Are you prepared to go to jail to preserve your right to deliver subluxation- and health-centered chiropractic care? That may be a scenario many of today’s chiropractic profession thought was a thing of the past. However, make no mistake; the opening salvo has been fired in re-launching a dark and dangerous attack from chiropractic’s not-so-distant past.
In the first installment of this six-part 33 Minutes series, the first-ever post using TCL’s Chiropractic Emergency Broadcast System, Dr. Gerry Clum describes an article that frames subluxation- and health-centered chiropractic care as illegal. By the end of this series, we hope to have provided you with a point-by-point library with which to address and counter the specious arguments and claims put forth in this article, titled “Chiropractic conservatism and the ability to determine contra-indications, non-indications, and indications to chiropractic care: a cross-sectional survey of chiropractic students.”
Click on the video below to learn more about why this article poses such a disturbing threat to chiropractors who provide subluxation-focused care within a health and wellness, neuromusculoskeletal framework. Or, keep scrolling for a transcript of the video conversation.
Clum: Good day to you, my friend. It’s good to be with you again.
Deitch: It’s great to be with you. One of the things we do at Today’s Chiropractic Leadership is everything we possibly can to make sure the profession stays aware and abreast of what’s happening in the profession internationally. Recently, you brought to my attention an article that has been, I’ll say of grave concern. We have had pressure and concerns and issues for decades. You’re not one to necessarily fear that the sky is falling. However, there’s been a recent article that has really perhaps broken a barrier of concern and today that’s really what we want to talk about. Gerry, I’m going to sort of just ask you to open up and share what the article is and then let’s get into, why this is potentially one of the most dangerous articles of our time.
Clum: Okay. Well, thank you my friend. Let me do this. If you’ll bear with me for a second, I’m going to try and open up a PowerPoint slide for us here. And let’s see if we can get that done. I’m going to share that and let me bump that up to full screen. And if I’ve done this properly, everybody should have a full screen view of the starting slide. We together on that?
Deitch: Right.
Clum: Well, Jason, as you said, I think this is one of the most dangerous articles that I have ever seen in my career and I’ve been around a long time in this, going on almost 50 years now, one way or another, and this is so significant that I’ve asked you to work with me and through Today’s Chiropractic Leadership, over the course of the next 12 weeks.
And we’d like to sit down every two weeks for 33 Minutes and walk through another portion of this article. That’s how significant this is, that we would spend close to two hours delving into this. And I can give you the punchline of this thing in three minutes. That’s not the issue. What my goal is, is that in time there’ll be a library that exists that if anybody is confronted with problems that arise out of this article, they can go back to that website and they can get a detailed walk from the first line of this article to the last line of the last reference of the article. And it’s going to take us some time to do that. And, so I’m going to ask you to bear with me, and I’m going to ask our colleagues to do the same thing and we’ll start out with this first discussion today, introduce the article, introduce the concern and introduce the first paragraph of the article. And then we’ll go on from there and we’ll be back in two weeks and check in and visit. And in the meantime, we’ll have everything posted, the transcripts available, things of that nature, and make sure that those, for those that want to study and want to delve into this, this, this article for its concern and what it represents to the profession, the tools will be there and they’ll be capable of doing that. Does that sound like a deal to you?
Deitch: That’s a great deal. I appreciate it. That’s what leadership is intended to do. So, thank you for that. Let’s also start off just creating some context. This is a relatively a relatively new article. I’ll let you go from here. Let’s just make sure people understand as you just said, and I’m going to repeat and then reiterate probably several times throughout [that] the British are coming, metaphorically. This is, as you just said, perhaps the most disturbing article you’ve seen in your 50-plus years of serving the chiropractic profession. I can’t underestimate how important that is for people to be aware of and to pay attention in what I know, what we all know, to be a very busy, noisy world. So let’s get right into it.
Clum: Okay. Thank you. Well, the article is entitled, as you can read on the screen, it’s Chiropractic conservativism and the ability to determine contra-indications, non-indications, indications to chiropractic care, a cross sectional survey of chiropractic students. And it was published in Chiropractic and Manual Therapies and it was a 2019 publication so earlier this year, and it was published by researchers out of the French institute, with campuses in Paris and Toulouse. …I’m sure they’re very sincere people, but I’m very concerned about the perspective that they have introduced into this discussion. So let’s look at the title of the article. And the article is focusing on the ability of students, first of all, to look at and to determine contra-indications, indications and non-indications for care. So, let’s jump into that real quickly and I need to adjust the slides here a little bit.
Well, let’s look at the background statement about the article and according to the authors, and I’ll trouble you by reading this. It said, “while there is a broad spectrum of practice within chiropractic, two subtypes can be identified. Those who focus on musculoskeletal problems and those who treat also non-musculoskeletal problems. The latter group may adhere to the old conservative, quote, subluxation, end quote, model. The main goal of this study is to determine if chiropractic students with such conservative opinions are likely to have a different approach to determine contra-indications, non-indications and indications to chiropractic treatment versus those without such opinions.” So let’s unpackage that just a little bit. So let’s look at the first sentence: “While there is a broad spectrum of practice within chiropractic, two subtypes can be identified.” Well, the problem there is there’s probably a hundred subtypes, but the authors are focusing on two subtypes and the subtypes that are broken out {are] those people who address musculoskeletal problems and those people who address presumably musculoskeletal problems as well as non-musculoskeletal problems.
And then their first leap in logic is that if you address non-musculoskeletal problems as a chiropractor, you – in their opinion – therefore must identify with a subluxation model of chiropractic. Now, I think it’s logical that those that do identify with the subluxation model of chiropractic would be more likely to provide care for musculoskeletal as well as non-musculoskeletal problems. My personal experience as a 12 year old kid, I got under chiropractic care because of problem of my vision, my eyesight. I never had spinal pain in my life. So obviously, that colored my experiences, but the reality is that the presumption…on the part of the authors is that they’re classifying or, made the leap in logic that anybody who would address a non-musculoskeletal problem would be following a subluxation model. Perhaps. I wish that were the case, but I don’t think that that’s a correct statement.
The next thing within that same sentence that we need to pay attention to is the perspective that…they are beginning to create a pejorative, diminutive role by referring to that as old conservative subluxation model, and the “subluxation” [using] quote, unquote, as if it’s made up, or something that’s out of the ether in this process. So they’ve begun it even in their second sentence, to introduce the idea that old conservative chiropractors practice this stuff. And by implication, modern advanced chiropractors don’t. Well, we think that’s pretty much an incorrect statement for sure…and let’s take it on to the next sentence. The goal of this study is to determine if chiropractic students with such conservative opinions are likely to have a different approach to determining contra-indications, indications, and non-indications from care. Now we’re getting down to something that might be useful.
Does a student’s perspective on some aspect of the profession translate into the care they’ll ultimately deliver or that they would like to deliver? I don’t have a problem with that question. I think that’s a reasonable question. So, when we begin to look at this, when you don’t understand what the goal of this thing was from the very beginning, and I’ll say it again. The goal of the study is to determine if students with conservative opinions are likely to approach patients differently in terms of indications, contra-indications and non-indications. Okay. That’s the goal of the thing. Let’s go on to the next statement within the article…
And I’m going to readjust, adjust our slide again here if I can. Excuse me just a second. There we go.
The method that was involved is that an anonymous and voluntary survey of third- and sixth-year French chiropractic students was conducted. For those of you in the United States or in Canada or different parts of the world, the French educational experience of a student…[they go] into chiropractic education straight out of high school in France, and they complete a six year curriculum that leads them toward the qualification to practice as a chiropractor and France, so on. So, they’re looking at students that are basically halfway through the curriculum and students that are at the end of the curriculum and they have an anonymous survey. Okay, great. And it’s a voluntary service. So nobody had their arm twisted to participate and individuals did if they want it to. The time period involved was between November, 2017 and January, 2018 so November, December, and January of that period. There were questions associated with the level of chiropractic conservativism and what they’re meaning by chiropractic conservativism is that the more you identify with a subluxation perspective in chiropractic, the more conservative you would be. Okay. So the level of chiropractic conservativism, the ten items, and the ability to determine contra-indications, non-indications, indications to care, were evaluated through a questionnaire.
Now what they did was, they provided the students with a survey and asked them to respond to ten questions about their attitudes toward chiropractic and subluxation perspectives. And they took those results and then they asked them to respond to a series of cases, where there were two that were clearly contra-indications in their opinions, the author’s opinions, four that were non-indications, which is ultimately going to be the crux of this argument. And then there were three that were contra-indications to care, and they cross reference those results. And it’s an important question. If a student has a very strong emphasis on subluxation, are they more likely to adjust a contra-indication to care or less likely? Or is it the same, regardless of where a student is on that continuum of thought. And then their other vantage point was looking at that at the halfway point and looking at that at the end of the curriculum and seeing how that changed over time.
So then they talked and said their attempt was, answers to these cases were dichotomized into appropriate and inappropriate answers. So they’ve decided on the two indication cases that yes, that person should’ve been adjusted and they decided on the three contra-indication cases, no, based on this case, that person should not have been adjusted. And then they have four cases in the middle that they refer to as non-indications of care. And this, as I said before, is really the crux of the issue. We’ll come back to that in just a moment. So then, they’ve got these two scales: one about your attitude towards subluxation, one about these three types of cases, and then they cross reference the answers and the responses. The level of conservativism, again, emphasis on subluxation, was classified into four groups, Group Four corresponding to the highest score. Descriptive data were provided, bivariant and multivariant and multivariate analyses were completed.
Logical regression was used to test the association between the level of conservatism and the ability to determine the suitability of chiropractic treatment. Okay. No, not a bad question. Okay, so let’s go on to the next level. The discussion. This is the result. Well, first of all, 67% of the students responded, which, good for them. That’s a great response from students; {you] get two thirds of your student body to do anything, anytime, that’s a good deal. In all, 359 of 536 or again, 67% of the students responded to the questionnaire. They generally recognized the number of contra-indications and indications to treatment. However, they found it more difficult to identify non-indications to care. The more conservative students…were more likely to intend to treat their patients, even if this was irrelevant. For example, those who were most conservative, again, more subluxation oriented, were much more willing than those who were least subluxation oriented, to treat “chiropractically” a five year old child with no history of back pain or disease to prevent future back pain and also to prevent non-musculoskeletal disease. So, what these authors have decided is that if you have a musculoskeletal problem, you may be a candidate for care.
If you have a contra-indication to care, regardless of whether you have a musculoskeletal problem or otherwise, you have a contra-indication to care. But we’ve got this group in the middle that is a non-musculoskeletal case that in the opinion of the authors means that care should not have been delivered.
And to the degree that the students agreed with the authors, they were right, and to the degree that they didn’t, they were wrong. Now the fascinating part of this as an educator, that I find, is they generally recognized the number of contra-indications and indications to treatment. The good news is that wherever anybody was on that spectrum, they got the list of things you should be adjusting clearly correct. And they got the things you shouldn’t be adjusting clearly quite correct. That’s a pretty good outcome. That’s a fabulous outcome, frankly. So…the battleground comes down to this middle ground of non-indications of care. And then for you and I, the critical point is who decides what the non-indication of care is? Who decides what the criteria are, whether a person should or should not be adjusted? Well, we’ll get into that in just a little bit.
Deitch: Okay.
Clum: Let’s talk about the conclusion of the article.
Deitch: Gerry, before you go on…can you go back one slide? I just want to point out something that I hope is clear for everybody.
Clum: Yes.
Deitch: The middle sentence: “The more conservative students are more likely to intend to treat their patients even if this was irrelevant.”
Clum: Yes.
Deitch: And I just want to make sure people are hearing is this definition of non-indications. That sounds very technical, “Oh, a no- indication.” Correct me if I’m off base here, but that translation, “non indication,” means that you have no musculoskeletal symptom.
Clum: Exactly.
Deitch: That requires chiropractic care, according to them…
Clum: Yes.
Deitch: And therefore, care recommended for non-musculoskeletal conditions is, in their word, irrelevant.
Clum: Absolutely.
Deitch: And it’s going to get worse. So please continue.
Clum: Yes sir. All right, so let’s look at the conclusion statement: “It is concerning that students who adhere to the subluxation model are prepared to operationalize their conservative opinions and a few in their future scope of practice, apparently willing to treat asymptomatic people with chiropractic adjustments.”
So, we get to the meat of this thing. And the bottom line here is that these authors have defined care for asymptomatic individuals as irrelevant care. And they go on to say the determinants of this phenomenon need to be understood.
Now, let’s take a step back. So, this should be a trigger ringing some bells for you for one important reason in particular, that being that if we look at the statement of the goal of the study…said the main goal of the study is to determine if chiropractic students with such conservative opinions are likely to have a different approach to determine contra-indications, non-indications, and indications to chiropractic care. So, this is about the different approach to determining contra-indications, indications and non-indications, is the goal of the study.
Now, the conclusion was students who adhere to the subluxation model are prepared to operationalize their approach in their future scope of practice, willing to treat asymptomatic people.
The reality is that the conclusion has nothing to do with the goal of the study. The goal was to determine the approach, is there a different approach that people who are subluxation-oriented have to determining contra-indications, indications or non-indications. And the conclusion was that they’re just prepared to provide care for asymptomatic people.
Deitch: And, it is “concerning”…
Clum: Concerning. And remember the word you pointed out, that such care would be “irrelevant.” Well, it gets worse.
And I’d ask you to stay with me here because now we’re into the body of the article…So this is the first paragraph of the body of the article and it begins with a statement, “Dual model in chiropractic.” And if you remember the introductory statement from the abstract, they talked about this, we can be dichotomized into two worlds…in that they view this dual model issue as a scope of practice issue.
And, the authors begin with, “In countries where chiropractic is regulated by law, it is generally accepted as a profession that deals with musculoskeletal conditions.” Now, that’s a pretty broad and sweeping statement. They haven’t identified the country or a country, but simply amorphous “in countries.” And then they go on to say that it is generally accepted as a profession that deals with musculoskeletal conditions and they offer a citation that happens to be from the European Chiropractors’ Union. So let me jump to that statement.
And that statement reads as follows…and you can go to the to the web, and if you had the slide, you can cut and paste…the citation. And, you can go to Google and you can bring up this article and you can bother to go through the entire publication of the European Chiropractors’ Union [ECU] from 2013, and I will tell you now that you’ll find a couple of sentences that relate directly to this discussion that these authors bring to the table. And they’re from the introduction, page one and page two, of the report on the status of the profession in Europe by the ECU and the ECU defines chiropractic as a health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the…musculoskeletal system. Well, at this point it sounds like they’re agreeing with the authors.
But what the authors failed to note is the next…phrase and that phrase reads, “…and the effect of those disorders on the function of the nervous system and on general health.”
It is not, “…on pain syndromes.” It’s, “…on general health.”
And the next sentence reads, “there is an emphasis on manual…treatments, including manipulation or adjustments.”
They go on, with the next paragraph to advise us, in Europe according to the ECU, “…by restoring normal function to the musculoskeletal system…” Sounds like they’re agreeing with the authors. Next phrase, “…chiropractors can play a major part in relieving disorders and any accompanying pain or discomfort…” Sounds like they’re agreeing with the authors, “…from accidents, stress, lack of exercise, poor posture, illness, and everyday wear and tear.” Again, well beyond the concept of musculoskeletal pain exclusively. So, the first criticism of the first sentence of the body of the article I have, is that your citation doesn’t match the statements you’re making, and that you have cherry picked a portion of the citation to support the statement, because that’s what you wanted to say, rather than quoting the entire statement and the implications that it has regarding general health, illness and everyday wear and tear, as opposed to a narrow musculoskeletal interpretation.
And we’ll come back to that musculoskeletal interpretation in just a little bit when we get farther into the article because there’s some play on words that the authors get into that I think most chiropractors will find somewhere between intriguing and infuriating. So, let’s look at the next sentence. I’m going to skip back a couple slides here and let’s look at the next sentence of the first paragraph: “Therefore, chiropractors working in such jurisdictions…”, and those jurisdictions, remember, were those regulated by law, “…who also claimed to prevent or treat non-musculoskeletal conditions may break the law.”
So, in two sentences, what these authors have purported, or attempted to report, is that chiropractic is a musculoskeletal thing and anything beyond musculoskeletal care is illegal.
The leaps in logic are phenomenal. Let me go back to my slide. And what’s concerning here is that, from where I sit, we’re beginning to see the purpose of the article.
Deitch: Okay.
Clum: The purpose of the article is not to determine the methodology by which a student, based upon their philosophic attitude or their attitudes towards subluxation, determines contra-indications, indications or non-indications.
Deitch: Okay.
Clum: The purpose of the article is to alarm the reader and cause the reader to invoke the reptilian brain response. Let me take a sidetrack here and talk about the Reptilian brain response. The oldest part of our brains is the reptilian brain.
Deitch: Okay.
Clum: It’s where survival instincts lie.
Deitch: Cool.
Clum: And when we dropped down into that level of thinking, we’re fierce, remarkably aggressive creatures. We don’t reason much. We don’t use much logic, we don’t have any compassion, we don’t have any apathy, but we can defend the hell out of our shelves and we can attack anything that’s attacking us with the sentence that reads, “Therefore, chiropractors working in such jurisdictions, those being regulated by law who claim to prevent or treat non-musculoskeletal conditions may break the law,” is attempting to tap into that. You’re a lawbreaker if you do this, and take it another step further. That guy or gal practicing near you, around you in your community, in your country is a law breaker that you need to do something about if they do that.
Now, from a practical standpoint, if you look at that sentence, what countries are we talking about?
Breaking laws are very precise things. You don’t sort of break a law. The law’s well described, the offenses are well described and the process of breaking that law is generally pretty clear. Now, they haven’t identified what country they might be talking about and furthermore they haven’t identified what law.
So, I would suggest to you that right from the get-go, these authors have identified, their goal as being radically different than their stated goal in the article.
And they have attempted to approach the chiropractor and the situation to put him or her in a position of fear, to cause him or her to question whether or not they’re breaking the law. And, like most people, you and I wouldn’t like to be law breakers.
We’d like to be part of the civil society. We’d like to follow the rules like to get along. So what would we do? Well, by God, we got to change our behavior in this regard. And the behavioral change these people are after, is do not adjust anybody for anything other than a musculoskeletal problem. Now, I don’t know about you, but I know how I got into chiropractic, and if this line of reasoning were applied by the chiropractor that gave me my first adjustment, I would likely be blind, living in western New York and having a radically different life that I’ve had over these last 50 years. I’m incensed by this. I’m angered by this and I am upset and concerned.
We started out today saying we’re going to spend six segments. Looking at this, we’ve completed the first 33 Minutes. In the next 33 minutes we’re going to get into what these authors have to say about subluxation, what they have to say about adjustment, what they have to say about conservativism quote on quote, and then what they have to say about the associated labeling of people who fall into or are related to those concepts.
I hope you’ll stay with us. I hope you’ll follow this and you you’ll get a sense for how concerning this is for the profession today and down the road, if we allow this reasoning to creep into our vernacular, into our politics into our structures of practice throughout the world. Jason, I thank you for your time and your cooperation and I look forward to joining you the next segment of this discussion in two weeks.
Deitch: Absolutely. Listen, thank you for watching. I think the key point here is to pay attention. Stay with us every two weeks. We will be going deeper into this conversation and our request is to engage, to get involved, to understand. I believe, Gerry, we’ll be able to put a link to the actual article if people want to read the entire article. We’ll include that. Read it yourself, but more importantly, consider sharing this conversation with our colleagues. This is something that’s going to require paying attention and being aware and being engaged. And, that’s our goal for Today’s Chiropractic Leadership. That’s our goal for these conversations. We invite you to join us in two weeks. You’ll see it. Please share it with others. Until then, Dr. Clum, thank you so much for bringing this to our attention, bring it to the profession.
Thank all of you for watching another edition of 33 Minutes.