Healthcare Update
FCER Points Out Error to Merck; Merck Confirms Change
In July 2004, a Doctor of Chiropractic voiced concern to the Foundation for
Chiropractic Education and Research over wording appearing in the oft-consulted
The Merck Manual. The bothersome wording was: “Manipulation may help pain
caused by muscle spasm alone but may aggravate an arthritic joint or further
rupture a disk and should thus be used with caution.”
On behalf of the doctor brining it to attention, FCER drafted a letter to The
Merck Manual editor-in-chief. Among the points raised were these:
Two lines of thought in this passage are problematic:
“The passage as it reads implies that spinal manipulation may relieve
pain by acting as a muscle relaxant alone … Even in the case of muscle
involvement, spasm is not the only mechanism responsible. The statement concerning
disk rupturing may have had its origins with the assertion made by Farfan over
34 years ago to the effect that rotational stress causes disk failure …
The safety of side posture manipulation in the treatment of lumbar intervertebral
disk herniations is described in detail in the literature review by Cassidy
et al.”
In a letter dated July 27, 2004, Merck responded: “We have completely
rewritten the chapter on back pain, and the statement you objected to is no
longer present. While we do not go into great depth on the etiology of back
pain, our new text emphasizes that the etiology is usually multifactorial, with
muscle spasm being just one factor. We do comment on the helpfulness of spinal
manipulation but retained a statement of caution in those with the possibility
of nerve damage from disk disease. This statement does not single out chiropractic
interventions: We include them with almost every intervention, including the
use of medications. In addition and for the first time, we will have a separate
entry on chiropractic.”
Chiropractic Care May Reduce Anxiety
According to the National Institute of Mental Health (NIMH), anxiety is the most
common mental health illness, affecting more than 19 million Americans ages 18-54.
A recent study, published in the Journal of Vertebral Subluxation Research (JVSR)
describes a 19-year old woman diagnosed with General Anxiety Disorder who suffered
from somatic and psychiatric symptoms for two years. After a four-month course
of chiropractic care, the young woman reported an 80 percent reduction in her
symptoms, including a 90 percent decrease in her headaches. The patient was able
to resume a normal lifestyle without resorting to prescription or over-the-counter
drugs.
The patient’s previous medical treatment had included multiple emergency
room visits; private specialists; and a rotation of drug therapies, which failed
to provide relief.
The research was co-authored by Dr. Madeline Behrendt, associate editor of JVSR,
and Dr. Nathan Olsen, a chiropractor in private practice in Boise, Idaho. The
patient’s history included at least three motor vehicle accidents between
1995 and 1997. In one of the crashes, her head shattered the windshield. The initial
chiropractic evaluation detected subluxations.
The NIMH also reports that patients with anxiety disorders make three to five
times more visits to doctors’ offices and emergency rooms and the Anxiety
Disorders Association of America reports that direct healthcare costs and lost
productivity of these conditions cost more than $42 billion per year.
The drug therapies commonly used in treatment for mental health disorders have
recently come under closer scrutiny because of their poor rate of effectiveness
and potentially deadly side effects, including increased suicidal tendencies in
young people.
Chiropractic Best Practices and Anti-Fraud Initiatives
The American Chiropractic Association is inviting insurance decision makers from
across the country to a national meeting where participants will discuss the progress
toward chiropractic best practices, including a timetable for completion and the
difference between guidelines and best practices. Known as the Claim Solutions
Work Group, the meeting is planned for Nov. 11, 2004, in New Orleans.
The Claim Solutions Work Group will also focus on ACA’s anti-fraud efforts,
and presenters will introduce the organization’s new clinical documentation
manual and illustrate the correct use of these codes by doctors of chiropractic.
“This is a meeting not to miss,” ACA President and meeting presenter
Donald Krippendorf, D.C. said. “Nowhere else will you find such a frank
discussion about pertinent insurance issues and how they relate to doctors of
chiropractic. Participants can expect networking with others who are experiencing
the same challenges, but who are finding answers.”
Attendance is highly recommended for insurance claim executives, medical directors,
medical review policymakers, claim managers, workers compensation administrators
and reimbursement/benefit plan administrators.
ICA Files Major Brief in Landmark Arkansas Chiropractic Board vs.
PT Case
The International Chiropractors Association has filed an extensive amicus curiae
or “friend of the court” brief in a landmark case in Arkansas that
has significant potential to halt the efforts of the physical therapy profession
to expand into chiropractic’s unique territory. The ICA’s brief in
the case of Teston vs. Arkansas Board of Chiropractic was filed on Sept. 14, 2004.
In this case, a physical therapist in Arkansas was found to be performing “spinal
manipulations,” for which only chiropractors are licensed. After rigorous
review by the Arkansas Board of Chiropractic Examiners, the defendant was found
to be in violation of the Chiropractic Practice Act. The Arkansas Chiropractic
Board levied a “civil penalty” of $10,000 following the determination
that the chiropractic code had been violated. The PT appealed the decision to
the Arkansas Supreme Court, and the ICA stepped up to prepare and file its amicus
curiae brief in support of the Chiropractic Board’s decision.
The ICA was invited to submit a brief in the case by the Arkansas Attorney General,
who is defending the Chiropractic Board, and the ICA’s efforts were coordinated
with the chiropractic community in the state to provide for maximum effectiveness.
National physical therapy groups have also intervened on behalf of the PT, and
briefs have been filed in the case with the Arkansas Supreme Court by the American
Physical Therapy Association and the Federation of State Boards of Physical Therapy.
“The Arkansas State Board appreciates the ICA for its efforts in this important
matter and feels this information will be invaluable on chiropractic’s behalf
in this important legal contest,” said Dr. Beverly J. Foster, president
of the Arkansas State Board of Chiropractic Examiners.
“This is an historic and important case since the professional boundaries
between PT and chiropractic are being challenged by physical therapy in an extra-legislative
and sophisticated manner,” said Dr. Henry Rubinstein, who was hired expressly
to take on this vitally important case because of his unique background. “The
ICA wants chiropractors who have endured decades of harassment to achieve and
maintain the recognition they deserve for the benefits that they bestow upon the
public that the physical therapists now want to claim as their own.”
Dr. Rubinstein, who is both an attorney and a chiropractor with decades of experience
in Florida, was able to present chiropractic’s position with exceptional
clarity. The ICA’s brief spoke to the intent behind the PT case, and this
is to expand the scope of physical therapy, without following the traditional
legislative path. In its brief, the ICA told the court, “The ICA cannot
sit idly by while organized medicine incorporates chiropractic techniques into
its branch of physical therapy in hopes of making chiropractic moot in the eyes
of insurance companies, federal programs, and the unsuspecting public.”
Key to the PTs’ argument is that there is no statutory difference between
“spinal manipulation” and other procedures authorized under state
law for the physical therapy profession. They have argued that the vagueness of
the statute gave the PT in the case the leeway to perform high-velocity thrust
procedures, within his PT license. The State Board of Examiners as well as the
ICA have clearly pointed out that this is simply incorrect and that the only time
”spinal manipulation” is mentioned in the physical therapy statute
is a specific passage excluding PTs from being authorized to perform these procedures.
The Arkansas Code gives PTs authority to provide: “Manual therapy techniques,
including soft tissue massage, manual traction, connective tissue massage, therapeutic
massage, and mobilizations, i.e. passive movement accomplished with normal range
of motion of the joint, but excluding spinal manipulation and adjustment.”
(Arkansas Code, 17-93-102(6)(B)(i)(c).)
The Arkansas Chiropractic Board followed due process, considered all the evidence
and allowed the physical therapists to provide their own point of view. But the
compelling balance of findings clearly show that the line was crossed, and that
the State Board acted correctly to fulfill its responsibility to protect the public.
Thus, it concluded its brief with the statement:
“It is, therefore, the ICA’s position that the Arkansas Supreme Court
uphold the decision of the Chiropractic Board and leave it to the legislative
branch to decide whether physical therapists may practice chiropractic, and in
the meantime leave such decisions to the Chiropractic Board, as has the legislature.”
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