Standards of Care

By Steven N. MacDonald, D.C.
Vol. 5, No. 4, November, 1994

In recent years the chiropractic profession has been actively involved in pursuing standards of care for our profession and finally culminating with the Mercy guidelines¹. Discussion will continue regarding these guidelines and eventually lead to further refining these standards, built upon the Mercy model.

Since its inception in 1967, the National Upper Cervical Chiropractic Association (NUCCA) has been at the forefront in stating the need for standards of care for chiropractic methods practiced in our profession.  NUCCA placed high standards on its own organization by forming the National Upper Cervical Chiropractic Research Association (NUCCRA) in 1971. NUCCRA was formed specifically to engage in a comprehensive research program designed to establish a scientific basis for the practice of chiropractic.  This research group worked to establish a body of acceptable knowledge that is testable, relevant to fact, and compatible with established and accepted scientific theories.  It continues to test existing chiropractic premises, beliefs and assertions; to establish an acceptable and scientific body of knowledge regarding the subluxation, its causes and physiological and pathological effects on the human organism; to design and develop equipment for the measurement of physical phenomena that have been observed to exist concurrently with the vertebral subluxation, and to assist chiropractic colleges, organizations and practitioners.²

Dr. Ralph Gregory, President of NUCCA from 1971 up to his death in 1990, stated in his editorial in the Upper Cervical Monograph³ that the NUCCA method was to be based on scientific theory, on measurement, demonstration, and verification, and on testing the physical phenomena observable when subluxation exists.This has continued to be the guidelines for the NUCCA work throughout its existence.⁴

Chiropractic in general lacks proper validating research for much of what is practiced. Many chiropractic techniques are founded on unsound mechanical principles. l believe that NUCCA has based its analysis and correction of the Atlas Subluxation Complex⁵ on sound mechanical principles.^6,7 NUCCA has taken the time to research and validate its premises so that they are founded in sound current scientific theory that is universally accepted today for all of science.^8-13 On Sept. 21, 1973 the NUCCA Directive Board adopted a resolution dealing with the use of questionable chiropractic techniques which violate relevant mechanical principles. The resolution was adopted in the interest of the public and the profession.¹⁴ It was forwarded to all chiropractic colleges existing at that time. It included a request for the cooperation of the colleges and associations to adopt the resolution for the general protection and welfare of the public and the chiropractic profession.  Only four colleges responded and none adopted it.

There are several articles on standards of care for the chiropractic profession in the proceedings of the 1990 International Conference on Spinal Manipulation sponsored by FCER. Shekelle¹⁵ in his article stated that standards of care must be acceptable and useful to the clinician; they must be consonant with the available scientific literature and expert opinion.  Adams¹⁶ from LACC in his article says there is widespread difference in the way in which doctors of chiropractic practice, thus giving mixed signals to the consumer public about what is considered to be appropriate chiropractic care. This is underpinned by the realization that much of chiropractic practice lacks rigorous scientific foundation. The development of standards should include reliable and valid methods which take into consideration consensus of practitioner and expert opinion, evidence produced by the scientific method, and application of logic and reason.  McMichail, et al.,¹⁷ in his article on standards of care in the 1990 proceedings says the only practicable criterion of validity ever produced by science is that of consistency.

In all of these preceding articles, the authors are agreeing that all chiropractic methods need to be based on current scientific theories and principles.  This has always been what NUCCA has advocated. I believe that NUCCA is one of the few chiropractic methods that has based its procedures on the scientific theories needed for standards of care.

Kaminiski, et al. (1987),¹⁸ in his article “A Model for the Evaluation of Chiropractic Methods,” asks a series of questions. How is a procedure defined?  What observations and measurements are made? Is it consistent with present science and substantiated by research? He lists four steps that must be satisfied in any chiropractic method:  1) Definition and description. This definition should clearly identify the therapy and eliminate any misunderstanding of terms.  2) Measurable observations require a description and cataloging of observations.  What parameters are measured, how are they measured and how does the measurement relate to the procedure?  3) Science knowledge. This involves a review of relevant scientific information, consistent with current scientific models, not necessarily a proven fact. Provisional acceptance is given to procedures that pass this inquiry. 4) Experimentation and testing. This requires the evaluation of pertinent research to substantiate all procedures with clinical studies and delineation of basic mechanisms. Full acceptance is given to procedures that pass this extensive inquiry.

A validation model is set forth that I believe NUCCA fulfills.  A definition is required consisting of detailed description of the procedure of practice which includes a comprehensive list of unique terminology, a history, and a basic statement of rationale.  This information has been collected throughout the years of the NUCCA organization.^19,20,5,21

Observations are also included in this validation model. This asks the question, does a consistent and meaningful relationship exist between two or more observed events? In other words does a specific adjustment predictably result in a specific outcome? Specific time is the measurement of these relationships. If you can’t measure them then the conclusion is not supported. Also it must be recognized that measurable observation only becomes meaningful when vested within a conceptual context. Adequate definitions and sufficient collection of appropriate observations are next assessed with respect to current scientific knowledge.  New knowledge must be analyzed in the context of current understandings. The procedure or practice should be both reasonable and logical. The NUCCA/NUCCRA organizations again have taken the time throughout the years to meet these criteria and have always realized their importance in validating the NUCCA work.^{2,4,8-13,22-36}

Provisional status in this validation model is given to emerging ideas that meet the test of scientific consistency. They still need to progress to full acceptance. All procedures deserve an avenue of possible validation. Forms of rejection provide a neutral status rather than a negative one. Unsubstantiated are those procedures that cannot stand the test of this process. This model is a tool for the definition, evaluation and classification of chiropractic methods.

I believe that NUCCA has gone the distance and continues to do so in fulfilling such a validation model for a chiropractic method. We have satisfied the requirements to reach provisional status and participate in experimentation and testing for full acceptance. As to how we fit in with the Mercy guidelines has yet to be established. As far as fulfilling a validation model for evaluation of chiropractic methods, I believe that we have done so. Our true objective is to maintain our scientific basis and sound mechanical principles in correcting the Atlas Subluxation Complex in our patients. It is through these objectives that we are able to truly help our patients.