Introduction to a Rewarding Career
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“The Chiropractic Assistant”
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To enter the health-care field as a chiropractic assistant is an adventure for the qualified individual. The nationwide trend in the primary care professions is not only to provide qualified health-care professionals but also to assure that assistants are qualified to carry out their duties and responsibilities in caring for the health needs of patients. To achieve this goal,
(1) chiropractic physicians are encouraged to use assistants to increase personal efficiency, and
(2) chiropractic organizations are encouraged to sponsor legislation establishing a nationwide accredited chiropractic assistants program.
All states and Puerto Rico have statutes recognizing and regulating the practice of chiropractic as an independent health service because the profession has proven its value as a public service. On foreign shores, the practice of chiropractic is officially recognized and regulated in Canada, Switzerland, Germany, New Zealand, Western Australia, Bolivia, and is acknowledged and accepted in the British Isles, South Africa, Rhodesia, Japan, France, Denmark, Belgium, Italy, and Egypt. Official recognition is being initiated in scores of other countries.
Note: While most doctors of chiropractic are males, the number of female practitioners is growing. Likewise, while the majority of chiropractic assistants are female, an increasing number of males are assuming the role of chiropractic assistant. For the sake of simplicity and not sexual bias, the pronoun “he” is used throughout this program when referring to the doctor of chiropractic, and the pronoun “she” is used when referring to the chiropractic assistant. This is solely to avoid the redundant “he or she” or “he/she” when referring to the doctor or assistant.
WHO ARE INVOLVED IN ADMINISTERING CHIROPRACTIC HEALTH CARE?
The Doctor of Chiropractic. The titles doctor of chiropractic (DC), chiropractic physician, and chiropractor are synonymous. A doctor of chiropractic is a physician concerned with the health needs of the public as a member of the healing arts who gives particular attention to the relationship of the structural and neurologic aspects of the body in health and disease. Being thoroughly educated in the basic and clinical sciences as well as related health subjects, the professional education of a chiropractor prepares him as a primary health-care provider. As a portal of entry to the health delivery system, the chiropractic physician must be well educated in diagnosis and case management to care for the human body in health and disease and to consult with or refer to other health-care providers.
The Chiropractic Assistant. The terms chiropractic assistant (CA) and chiropractic paraprofessional are synonymous. A chiropractic assistant is a professional aid to the doctor of chiropractic under whose direct guidance and supervision performs various technical duties, office and business functions, and/or assists in the preparation, control, and care of patients. The term chiropractic assistant may refer to either an administrative assistant or a clinical assistant.
Administrative Assistant. An administrative assistant is one whose major duties and responsibilities concern basic office administrative, business, and other nonclinical procedures.
Clinical Assistant. The terms clinical assistant and technical assistant are synonymous. A clinical assistant is one whose major duties and responsibilities are related to helping with supervised diagnostic and therapeutic procedures.
Certified Chiropractic Assistant. Certification is awarded to an assistant who has received education in chiropractic philosophy, terminology, various physical diagnosis procedures, anatomy and physiology, clinical laboratory procedures, ethics and jurisprudence, radiologic technology, adjunctive therapy, and basic office procedures, and who has been examined by a credible agency (eg, Chiropractic Board of Examiners) and found worthy to carry out the duties and responsibilities of a chiropractic assistant in harmony with legislated, professional, ethical, hygienic, and safety standards.
Certification is a form of licensure. It allows an assistant to a primary care physician to perform certain diagnostic, therapeutic, and rehabilitative services that are beyond the legal scope of an uncertified assistant. There is a growing trend to have assistants obtain specific certification and continuing education in the application of roentgenographic equipment, physiologic therapeutics, and other clinical procedures. These requirements vary from state to state. For example, assistants can be certified in Oklahoma to administer vitamin/mineral supplements by injection.
HOW CHIROPRACTIC IS SIMILAR TO OTHER HEALTH-CARE PROFESSIONS?
The federal government along with every state legislature recognizes three major professions as primary health provider groups. These healing arts in order of both number of practitioners and public utilization are the allopathic, chiropractic, and osteopathic branches of generic medicine. Governmental recognition, licensure in all states, educational standards maintained by an agency recognized by the U.S. Department of Education, inclusion in health-care programs, and utilization of standardized diagnostic procedures are but a few of the common factors among all recognized healing professions.
As explained above, practitioners of allopathic medicine (MDs), chiropractic (DCs), and osteopathic medicine (DOs) are the three types of primary health-care providers licensed in all states. Licensure is granted by state boards of examiners according to state statutes.
A listing of subjects common to all health sciences is shown in Table 1.1. It is an advantage of the aspiring chiropractic assistant to become quickly acquainted with these terms because they are commonly used. As other major health-care professionals, chiropractic health care is provided for in such federal programs as Medicare, Medicaid, the Government Employees Hospital Association Benefit Plan, the Mailhandlers Benefit Plan, and the Postmasters Benefit Plan, along with other programs. It is included in the policies of virtually every major health-insurance carrier and in federal and state Worker’s Compensation Acts. In addition, a substantial number of major international and local labor unions provide for chiropractic services in their health and welfare plans, and many industrial employers include chiropractic care in the health plans for their employees.
Table 1.1. Areas of Common Study and Specialties Among Primary Providers
Anatomy. The science that studies the structure of the organism and the relation of its parts.
Angiology. The study of blood and lymph vessels.
Bacteriology. The study of microscopic organisms. A specialist is called a microbiologist or a bacteriologist.
Cardiology. The study of the heart. A specialist is called a cardiologist.
Dermatology. The study of the skin. A specialist is called a dermatologist.
Diagnosis. The art or act of determining the nature of disease. A specialist is called an internist.
Dissection. The cutting of tissues of the body for the purpose of anatomical study or during autopsy to determine the cause of death.
Embryology. The study of the embryo and the origin and development of life.
Endocrinology. The study of ductless glands and hormones. A specialist is called an endocrinologist.
Gastroenterology. The study of the stomach and intestines. A specialist is called a gastroenterologist.
Gynecology. The study of diseases peculiar to women. A specialist is called a gynecologist.
Histology. The study of the microscopic structures of tissues.
Hygiene. The study of the rules of health. A person who emphasizes this aspect of health care is called a hygienist.
Kinesiology. The study of motion. A specialist is called a kinesiologist.
Myology. The study of muscles.
Neurology. The study of the nervous system. A specialist is called a neurologist.
Obstetrics. The care of the woman during pregnancy, parturition, and the puerperium. A specialist is called an obstetrician.
Ophthalmology. The study of the eye and vision. A specialist is called an ophthalmologist.
Orthopedics. The study of diseases of bones, joints, and related structures. A specialist is called an orthopedist.
Osteology. The study of bones and the morphology of bony parts.
Otolaryngology. The study of diseases of the ear, nose, and throat. A specialist is called an otolaryngologist.
Pathology. The study of the nature of disease. A specialist is called a pathologist.
Pediatrics. The study and treatment of children’s diseases. A specialist is called a pediatrician.
Physiologic therapeutics. The application of natural forces (eg, light, heat, cold, electricity, vibration, massage, exercise, rest, supports) to assist in normalizing function and enhance recuperation. A specialist is called a physiatrist.
Physiology. The study of the functions of the living body or its parts. A specialist is called a physiologist.
Proctology. The study and treatment of diseases affecting the rectum and anus. A specialist is called a proctologist.
Psychiatry. The study and medical treatment of abnormal psychologic disorders. A specialist is called a psychiatrist.
Psychology. The study of the functions of the mind, the relation of behavior to the environment, and the nonmedical treatment thereof. A specialist is called a psychologist.
Radiology. The study of x rays and their therapeutic application. A specialist is called a radiologist.
Roentgenology. The study of the diagnostic application of x rays. A specialist is called a roentgenologist.
Splanchnology. The study of viscera: organs of the thorax, abdomen, and pelvis.
Syndesmology. The study of ligaments.
Terminology. The study of health-care terms.
Toxicology. The study of poisons. A specialist is called a toxicologist.
Urology. The study and treatment of diseases of the urinary system. A specialist is called a urologist.
HOW CHIROPRACTIC DIFFERS FROM OTHER HEALTH-CARE PROFESSIONS?
Doctors of chiropractic are physicians who consider the human body an integrated being and give special attention to spinal mechanics and neurologic, osseous, muscular, and vascular relationships. The three types of primary health-care providers essentially differ in their philosophy of and approach to health care, emphasis, and legislated scope of practice (services).
The Chiropractic Approach
While facts are unalterable, viewpoint and emphasis can be different in an approach to health care. Disease, for example, is abnormal function, and abnormal function is function out of time and phase with environmental need. Disease does not involve a new function. It is only the consequence of change—change in quality, frequency, and/or channeling of nerve impulses and metabolism in terms of cellular nutrition, waste removal, and repair. Sickness is not the result of what something does to the body but what the body does about it because existing mechanical, chemical, and/or psychic impairment of the nervous system prevents adaptation. In other words, disease follows when environmental disturbances disturb the nervous system and prevent a normal adaptive response.
Commonly encountered mechanical irritants include physical injuries, gravitational and occupational overstress, postural defects and faults, developmental asymmetries, prolonged unbalanced work or play, and deforming changes in the articular beds of joints. In the latter, spinal and extraspinal changes often are sites of insult difficult to detect by those untrained in chiropractic methods.
Other potential environmental irritants include the toxins of pathogenic microorganisms; drugs, pesticides, and other chemicals; radiation, noise, and metabolic wastes or other pollutants. Of these, the metabolic wastes of cellular activity probably tax the adaptability of cells the most. The emotional and mental disturbances arising from the effect of hostile human relations and blocked self-actualization are the principal psychic irritants encountered in our society today. Rarely does an organic disease not have a psychic component that adds to the clinical picture.
It has been erroneously reported that chiropractors do not believe in germs. Nothing is further from the truth. It is a basic chiropractic precept that both internal and external environmental factors (and germs are an inescapable component of our environment) decide one’s potential for health and disease. Further, this is not a matter of belief or disbelief but a realistic scientific appraisal of the germ theory.
Summary. Any undue hindrance to nerve function can produce dysfunction and thus initiate disease in the susceptible individual. Pathology (disease) is always preceded by dysfunction. In broad terms, disease is the product of abnormal function and abnormal function is the effect of the body’s inability to cope with overstress. Such stress may result from one or a combination of irritations—mechanical, thermal, chemical, hormonal, bacteriologic, viral, parasitic, psychologic, and so forth. Susceptibility is also determined by many factors. A common external factor is the degree of noxious environmental demands, and a common internal factor is the body’s resistance. The quality of the latter is essentially determined by neurologic, nutritional, and hereditary factors.
THE NERVOUS SYSTEM: PRIMARY REGULATOR OF FUNCTION
Why do some get sick and not others during an epidemic? Freedom from infectious disease does not solely depend on the absence of microorganisms—a condition never realizable because bacteria are ubiquitous—but on maintenance of normal function (physiologic activity) despite their presence. The body tries to protect itself against noxious microorganisms by producing antibodies and other defense mechanisms to destroy invading microbes and/or their products. The production of antibodies and other pertinent cells is regulated both directly and indirectly by the nervous system. Hence, the most fundamental therapeutic approach (and protection) is to assure undisturbed function of the nervous system.
Many potentially dangerous microorganisms are normally found within the healthy body but their growth are held in check. However, an excessive environmental irritation of the nervous system can disturb this symbiotic balance and permit microorganisms already present to initiate the infectious process. This is why chiropractic has emphasized the importance of human ecology in relation to the nature of disease. The physiologic integrity of the host is usually more important than the microorganisms that invade it because progressing infection results from an inadequacy in natural defense mechanisms. Again, this inadequacy is due essentially to
(1) one or more noxious environmental forces affecting the nervous system (by whatever means) or
(2) unusual resilience or strength of the invading organism.
Contemporary medical practice emphasizes disease and the results of disease. After proper diagnosis, attention is given to relieve pain and other overt symptoms, neutralize chemical imbalances, and remove diseased tissues and organs. While such an approach has led to brilliant discoveries, much remains unchallenged. Chiropractic, in contrast, emphasizes health and the results of normal structure and balanced function.
Chiropractic: Often a Conservative Alternative
Little in life can be logically discussed in polarized terms of black or white. This is especially true within the healing arts. The chiropractic profession openly recognizes the positive results obtained in the cautious use of chemotherapy, but it also holds a concern over rigid rituals that fail to consider undesirable side effects. The profession also recognizes the need for necessary surgery, yet it is conscious of its dangers. Thus, the chiropractic profession feels that its more conservative approach should be offered objective appraisal before the patient is subjected to potent drugs or risk the dangers involved in surgical intervention. While potentially dangerous measures may be necessary, they should be considered as the last resort and not as the only alternative available in health care.
It has been explained that infection represents the change from an uneasy truce into a state of open warfare between microorganisms and host when a lowered resistance arises primarily from a morbid irritation to the nervous system. Therefore, the role of chiropractic therapy is to relieve irritation of the nervous system and restore optimal function.
Antibiotics and other potent drugs have certain beneficial effects in reducing bacterial populations. However, it must not be forgotten that chemotherapy may enhance other latent microorganisms. As a chemical irritant to the nervous system capable of upsetting functional equilibrium in minor infections, the antibiotic could trigger an unfavorable reaction and thus produce iatrogenic complications. Therefore, drugs should not be indiscriminately used in infections of a minor or moderate character. While chiropractic has voiced its concern of the indiscriminate use of “miracle” drugs for several decades, it has only been in recent years that the scientific community and governmental agencies have also become openly concerned.
Only unbiased judgment and clinical experience can help the physician in making the decision to chance the beneficial effects of a therapy as opposed to the possible detrimental effects it could or might produce. Pathologist William Boyd emphasized the importance of such judgment when he reported that “Old diseases are disappearing, but new ones are taking their place which are often man-made, the result of injudicious use of therapeutic agents.” Here we should realize that the disappearance of many diseases common in the past cannot be credited exclusively to the healing arts; the disappearance is due largely to accomplishments in sanitary engineering.
Chiropractic’s approach establishes and maintains optimal physiologic activity by correcting abnormal functional and structural relationships. Its goal is to help the body in using its own biologic resources for a return to normal function. Its focal point of concern is with the integrity of the nervous system because it is the nervous system that is responsible for integrating and coordinating the major functions in the body responding to internal and external change—normal and abnormal.
Rational thinking concludes that a comprehensive health-care system must be more than an attempt to hide symptoms or remove diseased organs. While a drug may be helpful in easing pain, it may not rectify the cause of the pain. While surgery may be necessary to remove a diseased organ, it may not address itself to why the organ did not function normally. The suppression of symptoms or the removal of disease by-products cannot be considered actions that automatically return a person to optimal health. Chiropractic physicians are convinced that a comprehensive health-care system must be a great deal more than recipe, relief, repair, or removal.
The position of the chiropractic profession is not negative. It is realistic and positive—compatible with the most advanced facts bearing on problems of human disease and disability. The encouragement of optimal nutrition, fresh air, sunlight, exercise, and personal hygiene long ago became an established routine of practice. The chiropractor is a champion of slum clearance and adequate housing who advocates working conditions avoiding unnecessary stress and an environment as free from pollution as possible. But he is not a radical. He considers fear campaigns and overly publicized situations leading to psychic stress a disservice to general health. He encourages the assurance of the highest level of efficiency of the nervous system and natural immune mechanisms and hence the best level of health and resistance to infection and tissue degeneration. He therefore encourages every effort that will decrease poverty or raise the level of living standards, general health, and physical fitness.
Because a basic cause of disease is adverse environmental irritation of the nervous system, it is apparent that any measure that will help relieve such irritation, despite its nature, constitutes indicated therapy. At times, the source of nerve irritation is obvious, simple, and accessible—making the therapeutic approach easy. Then again, the irritating factors may be complex, obscure, manifold, and inaccessible or long standing and thus pose a more complicated therapeutic problem.
Obviously, no single therapy offers a panacea. However, one approach may be better suited to a particular problem than another, or a combined effort might be advisable. This places an enormous responsibility on the physician because he has to decide which therapy or therapies are indicated for an individual patient’s status. There might be a case in which the patient’s disorder may be cared for by the therapeutic competency of one specific school of healing and other instances where the skill and wisdom of an alternative profession or more than one discipline of the healing arts are required. Principles oblige all physicians to discern according to their best ability which path of treatment should be followed. This obligation presents one of the most difficult tasks confronting practitioners of the healing arts.
EXAMPLES OF PROFESSIONAL RECOGNITION
In 1974, the Department of Family and Community Medicine of the University of Utah College of Medicine compared the effectiveness of the allopathic physician to chiropractic care. The study showed, in terms of both patient perception of improvement in functional status and patient satisfaction, that chiropractors are as effective if not more effective with the patients they treated as were the allopathic physicians. This conclusion has been arrived at by many similar studies since then.
The treatment of on-the-job injuries has not been avoided. Studies of worker’s compensation records in several states provide objective evidence of the efficacy of chiropractic care. Comparisons of chiropractic and medical treatment demonstrate dramatically that cases under chiropractic care show reduced treatment costs, reduced compensation costs, reduced work-time losses, and reduced worker disability and suffering.
Because chiropractic offers a more conservative approach, possibly a more humanized approach to health care, it is no wonder that this form of therapy is rapidly gaining in recognition and acceptance.
The Philosophy of Chiropractic
It would be extremely rare if not impossible to find a person ill from a single specific disease entity such as a stomach ulcer. Is not the ulcer the result rather than the cause of the disorder? While surgical removal may be advisable in advanced cases, it does not mean that conditions allowing the formation of the ulcer in the first place have been removed. Yet, referred postoperative chiropractic therapy has not been used to its maximum. This is unfortunate—reducing the level of public health. It underscores that a change of attitude in the medical establishment is needed.
It is the rare neighborhood, for example, that does not have its number of people who have had numerous operations by numerous surgeons who have made numerous incisions resulting in numerous adhesions to remove the numerous by-products of failing organs—while the cause of the failure continues in its nefarious path to be displayed in numerous types of adverse symptoms, signs, and syndromes. For this reason, chiropractors believe there should be more to health care than the numbing of pain, the camouflaging of symptoms, and the removal of pathologic tissue.
The relationship of biomechanics (structure) to biodynamics (function) has been emphasized by the chiropractic profession for almost a century. Evidence of the importance of removing and preventing spinal impairments is growing each year—a recognition that the nervous system maintains a primary role in integration of all body systems.
The central nervous system (CNS) originates in brain centers and extends down through the spinal column, ultimately reaching every part of the body through the peripheral nervous system. Interference anywhere in the nervous system impairs bodily function and induces disease. One common site of insult is that point where nerves exit or enter the spinal column. Such insults often result from what chiropractors call subluxations (partly displaced vertebrae) or fixations (partly restricted vertebrae) that cause or contribute to neurologic disorders altering both structural balance and functional tone.
The mechanical lesion (subluxation or fixation) is an attending complication of those structural, chemical, and/or psychic environmental irritations of the nervous system producing muscle contraction sufficient to cause dysfunction of spinal articulations. Once produced, the lesion becomes a focus of sustained irritation. It irritates nerves in the articular capsules, ligaments, tendons, and muscles of the involved spinal segment. A barrage of impulses stream into the spinal cord where they are relayed to motor and sensory pathways for control of muscles and glands. The contraction originating the lesion is thereby re-enforced, thus perpetuating both the subluxation and the pathologic process engendered. This vicious cycle is commonly recognized in clinical chiropractic. Not all the spinal irritation originates this way, however.
INTERVERTEBRAL FORAMEN IMPAIRMENT
Other complications involved include the effect on vessels and nerves as they enter or exit the spine through distorted “open doorways” called foramina. The injury (often microtrauma) attending the vertebral subluxation may set off an inflammatory reaction with swelling or bony compression that tends to encroach on the portion of the spinal nerves and attending vessels contained within the intervertebral channel. The process may terminate in adhesions. Greater encroachment may occur on the foraminal contents (such as the soft tissues, nerve trunk, and other elements) with the presence of developmental defects, congenital anomalies, osseous asymmetries, and degenerative and proliferative changes such as on the circumference of the channel or in the fibrocartilaginous discs between the spinal segments.
INTERVERTEBRAL DISC DISORDERS
Each vertebrae of the spine is separated from neighboring segments by a spinal disc. These 23 pad-like structures not only cushion the 24 movable spinal vertebrae but also make possible the flexibility of the spine that is so essential to normal bending movements. Disc disorders can lead to irritation of the spinal nerves directly or indirectly. With the contributory factor of the subluxation, such complications may trigger a full fledged syndrome of severe nerve root compression or irritation. Because almost all spinal nerves pass through movable passageways (the foramina), such contingencies by no means rare. The validity of this approach is attested by millions of chiropractic patients each year.
While such mechanical lesions are frequently associated with the spine, they also can exist in other parts of the musculoskeletal system (eg, articulations of extraspinal joints). As disturbances in one area may produce disorders in other areas, the accurate determination of cause and effect of a patient’s problem often involves detailed complicated analysis. The musculoskeletal system is intimately connected with all other body systems through the nervous system.
A corrective structural adjustment by a chiropractic physician (spinal or extraspinal) should not be confused with other forms of manipulation. Manipulative therapy in one form or another is used somewhat in all the healing arts. Allopathic manipulation is usually little more than a therapist putting a patient’s joint through its normal range of motion to stretch muscles and break adhesions. Osteopathic manipulation is designed to increase joint motion and relieve fixations. On the other hand, a chiropractic corrective adjustment is made only after careful analysis and delivered in a specific manner to achieve a specific predetermined goal. It is a precise delicate maneuver requiring special bioengineering skills and a deftness not unlike that required by a neurosurgeon. The effect is stimulating but seldom painful.
Most chiropractic corrective adjustments are made upon the joints, especially those of the spinal column. Some techniques, however, are light touch reflex techniques that involve the neurovascular, neurolymphatic, and neuromuscular systems—much akin to the systems involved in Oriental meridian therapy. These surface techniques, often applied remote from the spine, are far more than massage or trigger point releases because they involve prudent diagnosis and can be scientifically applied only after comprehensive training.
BRIEF HISTORY OF HEALTH CARE
Although the exact origin of therapeutic manipulation is lost in antiquity, anthropologic findings show that this health approach has existed throughout the world since the beginning of recorded time. Some of the earliest indications of manipulation are demonstrated by the ancient Chinese Kong Fou document written about 2700 BC. Greek papyruses dating back to at least 1500 BC gave instructions on the “maneuvering” of the lower extremities in the treatment of low-back disorders. There appears no single origin of the art. Therapeutic manipulation was practiced by the ancient Japanese, Chinese, Indians of Asia, Egyptians, Babylonians, Syrians, Hindus, Tibetans, Tahitians, and American Indians.
Records from as long ago as 5000 BC show that ancient societies had some type of standard of care for the sick and injured. Their theories were based on the religion and myths prevalent at the time. Around 2000 BC, certain men developed occupations as physicians in Egypt, Babylon, Assyria, and the Orient. Moses, an advocate of preventive medicine and hygiene, incorporated rules of health into the Hebrew religion around 1205 BC.
Hippocrates, the Father of Medicine, recognized the importance of spinal manipulation. Little was known at the time of human anatomy, physiology, and pathology, and there was no knowledge of biochemistry. Yet, despite these handicaps, he did much to separate medicine from mysticism and founded the first steps in giving it a crude scientific basis. Many of his classifications of diseases and descriptions of symptoms are still being used today.
A prolific writer, Hippocrates wrote at least 70 books on healing. They included Manipulation and Importance to Good Health and On Setting Joints by Leverage. Emphasizing the importance of the spine, he said, “Get knowledge of the spine, for this is the requisite for many diseases.” Summum bonum—the highest good is to remove the cause, taught Hippocrates: “Nature must heal; the physician can only remove the obstruction.” He taught that the body tends to heal itself and it is the physician’s responsibility to help nature.
Herodicus, a contemporary of Hippocrates, earned wide fame by curing diseases by correcting abnormalities in the spine, which he did in the relatively healthy through therapeutic exercises and in the weak by manipulations with his hands. The early Greeks also used a multitude of mechanical devices for stretching the spine and setting dislocations. A variety of crude traction devices was invented.
In later Greece, Claudius Galen (131—201 AD) was the most distinguished practitioner of his time. He studied, practiced, and taught in Rome. There he wrote over 500 treatises on health care and conducted research in experimental physiology and neurology. It was he who first taught the proper positions and relations of the vertebrae and the spinal column. He was the first to describe the cranial nerves and the sympathetic nervous system.
Galen was given the title “Prince of Physicians” after he corrected a paralysis of the right hand of Eudemus, a prominent Roman scholar. He did so by treating the patient’s neck, apparently by adjusting the cervical vertebrae interfering with normal nerve transmission to Eudemus’ hand.
Like Hippocrates, Galen recognized the importance of the nervous system. He taught his students to “Look to the nervous system as the key to maximum health.”
RESISTANCE TO NEW THOUGHT BY THE MEDICAL ESTABLISHMENT
During the Dark Ages, public opinion was thwarted by religious and political leaders who believed that all what could be learned was known. They held ancient religious teachings and the historic theories of Hippocrates and Galen as law. Thus, innovation was considered highly questionable behavior. It was not until universities formed in the 16th Century that the observation of the sick began to evolve as a study of theories of disease.
Throughout this period, the tendency to deviate from orthodox teachings was ridiculed. The Belgian anatomist, Vasalius (1514—1564), now considered the Father of Modern Anatomy, broke with many of Galen’s teachings and was severely persecuted. This was also true for studies by William Harvey (1578—1657) on the heart and circulation—brilliant reasoning that was not fully recognized by the medical establishment until 200 years later.
The Hungarian physician, Philipp Semmelweis (1818—1865) recognized that some diseases were transmitted by physical contact. He ordered students and colleagues entering his wards directly from autopsy and dissecting rooms to wash their hands with a disinfectant (a solution of chloride of lime). Al-though this practice greatly reduced the spread of puerperal fever (that following childbirth), his hygienic measures were met with violent opposition. Later, Louis Pasteur (1822—1895), the Father of Bacteriology, and Joseph Lister (1827—1912), the Father of Sterile Surgery, proved Semmelweis correct, but they too suffered years of humiliation by the establishment who believed that infection and pain were God given and inevitable.
Even Florence Nightingale (1820—1910), the creator of the Women’s Nursing service during the war in Crimea was regarded as a “troublesome female intruder” when she advocated hygienic practices and that nurses receive special training and experience. The same was true for philanthropist Clara Barton (1821—1912) when she tried to improve medical record keeping and the recruitment of supplies and to organize a Red Cross Committee during the Civil War.
During the Middle Ages and Renaissance, the art of manipulation (often called “bonesetting”) was handed down from father to son or mother to daughter and practiced by at least one supposedly “gifted” person in most communities of Europe, North Africa, and Asia. Because of the archaic state of medical practice in those days, the results obtained by these individuals were so unusual to traditional thinking that the people believed that the manipulators had inherited a divine gift to heal the sick. All but a few medical practitioners considered them “quacks.”
Highly skilled but without the benefit of formal education, the bonesetters of Europe, particularly in England, met with flourishing success. Because of their eclat with many patients labeled hopeless by traditional physicians, early manipulators were inspired to exaggerate claims of cure that further alienated the “orthodox” medical community. Gradually, succeeding manipulators became more clinically and scientifically oriented and less prone to rash claims. But unpalatable memories remained, and the establishment kept their minds closed to any scientific advances made by the manipulators. Other physicians, though realizing the merit of manipulation, selfishly rationalized by rejecting it under the guise of “scientific unacceptability.”
This bias has remained for centuries. Despite mounting scientific evidence to the contrary, political medicine has been stubborn in maintaining a monopoly in health care.
Birth of Modern Chiropractic
Modern chiropractic reflects the rediscovery of therapeutic manipulation.It was revealed, improved, and founded in the United States by Dr. D. D. Palmer in 1895. In his first book, he wrote: “I am not the first person to replace subluxated vertebrae, but I do claim to be the first person to replace displaced vertebrae by using the spinous and transverse processes as levers ...and to develop the philosophy and science of chiropractic adjustments.”
By the late 19th Century, many basic concepts and clinical principles of modern day usage had been established. It seems probable that the genesis of modern theory and practice of manipulative therapy used by chiropractors and osteopaths arose from concepts generally acceptable to many 19th Century medical practitioners and scientists because it was during this period that the role of the spinal cord in health and disease was being vigorously explored and discussed.
THE EFFECT OF POOR COOPERATION
However, the three contemporary clinical professions (MDs, DCs, DOs) have developed in relative isolation from one another. Each group evolved primarily in a clinical setting with a self generated terminology specific to the history of their particular clinical school of thought. Individuals from each philosophy of therapy have crossed professional lines as students or instructors, but this has not been done openly or in large numbers. As a result, a major problem is the difficulty of sharing clinical experiences and scientific results because of self-developed terminology and interprofessional isolationism. In recent years, this barrier has begun to weaken.
THE DAWN OF A NEW APPROACH
Since its inception, chiropractic has felt that health is the result of the body’s remaining in harmony with the principles of nature. Chiropractic pioneers were severely attacked for their criticism of drug overutilization, involuntary immunization programs, the perversion of food during processing, and the neglect of physical fitness. Today we realize the validity of such criticism. Both society and science now realize that we have placed too much attention on prescription rather than prevention, too much attention on weakening invaders rather than on strengthening their host. Concern for both the internal and external environments should be kept in balance. Ecology concerns our total environment—both within and without.
Scope of Chiropractic Practice
Spinal analysis and adjustment have always been emphasized within the practice of chiropractic, but they by no means constituted the sole scope of practice used by the majority of practitioners. In fact, several forms of therapy now gaining popularity within all the healing arts can thank chiropractic pioneers for their development in this country. Many physiotherapy modalities, for example, were perfected by DCs and their use taught in chiropractic colleges long before the profession of physiotherapy was created. History records that the use of physiologic therapeutic devices within the healing arts was initiated and developed in this country by nonallopathic professions, with pioneer chiropractors offering major leadership in both application and development.
Therapeutic nutrition also has been an important subject within the chiropractic curriculum for decades. Unfortunately, even during the enlightenment of today it is allowed only a few hours of instruction in medical schools. Emphasis is locked on chemotherapy and surgery.
While Oriental acupuncture and acupressure have received much publicity within the popular press and interest within the majority profession since the late 1960s, the use of peripheral stimulation to elicit certain physiologic reactions has been known and commonly applied within chiropractic since the turn of the century. It has always been an attribute of chiropractic to seek and develop conservative health-care measures.
HEALTH-CARE EDUCATION IN AMERICA
Flexner (1866—1959), received a commission from the Carnegie Foundation to study the quality of medical education that substantial improvement in medical education was made. The Flexner Report of 1910 resulted in many of the 155 medical schools rated to be closed because of their extremely poor quality of instruction and teaching facilities.
Few realize that it only has been in this century that medical education has been refined. During the early years of this country, the typical medical doctor had little formal education. In the western states, a candidate would observe a recognized doctor’s work until that physician thought that the candidate was ready for solo practice. State licensure did not become widespread until after the turn of the century.
In 1893, John Hopkins University Medical School in Baltimore was the first medical college to require entrants to have a year’s training in the natural sciences. It also established the first teaching hospital. However, it was not until an educator, William be closed because of their extremely poor quality of instruction and teaching facilities.
Modern Chiropractic Education and Professional Development
State licensed and regulated, the chiropractor is a valuable member of the health-care professions. Six years or more of college study and internship go into the making of a doctor of chiropractic—more if the DC selects a special area of interest (eg, orthopedics, roentgenography, etc).
The doctor of chiropractic has at his disposal modern x-ray, laboratory, and other diagnostic instruments and is thoroughly trained and skilled in orthopedic and neurologic procedures. Chiropractic examinations seek to determine what is causing the patient’s body not to function properly. If the problem is one for which recognized chiropractic methods of treatment are applicable, the chiropractor will recommend a treatment plan.
A minimum of 2 years of pre-chiropractic college work are required for admission to an accredited chiropractic college. After that, 4 academic years of resident study at a chiropractic college, including practice in a teaching clinic, are required for the Doctor of Chiropractic degree. Courses are offered in a wide range of scientific areas such as human anatomy; biochemistry; physiology; microbiology; pathology; public health; physical, clinical, and laboratory diagnosis; gynecology; obstetrics; pediatrics; geriatrics; dermatology; otolaryngology; roentgenology; psychology; dietetics; orthopedics; physical therapy; first aid; spinal analysis; principles and practice of chiropractic; adjustive technic; and other appropriate subjects.
Clinical Experience. In the teaching clinics of chiropractic colleges, advanced students obtain experience in diagnosis, followed by treatment or referral. This represents the culmination of the academic learning experience and the transition from students to chiropractic physicians.
The primary professional accrediting agency for chiropractic colleges is the Commission on Accreditation of the Council on Chiropractic Education (CCE). The Council has advocated and established high standards of quality in chiropractic college education and in postgraduate or continuing education programs. The CCE dates from 1947. Its work, including that of predecessor groups, dates from 1938. The Commission on Accreditation of the Council on Chiropractic Education was added to the United States Commissioner of Education’s list of Nationally Recognized Accrediting Agencies and Associations in 1974. In l976, the Commission was officially recognized by the Council on Postsecondary Accreditation (COPA) as the accrediting agency for chiropractic educational institutions and programs.
Postgraduate Continuing Education
Most states require attendance at approved postgraduate educational pro-grams as a prerequisite to annual license renewal. The chiropractic profession was pioneer in requiring practitioners to attend approved postgraduate programs as a prerequisite to annual license renewal. The state of Colorado adopted the first requirement in 1933.
The Foundation for Chiropractic Education and Research (FCER) is a nonprofit organization established by the profession. It makes direct grants to colleges, grants for scholarships and faculty assistantships, grants for research projects, and grants for support of the CCE. The most important source of FCER funds is a percentage of the dues paid by the general members of the American Chiropractic Association. Other sources include memberships in the FCER itself, memorial giving, annual giving, donations earmarked for scholarships, interest on the FCER endowment fund, and bequests and wills.
FCER funds have been allocated directly to colleges for research, upgrading programs, and assisting in progress toward CCE accreditation goals. These programs benefit the public through progressive improvement of chiropractic care.
Sadly, the FCER was dismantled in late 2009.
BASIC PRINCIPLES OF CLINICAL CHIROPRACTIC
Diagnosis plays the same role in chiropractic as in all the healing arts: the basis for determination of the treatment. A chiropractic diagnosis is usually arrived at after an interview, physical examination, and the use of necessary diagnostic aids and laboratory tests. Chiropractic, regardless of jurisdiction, is built upon three related scientific theories and clinically established principles. Although these have been refined over the years, they represent in essence the basic concepts established by chiropractic pioneers early in the century. Today, they are accepted premises throughout the scientific community.
Disease may be caused by disturbances of the nervous system. While many factors impair health, disturbances of the nervous system are among the most important factors of disease etiology. The nervous system coordinates cellular activities for adaptation to external or internal environmental change. Environmental agents and conditions unduly impairing the nervous system and to which the body cannot successfully adapt produce fluctuations in the pattern of nerve impulses deviating from the norm. Thus originate many disease processes.
Disturbances of the nervous system may be caused by derangement of musculoskeletal structures. Subluxations and fixations of vertebral and extra-spinal articulations represent a common clinical finding. Extended abnormal involvement of the nervous system may result from disturbances arising within the neuromusculoskeletal system due to the body’s attempt to maintain an erect posture. The mechanical lesion (subluxation) is a common result of gravitational strains, asymmetric activities and efforts, developmental defects, or other mechanical, chemical, or psychic irritations of the nervous system. Once produced, the lesion becomes a focus of sustained pathologic irritation that may trigger a full-fledged syndrome of severe nerve root irritation.
Disturbances of the nervous system may cause or aggravate disease in various parts or functions of the body. Vertebral and extraspinal subluxations may be involved in common functional disorders of a visceral and vasomotor nature and at times may produce phenomena relating to special organs. Under predisposing circumstances, almost any component of the nervous system may directly or indirectly cause reactions within any other component by reflex mediation.
No scientist, pathologist, physiologist, or clinician with good conscience can find fault with these established principles. They are a matter of every-day occurrence in health science and of much more frequent incidence than commonly realized by those not directly involved in their study.
A human being is a total integrated entity. A disorder in a specific organ or tissue will have its affect on other organs and tissue function. In addition, we must realize that summation of independent causes of dysfunction may jointly have more serious debilitating effects than these cause might have separately. For example, subluxation or fixation may be a contribution to the “triggering” or exacerbating of migraine types of headaches, asthmatic syndromes, indigestion, and certain types of neurovascular and neurovisceral instabilities though they may not be the sole cause of the illness. Correction of spinal lesions often is an imperative toward the effective total management of the case.
FORMS OF CHIROPRACTIC PRACTICE
As with medical physicians, most DCs establish an unincorporated sole proprietorship in which an individual doctor holds the rights and title to all aspects of the practice and may or may not employ others to participate in the practice. In a solo practice, the owner is potentially liable for all acts of his employees but is not entitled to employee fringe benefits. Due to the in-creasing complexity of health-care practice and the necessity of carrying the burden of expensive equipment singularly, the number of solo practices has begun to diminish in recent years.
A specialty practice is one in which a doctor voluntarily narrows the practice to a special area of interest. In chiropractic, specialty councils have been established in:
(1) Diagnosis and Internal Disorders,
(7) Diagnostic Imaging,
(8) Sports Injuries and Physical Fitness, and
(9) Technique. Doctors who advertise themselves as a specialist are required to attain a higher level of certified education in a certain field and are held to a higher standard of care than general practitioners.
A partnership is a legal contract between two or more doctors in which all rights, obligations, and responsibilities of each partner are defined. Each partner is liable for the acts and conduct of the other partners unless other-wise specified in the partnership agreement.
An associate practice is one in which two or more doctors agree to share office space in the same building and possibly certain equipment facilities (eg, x-ray department, clinical laboratory) and certain employees (eg, receptionist, bookkeeper) but conduct their practices as sole proprietors. Some-times a doctor employer will refer to an employed colleague as an associate, but this should not be confused with the legal definition of the term.
A professional corporation (PC) is composed of one or more doctors who serve as shareholders of the corporation. The practice is an artificial entity having a legal and business status that must meet strict state regulations. The doctors involved are considered employees of the corporation and liable only for their own acts. There are certain tax advantages in this legal entity, and the practice does not terminate with a change in shareholders. However, the legal and administrative complexities of a professional corporation discourage this type of arrangement for most physicians.
A group practice has three or more physicians engaged in a mutually agreeable, formally organized, and legally recognized contract in which each member of the group attends assigned patients and shares in the group’s expenses, receipts, personnel, facilities, equipment, and records involved in patient care and business management of the group practice. Most small group practices consist of doctors with complementary specialties.
Attention is given in this chapter to the chiropractic profession in general: its history, approach to health care, and standard office routines so that a perspective chiropractic assistant may better appreciate her role within the office as part of the health team. In the next chapter, an overview of office philosophy and practice goals is given, along with general business aspects of practice, assistant qualifications, duties and responsibilities, the essentials of professionalism, and office policies.