the Job Analysis of Chiropractic conducted by the National Board of Chiropractic Examiners in 2000 rated electromyography was “of little importance” and indicated they rarely referred patient for such studies. Thermography was not rated at all. This type of equipment was not provided for doctors of chiropractic in the DoD Demonstration Project. Doctors of chiropractic wishing to use these modalities could request them in their privileges, but the majority of the Committee does not believe they should be recommended for inclusion in initial privileges. Recommendation 7: Additional Privileges After the initial annual evaluation, the doctor of chiropractic may request additional privileges, which may be granted by the privileging facility consistent with the needs of the facility and the licensure held by the doctor of chiropractic, upon demonstration of appropriate training and competency. Rationale: The Committee understands that the privileges granted doctors of chiropractic will reflect not only the scope of the doctor of chiropractic’s license, but also the mission and resources already available within the facility. In the event that a facility does not initially grant privileges up to the scope of the doctor of chiropractic’s license, training and competency, Recommendation 7 suggests a timeframe for consideration of additional privileges after the facility has had experience in providing chiropractic care. Recommendation 7 also provides for additional privileges not included in Recommendation 6. Recommendation 8: Publication of Information Letter VHA should publish an Information Letter providing guidance to facilities regarding the recommended privileges approved by the Secretary. Rationale: The chiropractic profession is new to VHA and most doctors of chiropractic practice in private practice settings rather than in health care organizations. An Information Letter that provides information regarding privileging of doctors of chiropractic will assist in providing some degree of consistency in process within VHA. An Information Letter provides guidance rather than a mandated policy. D. Access to Chiropractic Care The Committee did not reach consensus on how veterans should be able to access chiropractic care within VHA. Six members of the Committee favored a referral only system and 5 favored a more direct form of access. Therefore, two recommendations are presented. The Committee also made a third recommendation (Recommendation 10) to allow direct access for newly discharged veterans who had been receiving chiropractic care through DoD in order to ensure continuity of care. Recommendation 9: Access to Chiropractic Care Access to chiropractic care should require referral from the patient’s primary care provider or another VA clinician who is treating the patient for the condition(s) for which chiropractic care is indicated. The referral process should be expedited without barriers. Veterans who have been referred to and have received care from a doctor of chiropractic should continue to have access to the doctor of chiropractic for the continuation of care or treatment, consistent with facility policy for specialty care access. Rationale: VHA uses a primary care model of healthcare delivery, with access to almost all specialty care through referral. Allowing direct access to chiropractic care would create a specific exception to that overall model. It has not been VHA’s practice to permit a patient to receive specialty care upon request; rather, another clinician, usually the patient’s primary care provider, must refer the patient. It is felt that the patient’s primary care provider, or another provider who has evaluated the patient, has the best knowledge of the patient’s overall health status and potential contraindications to chiropractic care. Mandating that patients should be able to receive chiropractic care upon request may be poorly received by VA facilities, and may create demands for direct access to other specialty care. Allowing direct access for only chiropractic care may also create animosity toward a new program and interfere with the successful integration of chiropractic care into VHA. The successful integration of chiropractic care into the DoD healthcare system was heavily dependent upon support from upper management and placement of doctors of chiropractic within a health care team where collaborative relationships developed. Although there is anecdotal evidence some VA physicians have significant anti-chiropractic biases, many others do not. Some have indicated openness and acceptance of chiropractic care as evidenced by referrals for fee-basis chiropractic care. Still others are unfamiliar with chiropractic care and have no experience in collaborating with doctors of chiropractic. Integrating doctors of chiropractic into a health care team and using existing operating procedures for collaboration will most likely lead to acceptance of chiropractic care within VHA. (See Appendix B for descriptions of models of integration.) Creating a different model of care delivery for chiropractic will tend to separate and isolate the doctors of chiropractic, with the detrimental effect of decreasing the professional interactions that will lead to greater collaboration and acceptance. While new enrollees currently experience long delays in accessing primary care, existing patients are less likely to encounter significant delays in obtaining routine appointments. Patients with new acute conditions have access to urgent care or, in some facilities, same day appointments. Because the primary care provider or another provider who has been seeing the patient will have previously examined the patient and know the patient’s history, the referral process should not cause significant delays. Some members believe permitting direct access to chiropractic care may lead to patients attempting to use that access to circumvent the primary care backlog, with expectations that doctors of chiropractic can then move them to the head of the line for non-chiropractic care. One member believes that establishing a policy where veterans may self-select chiropractic care may represent a mechanism for doctors of chiropractic to function as primary care providers. Some members also expressed concerns that allowing direct access would quickly overload the capacity to provide chiropractic care. Dissenting Recommendation: VHA facilities should establish processes that will ensure patients are adequately informed about treatment options, including chiropractic care, when presenting to urgent care with acute neuromusculoskeletal conditions appropriate for chiropractic care, when calling to request a primary care appointment for acute neuromusculoskeletal conditions, or when receiving care for difficult, chronic and otherwise unresponsive neuromusculoskeletal conditions. Patients presenting with neuromusculoskeletal complaints who prefer chiropractic care as their treatment option should be referred to a doctor of chiropractic for evaluation and care. Rationale: VHA Notice 99-02, Shared Decision Making, dated June 15, 1999, defines shared decision making as “…the case for letting patients decide which choice is best….A process by which patients are educated about likely treatment outcomes, with supporting evidence, and engaging with them in deciding which choice is best for them, taking into account their preferences, values and lifestyles. ” Patients who present to urgent care or who call for a primary care appointment for acute neuromusculoskeletal conditions, as well as patients with difficult, chronic and otherwise unresponsive neuromusculoskeletal conditions should be provided with complete and unbiased information regarding evaluation and treatment options, including chiropractic care, and be permitted to make a choice regarding their health care. Established patients known to the provider and who are absent any “red flags” or overt contraindications for receiving chiropractic care should be referred appropriately. New patients presenting to urgent care, or established patients who come in after normal hours and are seen by a provider who does not know them, will be examined by the provider on duty, provided information on treatment options, and then referred according to their preference for treatment. Other treatment regimes should not be required before referral for chiropractic care when that is the patient’s preference. Then, if chiropractic care is selected, the doctor of chiropractic will conduct an evaluation and, if chiropractic care is appropriate, provide treatment as indicated. Most of the chiropractic members of the Committee believe veterans should be able to select and have easy access to chiropractic conservative care interventions for acute neuromusculoskeletal conditions and to chiropractic consultation for difficult, chronic and otherwise unresponsive neuromusculoskeletal conditions. This approach would allow patients to access chiropractic care for acute neuromusculoskeletal conditions in a timely manner without utilizing scarce primary care capability. Most of the doctors of chiropractic on the Committee continue to have serious concerns that some VA physicians have significant anti-chiropractic biases, will not refer patients, and will continue to impose barriers, such as requiring other treatment regimes, before referring patients for chiropractic care. They believe requiring the veteran to obtain a primary care appointment and referral may result in the veteran being unable to obtain chiropractic care in a timely manner. While VHA endorses and is moving toward a primary care model of healthcare delivery, with access to almost all specialty care through referral, local variations still exist. These variations result from differences in the size and configuration of VHA facilities, staffing patterns, and local business practices. Currently, patients experience lengthy delays for enrollment for primary care and/or availability of primary care appointments. While VHA is diligently striving to reduce those delays, they remain a fact of life. The result is that patients may be unable to access chiropractic care in a timely manner. Recommendation 10: Continuity of Care for Newly Discharged Veterans Newly discharged veterans who have been receiving chiropractic care through the Department of Defense while on active duty and who have service-connected neuromusculoskeletal conditions, or who are newly returned from a combat zone, or who have applied for service connection for the neuromusculo-skeletal condition for which DoD provided chiropractic care, should have direct access for continued chiropractic care at a VHA facility. Rationale: Newly discharged veterans who were receiving chiropractic care through the Department of Defense while on active duty should be able to receive continuing care from VHA without delays resulting from being placed on a waiting list for primary care enrollment. Any veteran who, at the time of discharge, is receiving chiropractic care for a neuromusculoskeletal condition, through a DoD provided source, is likely to become service connected for that condition. Some veterans are receiving service connected status at the time of discharge under the Benefits Delivery at Discharge program. Newly discharged veterans who did not have the opportunity to participate in the Benefits Delivery at Discharge program and who have applied for service connected status for the condition that was under treatment by DoD doctors of chiropractic also should be allowed to continue treatment without the delay created by the length of time required for adjudication of the claim. Newly discharged veterans returning from a combat zone are eligible for VA care for two years after leaving active duty even without a service connected disability. The President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans recently recommended that VA and DoD improve their collaboration and sharing of information in order to improve the processes for transition from military service to veteran status. The need to share health information and improve continuity of care between DoD and VA has been a major focus of VA/DoD Joint Executive Council and has been included in the VA/DoD Joint Strategic Plan that was approved April 15, 2003 by the Joint Executive Council. Comment: One member voiced concern that this might create a large pool of people who would attempt to circumvent VHA’s normal referral process by applying for service connected benefits in order to continue to receive chiropractic care without a primary care provider. Recommendation 11: Inpatient Care Doctors of chiropractic may see inpatients, including patients in VHA’s long term care facilities, upon referral from another VHA provider, but will not have admitting privileges. Rationale: Almost all chiropractic care in the private sector is provided in outpatient settings. If chiropractic care is indicated during an inpatient stay, the attending physician should request it through the consult process. Recommendation 12: Chiropractic Care in Community Based Outpatient Clinics (CBOCs) Chiropractic services should be provided in a CBOC when the parent facility determines that the need exists and when the resources are available to provide such services. The existing fee basis program can be utilized if staff or contract doctors of chiropractic are not available at the CBOC. Rationale: VHA’s CBOCs vary in size and resources. Decisions regarding provision of chiropractic care in CBOCs should be made as a part of overall facility/VISN planning for optimum provision of services. Chiropractic services provided at CBOCs will use the same guidelines and protocols as the parent facility. Recommendation 13: Fee Basis Care Chiropractic care should continue to be available through the fee-basis program. An evaluation may be required prior to authorization of fee-basis care; however, the authorization mechanism should be consistent with the requirements for all other fee basis authorizations within the facility. Rationale: Chiropractic care should continue to be available to patients who live in areas distant from a VHA facility providing chiropractic services. Recommendation 14: Occupational Health Programs Doctors of chiropractic can be utilized in the VHA facility’s occupational health program. Rationale: At the National Naval Medical Center (NNMC), Bethesda, the doctors of chiropractic participate in the occupational health program by providing chiropractic care for work-related injuries, providing workplace ergonomic evaluations and recommendations, and providing classes in back care and ergonomics. The chiropractic staff believes that their initial involvement in treating NNMC staff played an instrumental role in acceptance of chiropractic care at that facility. This recommendation is offered as an option that individual facilities may wish to consider. NNMC is different from VA facilities in that many of the NNMC personnel are active duty military, and receive all of their health care there. VHA personnel are civilian employees who are covered under the Federal Employee Compensation Act (FECA). While VHA would be able to bill Department of Labor for treatment of work-related injuries by VHA doctors of chiropractic, the chiropractic services that may be reimbursed are limited by the FECA to “treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist.” Comment: Two members of the Committee do not agree that this recommendation should be included, as it does not pertain to providing services to veterans. While VA employees may receive treatment of work-related injuries at a VHA facility if they wish, availability of such care is limited by the capacity of the treating service to provide services to employees without interfering with the care of veterans. A number of Committee members believe it is unlikely the doctors of chiropractic will have time to evaluate or treat employees or to teach classes. There was strong disagreement from one member regarding the provision of ergonomic evaluations or classes by any provider, as there is no evidence that such evaluations and classes lead to any health gains and some randomized trial evidence indicates such classes lead to increased back pain claims. E. Referrals to and from Doctors of Chiropractic Recommendation 15: Screening of Patients The doctor of chiropractic should screen patients to identify the following “red flags” or contraindications to manual therapy. a. Possible fracture from major or minor trauma in an osteoporotic patient. b. Possible tumor or infection in patients with a history of cancer, recent fever, unexplained weight loss, recent bacterial infection, IV drug abuse or immune suppression c. Possible cauda equina syndrome noted by saddle anesthesia, recent onset of bladder dysfunction, progressive neurologic deficit or major motor weakness in the lower extremity (not sciatica), unexpected laxity of the anal sphincter or perianal/perineal sensory loss. Rationale: The presence of these conditions suggests the need for medical consult prior to receiving chiropractic care. Recommendation 16: Referral Service Agreements VHA should encourage the development of referral service agreements between doctors of chiropractic and both primary care and other specialty providers regarding the types of conditions appropriate for referral to chiropractic care, and the pre-referral testing that will be useful to optimize the provider’s time. The authorization mechanism for chiropractic referrals, follow-up, and recurrent care should be consistent with the facility’s business practices for other referrals. Rationale: In VHA models of health care delivery that do not allow direct access to specialty care, the goal of the referral process is appropriate access to chiropractic care for veterans with acute or chronic neuromusculoskeletal conditions (to include the subluxation complex) amenable to chiropractic care. A number of VHA facilities have developed service agreements to expedite the referral process. Chiropractic patients typically present with a wide variety of neuromusculo-skeletal complaints; however, the large majority of patient complaints are related to back pain, neck pain, headaches and peripheral joint pain. (See Appendix A.) While VHA’s electronic medical record facilitates communication among multiple providers, development of service agreements can be used to clarify expectations regarding coordination of care and case management. Development of service agreements may also assist in the joint education of doctors of chiropractic and other VHA providers regarding the provision of care for neuromusculoskeletal conditions and the subluxation complex within VHA. Comment: The subluxation complex (or vertebral subluxation complex) is an entity unique to chiropractic, as recognized by many State practice acts. Many chiropractic techniques are designed specifically to care for the subluxation complex, which may or may not be associated with neuromusculoskeletal symptoms (i.e., the subluxation complex may not be symptom specific or symptom dependent). Some members of the Committee do not agree that this is a clinically definable entity. Comment: Chiropractic members of the Committee believe that patients presenting with vertebral malposition, abnormal spinal segmental motion, soft tissue tenderness and compliance, and asymmetric or hypertonic muscle contractions, are appropriate for referral to a doctor of chiropractic. Non-chiropractic members of the Committee believe that physical therapists, physiatrists or doctors of osteopathic medicine also are qualified to provide evaluation and care. Comment: Chiropractic care often requires multiple patient encounters over a period of time. Patient response may range from complete recovery after a single treatment to a stabilization of the patient’s condition without total resolution of the problem. It is the opinion of some chiropractic members of the Committee that, in the latter case, patients often benefit from periodic care over an indefinite period of time. They believe that while such an ongoing treatment regime may seem counter to effective case management, in many cases, the alternatives – no care or more aggressive care – may leave the patient in a more debilitated condition or involve more expensive or invasive medical care. Other Committee members insist that there is no convincing evidence that periodic chiropractic care over an indefinite period of time provides any health benefit or can prevent the use of other health care procedures for any health condition. Recommendation 17: Referrals from Doctors of Chiropractic Doctors of chiropractic may make referrals to other VHA services and/or providers as appropriate, subject to facility protocols. Rationale: In some cases, doctors of chiropractic may need to refer to other providers for specific services, e.g., orthotics or supportive bracing, if direct provision of those services are not within the privileges of the doctor of chiropractic, or social work service for family issues. The doctor of chiropractic also should have the ability to request further diagnostic evaluations and medical consultations with appropriate services (including specialists) within the VHA facility or system if potential contraindications to chiropractic care are identified. The doctor of chiropractic may encounter situations in which a patient presents with a medically urgent condition that requires immediate referral. Making such referrals directly when the need becomes evident during a patient visit will expedite appropriate intervention. F. Integration of Chiropractic Care into VHA Recommendation 18: Coordination of Care The doctor of chiropractic and the patient’s primary provider, in conjunction with other appropriate VHA providers, should develop a collaborative treatment regime when patients present with concurrent neuromusculoskeletal and non-neuromusculoskeletal problems. Rationale: The VHA health care system encourages an integrated, interdisciplinary, interdependent and collaborative team approach to patient care. A holistic, integrated approach is essential for many VA patients who have multiple health problems. Recommendation 19: Co-management of Care As a member of the VHA health care team, doctors of chiropractic should co-manage patient care for neuromusculoskeletal conditions as appropriate, along with the patient’s primary provider, other team members, and specialists. Rationale: Doctors of chiropractic should provide co-management of care when patients present with concurrent complex neuromusculoskeletal and non-neuromusculoskeletal problems. Recommendation 20: Placement of Doctors of Chiropractic within a Health Care Team Doctors of Chiropractic should be integrated into the VHA health care system as a partner in a health care team. Rationale: The Department of Defense Chiropractic Health Care Demonstration Project demonstrated that chiropractic care was accepted best when the doctors of chiropractic were incorporated within a traditional medical team housed within the main medical facility, rather than functioning as a separate entity. The Committee describes several models of integration in Appendix B. Decisions regarding placement should consider the functional working relationships appropriate to the care of patients with neuromusculoskeletal conditions in the facility. Teams may be organizationally defined or exist in a functional capacity. The doctor of chiropractic should be a part of whatever team is most likely to deal with initial presenting complaints related to the neuromusculoskeletal system. Recommendation 21: Site Selection The VISN Clinical Managers should provide recommendations for sites they believe will be most successful in integrating chiropractic care into a facility while meeting the needs of veterans. Rationale: P.L. 107-135 requires that chiropractic care be offered at a minimum of one VHA site in each VISN. Site selection for the initial placement of doctors of chiropractic should, to the extent possible, be driven by the interest and acceptance of chiropractic at facilities in each VISN, as well as by the most advantageous use of resources. Recommendation 22: Doctor of Chiropractic Staffing Each facility providing chiropractic services should have enough doctors of chiropractic on staff to provide patient care. Patient volume may determine whether the positions would be full-time, part-time, or contract. Rationale: Customarily, at least two doctors of chiropractic are necessary to be able to provide coverage and continuous patient care during vacations or other absences, and to provide for peer quality review. The DoD Chiropractic Demonstration Project provided two doctors of chiropractic at each site. Additional doctors of chiropractic may be required based on patient demand, subject to availability of VHA resources. Recommendation 23: Support Staff Personnel functioning as chiropractic assistants should come from existing job classifications, receiving additional on-the-job training from the doctor of chiropractic. Clerical staff for scheduling and other administrative clinic duties will also be needed. Rationale: Chiropractic assistants provide assistance in patient care, similar to that provided by nursing assistants in other clinics. Facilities have the latitude to write new position descriptions, which are then locally classified under existing job series and titles. Clerical staff may be shared if the doctors of chiropractic are co-located with collaborating providers, but the addition of a new service and additional providers may require additional clerical support. Recommendation 24: Space Clinic space assignments should be consistent with existing provider space assignments. Ideally, each examination room should be 12 by 20 feet and contain a sink. Rationale: The space required for a chiropractic examination table is larger than that required for most general medical examination rooms and more consistent with that found in a physical therapy or physical medicine area. The standard chiropractic examination table is 2 feet by 7 feet 5 inches, and sufficient space must be available on all sides for the doctor of chiropractic to move about during treatment. Desirable clinic space requirements include a reception/waiting area (which can be shared with other clinics) and two examination/treatment rooms per doctor of chiropractic. As has been noted for primary care clinics, an excess of two treatment rooms facilitates the ability to see a greater number of patients. Office space for the doctors of chiropractic should preferably be in close proximity to the patient care area. Recommendation 25: Co-location with Collaborating Providers and Services Where feasible, the doctors of chiropractic should be located with or near collaborating providers or services. Rationale: Co-location will facilitate communication and interaction with other providers and enable sharing of reception/waiting space, administrative support staff and space, and potentially some equipment. It is, however, important that providing space for chiropractic care not penalize or create hardship for other services. Recommendation 26: Equipment Chiropractic adjusting tables and specialized diagnostic evaluation equipment particular to chiropractic needs will be needed. See Appendix C for list of equipment and supplies needed for each examination room. Rationale: In addition to standard office and examination equipment, some specialized equipment is needed for chiropractic evaluations. Chiropractic table types vary with some designed for specific types of care. Facilities should consult with the doctors of chiropractic before purchasing tables. Comment: Two doctors of chiropractic on the Committee wished to have equipment for surface electromyography and thermography added to the equipment list in Appendix C. Respondents to the Job Analysis of Chiropractic conducted by the National Board of Chiropractic Examiners in 2000 rated electromyography as “of little importance” and indicated they rarely referred patient for such studies. Thermography was not rated at all. This type of equipment was not provided for the DoD Demonstration Project. This equipment would be needed only if doctors of chiropractic received privileges to perform these tests. See Recommendation #6. Recommendation 27: Orientation A standardized orientation program on how chiropractic care is to be integrated into VHA should be developed and presented to clinical and administrative staff at each facility prior to the actual implementation of a chiropractic service. VHA should develop a basic orientation program for doctors of chiropractic that can be modified for differences in facilities. Rationale: VHA staff will need an orientation regarding the availability of chiropractic care, including how patients may access the care. Doctors of chiropractic will also require orientation to VHA, including orientation to the services provided at the facility and care processes, in addition to the general orientation all new employees receive. Assignment of mentors who are accepting of chiropractic care to the new doctors of chiropractic may assist in orientation and integration. Recommendation 28: Ongoing Education of Providers Doctors of chiropractic should participate in facility interdisciplinary educational activities in order to encourage collaboration and gain familiarity with the care provided by other services. Rationale: Once the chiropractic service has been implemented, additional interdisciplinary educational encounters will need to be provided to address new concerns or questions as well as to encourage collaboration among staff. Observation and participation in hospital rounds and patient care conferences may assist doctors of chiropractic in enhancing current skills as well as continuing to educate them regarding the variety of veteran patient conditions and needs. In addition, these educational encounters will serve to inform other professional staff regarding the services provided by doctors of chiropractic. Recommendation 29: Education of Patients VHA will provide standardized information to patients regarding the availability of chiropractic care. Each VISN will provide information to patients on how to access chiropractic services within the VISN. VISN Directors should assure the widest dissemination possible using multiple modalities. Rationale: VHA published a patient education brochure regarding chiropractic care in May 2001,and distributed it through the VISN Clinical Managers. It is unclear how widely it was used, and many patients who have inquired about chiropractic care report that they have never seen it. VHA should make all veterans aware that chiropractic care is a part of its Medical Benefits Package. The Committee will provide recommendations at a later time regarding content and methods of distributing educational materials. Comment: One member of the committee stated that the information provided to patients should provide a “balanced perspective on the evidence” of the effectiveness of chiropractic care to insure patients are able to make informed decisions. Recommendation 30: Quality Assurance Chiropractic care should be incorporated into each facility’s quality assurance program. Rationale: Chiropractic care should conform to VHA quality assurance processes in a manner that is consistent with other providers/services and the requirements of the Joint Commission on Accreditation of Healthcare Organizations. The Committee will provide recommendations at a later time regarding quality measures for the chiropractic care program. Recommendation 31: Performance Measures VHA should develop performance/outcome measures for chiropractic care. Rationale: VHA’s experience has shown that the use of performance/outcome measures is useful in improving the quality of care provided to veterans. The Committee will provide recommendations at a later time regarding performance measures. Recommendation 32: Evaluation of Chiropractic Care Program A formal evaluation of the challenges and benefits of providing chiropractic care within VHA should be completed by the conclusion of the third year of implementation. Formal progress reports should be completed at least annually. Rationale: This evaluation should include the variations in organizational placement and models of delivery utilized across the VISNs and a determination of how these variations impacted the implementation of the chiropractic service. Data to be analyzed should include, at a minimum, the number and characteristics of patients receiving chiropractic care, waiting times for access to chiropractic care, and the impact on the use of the fee basis program for chiropractic care. It is essential that evaluation factors be established and data collected in a prospective manner so VHA managers and doctors of chiropractic will be able to use the data for program improvement. Mechanisms should be established to enable the sharing of information regarding successful implementation strategies as well as lessons learned. The Committee anticipates that Members of Congress will request such data. Therefore formal progress reports should be produced at least annually. Recommendation 33: Medical Staff Voting Privileges All doctors of chiropractic, once credentialed and privileged by a VHA facility, should be members of the Medical Staff and have full voting privileges. Rationale: To fully integrate chiropractic care into the VHA healthcare system, doctors of chiropractic should be full voting members of the Medical Staff. In most VHA facilities, both podiatrists and optometrists are voting members of the medical staff. Comment: Two members of the Committee stated that medical staff voting privileges should be at the discretion of the local facility and consistent with existing VA guidelines. Recommendation 34: Continuing Education Doctors of chiropractic employed by VHA should be expected to obtain continuing education as required for the maintenance of licensure and competency. VA should fund such training in accordance with existing VA policy. Rationale: VHA expects all professional staff to maintain and enhance competency through continuing education programs. Doctors of chiropractic should be able to access funding for educational programs in the same manner and to the same degree as other staff. Recommendation 35: Oversight and Consultation for the Chiropractic Program VHA should create a mechanism for providing oversight of and consultation on the implementation of chiropractic care. This may be accomplished through the appointment of a chiropractic advisor, similar to the position of the physician assistant advisor or the directors of podiatry and optometry, or a field advisory committee. Rationale: All other professions have representatives to provide advice and input to the Chief Patient Care Services Officer and the Under Secretary for Health. A structure for obtaining input from practicing doctors of chiropractic is essential to the success of the chiropractic care program within VHA. All current occupational representatives within Patient Care Services are field-based and perform these duties on a part-time basis. A full-time chiropractic advisor/director position could occur only as a VACO position, and there are distinct benefits in having a field-based practicing clinical doctor of chiropractic in this position. As a profession new to VHA, it will be important for the person in this position to have a hands-on working knowledge of VHA operations. In addition, field-based positions allow for the recruitment of the best-qualified individuals rather than just someone who is willing to move to Washington, DC. Comment: Two members of the Committee recommended a field advisory committee with a rotating chair. Two members of the Committee suggested that, given the challenges associated with the system-wide implementation of a new and somewhat controversial program, an office for chiropractic oversight and advisement at the Central Office level should be considered. Recommendation 36: Committee Membership Doctors of chiropractic should be included in the membership of appropriate facility, VISN, and national clinical and administrative committees, work groups and task forces in a manner consistent with the participation of other providers. Rationale: Doctors of chiropractic should provide input through membership on committees, work groups and task forces that discuss, evaluate or make recommendations regarding or otherwise impact the provision of chiropractic care. Recommendation 37: Academic Affiliations VHA should provide opportunities for educational and training experiences for senior chiropractic students and recent graduates from chiropractic programs, consistent with graduate preceptor programs sponsored by chiropractic educational programs. These educational experiences should expose the student to a wide range of services provided in the VHA facility to broaden the participant’s understanding of clinical care and to help the student to experience chiropractic care in a multidisciplinary setting. Rationale: Health professional training is one of VA’s missions. VHA is noted for its leadership in providing clinical experiences for a variety of health care professions. Recommendation 38: Research VHA, in conjunction with its chiropractic providers and chiropractic educational programs, should conduct clinical research relevant to the type of conditions and services provided by doctors of chiropractic. Emphasis should be placed on common service connected conditions. Research related to integration of multidisciplinary providers into teams should also be undertaken. Rationale: Neuromusculoskeletal conditions are among the most common reasons for service connected status. VHA has a unique opportunity to develop research programs to evaluate the efficacy of chiropractic care in the treatment of these conditions as well as to evaluate the dynamics of developing and integrating multidisciplinary teams. APPENDIX A CONDITIONS COMMONLY SEEN BY DOCTORS OF CHIROPRACTIC (Not all inclusive) Chiropractic patients typically present with a wide variety of neuromusculo-skeletal complaints; however, the large majority of patient complaints are related to back pain, neck pain, headaches and peripheral joint pain. Doctors of chiropractic commonly manage the conditions on this list, which is provided as information for persons not familiar with the scope of chiropractic practice. This list does not imply that only doctors of chiropractic can manage these conditions or that other health care providers are not trained to manage these conditions. One Committee member stated that there are no evidence-based studies to support the therapeutic value of spinal manipulative therapy for some of these conditions. A doctor of chiropractic on the Committee pointed out that a doctor of chiropractic may manage some conditions, such as osteoporosis, with dietary and exercise recommendations, rather than spinal manipulation. The DoD Demonstration Project limited the doctors of chiropractic to treatment of “spine-related neuromusculoskeletal complaints or problems”. Since completion of the Demonstration Project, DoD has expanded the scope of practice for the doctors of chiropractic to “neuromusculoskeletal problems.” 1. Subluxation 2. Chronic pain 3. Strain/Sprain (traumatic) 4. Lumbosacral strain/sprain 5. Intervertebral disc syndrome 6. Sacroiliac syndrome 7. Cervical strain/sprain 8. Symptomatic Scoliosis 9. Thoracic sprain/strain 10. Torticollis (acquired) 11. Myofascial pain syndrome 12. Acute cervical pain 13. Osteoporosis 14. Osteoarthritis 15. Peripheral neuropathies 16. Migraine 17. Posterior facet syndrome 18. Chronic daily headache (tension) 19. Vertebrogenic headache 20. Scheurman's disease 21. Carpal tunnel syndrome 22. Rotary cuff tendonitis 23. Mechanical disorders (thoracic) 24. Chest wall syndrome 25. Tendonitis (traumatic) 26. Disc syndrome (cervical) 27. Bursitis (traumatic) 28. Compartment syndrome 29. Patellofemoral syndrome APPENDIX B MODELS FOR INTEGRATED CARE DELIVERY The following models of integrated care delivery may be useful to VHA administrators and clinical staff in planning to incorporate chiropractic care into VHA facilities. The Committee believes chiropractic care should be integrated into existing multi-disciplinary care delivery models, in a manner consistent with current business processes and the privileging and use of other health care providers. While the different organizational structures and functional processes found among VHA facilities will influence how chiropractic care is integrated at any given facility, the Committee believes the following principles should be used: • The systems and structures used to integrate doctors of chiropractic should facilitate the timely, efficient provision of care to veterans. • Decisions regarding care delivery should focus on the provision of care, not the location of care. • Decisions regarding care delivery should focus on the skills a person needs to provide that care, not the profession of the person. Model 1: Integration into primary care setting or service line. This model replicates a method used for integrating psychiatry into the primary care setting at the West Los Angeles VA and other facilities. A doctor of chiropractic (DC) would be physically located within the primary care area. The DC would see patients on referral from primary care providers, usually on a same day basis for initial evaluation. The DC also would be able to provide immediate evaluation and care for patients who call or walk in with acute neuromusculoskeletal complaints when it is the patient’s choice to see a DC. Patients would be referred back to their primary care provider with specific recommendations if chiropractic care is not indicated. When chiropractic care is indicated, the patient would be scheduled for visits with the primary care clinic chiropractor. The patient’s neuromusculoskeletal condition may be co-managed by the primary care provider and chiropractor, or for patients whose chief complaint is neuromusculoskeletal, the DC may become the principal provider of care with collaboration with other team members as needed. Organizational placement for administrative purposes may or may not be under primary care, and would depend on the overall organizational structure of the medical center (i.e., traditional services vs. service lines.) Advantages: • Doctor of chiropractic is available in the primary care area for short, informal consultations, which may obviate the need for a formal consolation, thus increasing efficiency. • Allows quicker access to chiropractic evaluation and initiation of care. • Improved patient satisfaction as a result of immediate referral during one visit. • Care is viewed as continuous over time rather than as discrete treatment episodes, improving coordination of care across disciplines. • Allows more efficient utilization of the primary care providers. • The doctor of chiropractic becomes a functional member of the primary care team, and as such, is present and provides appropriate input during educational sessions and patient care planning conferences. Disadvantages: • Finding space in existing primary care areas. • The chiropractic area within the primary care setting would become the de facto chiropractic clinic with additional patients being referred from other providers (e.g. orthopedics.) increasing space needs. • Need for duplicate equipment (e.g., chiropractic tables; other modalities such as electrostimulation, ultrasound, hot packs, if DC is privileged to provide these modalities) if there is a separate chiropractic clinic located elsewhere. • Need to coordinate chiropractic visits with physical therapy if DC is not privileged to provide the modalities mentioned above. • Staffing needed to maintain availability of DC if/when patient load increases. Model 2: Integration into a specialty service or service line with liaison to primary care. This model replicates the method used for integrating physical therapists into primary care at the VA Salt Lake City Healthcare System. When veterans present to primary care, the emergency department, or call with an acute neuromusculoskeletal complaint, the provider would be able to page a DC who is available to evaluate the patients. Both providers might examine patients collaboratively and discuss options for care with the patient. When the p