Is neuromusculoskeletal medicine a chiropractic specialty?

By James Lehman

Whenever I am asked whether the chiropractic profession should claim neuromusculoskeletal medicine as a specialty, my answer is a resounding yes. When a chiropractor performs

a chiropractic adjustment or provides a soft tissue treatment to alleviate pain or dysfunction, the patient’s neurological and musculoskeletal systems react to the interventions. It is time for the chiropractic profession to claim its area of expertise and prevent attacks on our scope of practice.

The Texas Medical Association (TMA) has been pursuing an anti-competition attack on chiropractors in the state since 2006. The TMA sued the Texas Board of Chiropractic Examiners (TBCE) claiming their practice act did not permit chiropractors to diagnose. Then in 2016, the TMA sued the TBCE claiming that the chiropractic scope of practice does not permit use of the terms musculoskeletal system, nerves, subluxation complex, or neuromusculoskeletal conditions, and the judge agreed. In my opinion, antiquated chiropractic practice acts do not protect our privilege to practice chiropractic medicine.

As an associate professor of clinical sciences at the University of Bridgeport School of Chiropractic (UBSC) in Connecticut, I support its model of healthcare, which stresses the importance of evaluation and management of neuromusculoskeletal conditions. I suspect that if you review your chiropractic institution’s model of healthcare, it would be very similar to the one offered by UBSC.

As a chiropractic specialist, board certified in chiropractic orthopedics, and a provider of healthcare services to patients suffering with chronic pain within a Federally Qualified Health Center, I realize the need to specialize in the evaluation and management of neuromusculoskeletal conditions that cause chronic pain. It has become quite clear to me that chiropractic care is not available to more than 30 million Americans in pain who receive care in community health centers (CHC) and rural health centers, because very few of the centers credential chiropractic specialists.

According to the European Chiropractic Union, chiropractors focus on evaluation and management of musculoskeletal problems. “In countries where chiropractic is regulated by law, it is generally accepted as a profession that deals with musculoskeletal conditions” they state.

The profession should modernize its scopes of practice with one National Practice Act that promulgates evidence-based and patient-centered care without antiquated limitations. The National Practice Act should offer a scope of practice that supports postdoctoral education in the form of resident training, board certified specialization, and expansion of scope based upon pertinent training and credentialing. Fortunately, the chiropractic scope of practice in Connecticut offers the musculoskeletal scope of practice:

The practice of chiropractic means the practice of that branch of the healing arts consisting of the science of adjustment, manipulation and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, which may be a cause of disease, are adjusted, manipulated or treated.

In 2009, the Community Health Center, Inc. of Middletown, Connecticut contacted the Connecticut Chiropractic Association (CCA) and asked for assistance with the integration of chiropractic care for the evaluation and management of chronic pain. The CCA referred the community health center to the UBSC. Consequently, the dean of the chiropractic college asked me to meet with the organization. It was obvious that this non-profit organization was searching for chiropractic specialists to enhance the evaluation and management of their chronic pain population. While the 2010 pilot study was in process at the Meriden primary care site, the Institute of Medicine was studying pain as a significant health problem in our country:

In 2010, the National Institutes of Health (NIH) contracted with the Institute of Medicine (IOM) to undertake a study and make recommendations “to increase the recognition of pain as a significant public health problem in the United States.”

While credentialed as a chiropractic orthopedist in the Lovelace Medical Center, I provided chiropractic services to patients in pain that were referred by primary care providers, medical specialists, and physical therapists. A three-year study concluded that medical physicians and surgeons were pleased to refer patients in pain to a chiropractic specialist within their institution. Today, the chiropractic profession enjoys many opportunities to integrate chiropractic services into Federally Qualified Health Centers, private and public hospitals, medical schools, health science centers, military hospitals, and Veterans Administration hospitals, and provide non-pharmacological treatments to those patients suffering with painful neuromusculoskeletal conditions.

A study funded by the Mayday Foundation revealed that medical education does not properly prepare medical physicians to evaluate and manage patients in pain:

Most people in pain, including those with chronic symptoms, go to primary care providers to get relief. But current systems of care do not adequately train or support internists, family physicians and pediatricians, the other health care providers who provide primary care in meeting the challenge of treating pain as a chronic illness. Primary care providers often receive little training in the assessment and treatment of complex chronic pain conditions.

Chronic pain, if not recognized and treated as a chronic illness, takes an enormous personal toll on millions of patients and their families, and leads to increased health care costs.

Chronic pain in America is an epidemic and non-pharmacological pain treatment offered by chiropractic specialists is part of the solution. Not only do the chiropractic schools prepare chiropractors to evaluate and manage neuromusculoskeletal conditions, both postdoctoral training and board certification are available to train and credential chiropractors as chiropractic specialists. Since the Joint Commission calls for chiropractic care and the Centers for Medicare and Medicaid Services cover the costs of chiropractic care for chronic pain, it is time for chiropractic specialists to become more available within Federally Qualified Health Centers.

I close this article with a question for the chiropractic profession: will chiropractors accept the challenge to become chiropractic specialists, integrate into healthcare systems, and offer non-pharmacological, pain treatment as called for by the Joint Commission?

References

A Call to Revolutionize Chronic Pain Care in America: An opportunity in health care reform. Retrieved from: http://www.maydaypainreport.org/

Babcock S. (2006) Texas Arm of the AMA Strikes Out at Chiropractic: Texas Board of Chiropractic Examiners Sued Over Scope-of-Practice Procedures. Dynamic Chiropractic.

BenElihahu, D. (1996) Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. Journal of Manipulative and Physiological Therapeutics.

Borody, C. (2004) Neck-tongue syndrome. Journal of Manipulative and Physiological Therapeutics.

European Chiropractors’ Union. (2013) The Status of Chiropractic in Europe: a position paper. Retrieved from: https://chiropractic-ecu.org/wp-content/uploads/2017/02/Status-of-Chiropractic-in-Europe-A-Position-Paper-May-2013.pdf.

Heyward, J. (2018) Coverage of Nonpharmacological Treatments for Low Back Pain Among U.S Public and Private Insurers. Journal of the American Medical Association 2018. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/30646222.

Joint Commission New Regulations for Pain Management Emphasize Monitoring and Non-Pharmacological Approaches. Retrieved from: http://blog.beekley.com/joint-commission-new-regulations-for-pain-management-emphasize-monitoring%2C-non-pharmacological-approaches.

Lehman, J., Flinter, M., Channamsetty, V., and Anderson, D. (2016) Health Care Reform: Integration of Chiropractic Care for Chronic Pain Treatment in Community Health Centers.

Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. (2011) Institute of Medicine.

Pasternak, D., Lehman, J., Smith H., and Piland, N. (1999). Can medicine and chiropractic practice side-by-side? Implications for healthcare delivery.

Polkingham, B. and Colloca, C. (2001) Chiropractic treatment of postsurgical neck syndrome with mechanical force, manually assisted short-lever spinal adjustments. Journal of Manipulative and Physiological Therapeutics.

Texas Chiropractic Association. (2016) Court Sides with TMA on Chiropractic Scope of Practice Lawsuit. Retrieved from: https://www.chirotexas.org/index.php?option=com_content&view=article&id=2903:court-sides-with-tma-on-chiropractic-scope-of-practice-lawsuit&Itemid=173.