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Proposed
Revisions of the CCE Standards for Doctors of Chiropractic Programs and
Requirements for Instiitutional Standards.
"Call for Public Comment" on the Proposed
Revisions of the CCE
Standards
http://www.cce-usa.org/2004-10-15%20Public%20Announcement.pdf
Time sensitive Information:
Colleagues--
CCE has several proposals pending. Few in the field are aware of these proposals. CCE is soliciting comments from interested parties. Unfortunately, such comments must be received by CCE no later than November 15. That means you must act NOW.
The revisions of greatest concern would
1. Mandate the teaching of "physiological therapeutics" and2. Mandate that only DACBR’s and their residents can teach any radiology courses, including positioning, physics, and interpretation. This would have a devastating effect on x-ray spinography for subluxation analysis.
We do not have the luxury of time to deal with wordsmithing, boards, votes, meetings, etc. You must act TODAY.My suggestion is that you send a sample letter by e-mail to your membership, with a cover letter emphasizing the important of Faxing their opinions to CCE at 480-483-7333.
I'm attaching a sample letter with references. Modify to suit, but get SOMETHING out immediately.
Last year, when they tried to mandate PT, an aggressive FAX campaign caused them to table the issue.We need numbers.
To view the proposals and call for comments, visit:
http://www.cce-usa.org/SUMMARY%20OF%20REVISIONS.pdf
http://www.cce-usa.org/2004-10-15%20Public%20Announcement.pdfDr. Christopher Kent
First Sample Letter:
TO: Martha S. O’Connor, Ph.D., Executive Vice President, CCE
FROM:
RE: Public comments on proposals
Dear Dr. O’Connor;
This letter is in response to the open comment period on proposal changes to the Standards posted on your web site:
Sec. 2.III.C.2 Page 17 and Sec. 2.III.C2.Page 17 (Physiological Therapeutics and non-adjustive therapeutic procedures).
I strongly oppose any mandate to include physiotherapy or non-adjustive therapeutic procedures in accredited Doctor of Chiropractic programs. The decision to include or exclude instruction in such subjects should be discretionary.A. Issues of philosophy and institutional autonomy
Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status (January 2004—Page v) state, inter alia, “The CCE does not seek to define or support any philosophy regarding the practice of chiropractic, nor are the CCE Standards intended to support or accommodate any philosophical position. These are the responsibility of the profession and each educational DCP, giving consideration to the requirements of the jurisdiction within which the professional may practice, professional associations, and in the final analysis, the practitioner’s own philosophy of chiropractic.”
The decision to teach or not to teach courses in physiological therapeutics or non-adjustive therapeutic procedures goes to the heart of the philosophical division in the chiropractic profession. It is a philosophical decision, determined by the mission and objectives of the institution. It is not an issue of educational quality. Teaching such courses should not be mandatory for CCE accreditation.
Of course, if an institution elects to offer such courses, either as part of the DCP or as electives, it is reasonable to prescribe standards that address quality of instruction and adequacy of clinical training in these subjects.
B. Legal issues
The use of adjunctive procedures is regulated by state law. The use of procedures outside the state scope of practice may result in charges of engaging in the unauthorized practice of medicine, and tort liability.
For example, In Treptau v. Beherens Spa, Inc., 20 N.W.2d 108, 247 Wis.438, a chiropractor undertook to examine and treat a patient's foot using bandages and diathermy. The Wisconsin Supreme Court stated, "Plaintiffs do not claim there was malpractice on the part of the defendant while Beherens was engaged in the practice of chiropracty (sic) by chiropractic manipulation or adjustments of the spine. Instead, plaintiffs contend there was malpractice when he and his associates went beyond the practice of chiropracty (sic) and entered into the general field of the practice of medicine...in so far as there was thus an invasion of the general field of that practice, the methods thus used by defendant's employees in diagnosis and treatment were subject to the rules applicable to the practice of medicine and surgery."
The court in Treptau relied on Kuechler v. Volgmann, 192 N.W. 1015, 180 Wis. 238, 242-43. The Kuechler court held, "When a chiropractor assumes to diagnose and treat disease he must exercise the care and skill in so doing that is usually exercised by a recognized school of the medical profession."
While the use of physiotherapy may be lawful in some jurisdictions, the scope of such authority varies. Furthermore, some jurisdictions prohibit their use by chiropractors.
Of equal importance is the fact that a growing body of scientific literature reports that passive physical modalities are of little or no value in addressing musculoskeletal pain, and may actually prolong disability.
While a review of the relevant literature is beyond the scope of this letter, the following papers illustrate the trend:
Van den Hoogen et al published the results of a study involving 269 patients. The objective of these investigators was to identify prognostic indicators of the duration of low back pain in general practice, and the occurrence of a relapse. It was concluded that receiving physical therapy was associated with a longer duration of low back pain.
The authors reported, "at every moment in time, patients receiving physical therapy had a 61% less chance to recover in the following week than patients not receiving physical therapy." (1)
Clinical Guidelines for the Management of Acute Low Back Pain, produced by the Royal College of General Practitioners in Great Britain, address the appropriateness of physical agents and modalities.
The Guidelines state that, "Although commonly used for symptomatic relief, these passive modalities do not appear to have any effect on clinical outcomes." The modalities listed in the Guidelines include ice, heat, short wave diathermy, massage, and ultrasound.
In reference to bed rest and traction, "Traction does not appear to be effective for low back pain or radiculopathy.. The evidence shows that bed rest with traction is ineffective. It adds the complications of immobilsation to the deleterious effects of bed rest."
Furthermore, "There is no evidence that manipulation under general anesthesia is effective. It is associated with an increased risk of neurological damage." (2)
The AHCPR Guideline for Acute Low Back Problems in Adults concurs: "The use of physical agents and modalities in the treatment of acute low back problems is of insufficiently proven benefit to justify their cost.
"...Only two studies evaluated physical agents and modalities in patients with acute low back pain. Neither found significant differences in self-rated pain relief or other outcome measures between patient groups receiving physical agents and modalities (including diathermy, ultrasound, flexion/extension exercises, massage, and electrotherapy) and groups receiving a placebo." (3)
Concerning TENS for pain control, a study of 324 patients found no differences in outcomes in those receiving three different types of TENS and those given a sham TENS unit with indicator lights but no output. (4)
Regarding ultrasound, Gam and Johannsen reviewed 293 papers published since 1950 to assess the evidence of effect of ultrasound for musculoskeletal disorders. Serious methodological problems existed in many of the papers. However, in 13 cases data were presented in a way that made pooling possible. The conclusion: "None of the methods gave evidence that pain relief could be achieved by ultrasound treatment." (5)
Another meta-analysis looked at 400 randomized clinical trials. Meta-analyses were performed for disorders of the back, neck, shoulder and knee. Results indicated that, "In general, the methodological quality of the studies appeared to be low, and the efficacy of physiotherapy was shown to be convincing for only a few indications and treatments." (6)
A controlled study was performed comparing osteopathic manipulation and short-wave diathermy in the treatment of non-specific low back pain The placebo group, which received fake diathermy, did about as well as those receiving real diathermy or osteopathy. The authors stated, "Benefits obtained with osteopathy and short-wave diathermy in this study may have been achieved through a placebo effect." (7)
In a study comparing drug therapy, conservative physiotherapy and manipulative physiotherapy, "Serial assessments of pain and spinal mobility showed similar response rates in all three treatment groups and no significant difference between therapies." (8)
If CCE purports to encourage evidence-based practice, mandating the instruction or use of such modalities is disingenuous, and not in the interests of the profession or the patients it serves.
C. Recommendation
Do not implement the proposed revisions to Sec. 2.III.C.2 Page 17 and Sec. 2.III.C2.Page 17.
2. Sec.2.III.E.1.b. Pages 18-19 and Sec.III.E.1.b. Page 19. Qualifications for persons teaching courses in diagnostic imaging.
I strongly oppose a mandate that only DACBRs and residents in approved radiology residencies may teach diagnostic imaging courses. There are several reasons for this.
A. Other imaging specialists are qualified to teach such courses
I have no objection to requiring persons teaching radiology courses to have appropriate training. However, it is improper to grant a monopoly to DACBRs and radiology residents seeking DACBR status.
For example, in addition to DACBRs, there are Diplomates of the ICA College of Chiropractic Imaging who have completed a minimum of 300 hours of postgraduate training in diagnostic imaging, and passed comprehensive written and practical examinations. Several such Diplomates have taught radiology courses in CCE accredited colleges.
Several chiropractic colleges offer or have offered postgraduate certification courses in specialized imaging techniques, such as videofluoroscopy.
Some chiropractors have completed postgraduate courses, such as visiting fellowship programs, in advanced imaging techniques such as magnetic resonance imaging.
Courses in imaging physics and technology may be effectively taught by physicists specializing in diagnostic imaging, or radiologic technologists.
Although the proposed revision to Sec.III.E.1.b. Page 19 permits medical radiologists to teach imaging courses, Sec.2.III.E.1.b. Pages 18-19 does not.
Some institutions offer courses that include integrated clinical, laboratory, and imaging instruction. There are also courses which deal with radiological interpretation as related to biomechanical, subluxation analysis and chiropractic technique. Such individuals frequently have postgraduate training in specific chiropractic techniques. DACBRs often lack training and experience in specific systems of spinographic analysis, despite expertise in general radiology.
B. Philosophy and institutional autonomy
As stated in 1. supra, Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status (January 2004—Page v) state, inter alia, “The CCE does not seek to define or support any philosophy regarding the practice of chiropractic, nor are the CCE Standards intended to support or accommodate any philosophical position. These are the responsibility of the profession and each educational DCP, giving consideration to the requirements of the jurisdiction within which the professional may practice, professional associations, and in the final analysis, the practitioner’s own philosophy of chiropractic.”
C. RecommendationDo not implement proposed revision to Sec.2.III.E.1.b. Pages 18-19. Change the wording on Sec.III.E.1.b. Page 19 to read as follows:
(4) All radiology courses, including radiological anatomy and x-ray positioning, should be taught by individuals with specific credentialing in the radiology course(s) in which they serve as faculty.
Thank you for your kind consideration.
Sincerely,
REFERENCES
1. van den Hoogen HJM, Koes BW, Deville W, et al: "The prognosis of low back pain in general practice." Spine 1997;22(13):1515.
2. Clinical Guidelines for the Management of Acute Low Back Pain. Royal College of General Practitioners. September, 1996. Available at http://www.rcgp.org.uk
3. "Clinical Practice Guideline Number 14." Acute Low Back Problems in Adults. Agency for Health Care Policy and Research. December 1994.
4. "No better than placebo. Another look at TENS units for low back pain." Spine Letter 1997;4(5):2.
5. Gam AN, Johannsen F: "Ultrasound therapy in musculoskeletal disorders: a meta-analysis." Pain 1995;63(1):85.
6. Beckerman H, Boulter LM, van der Heijden GJ, et al: "Efficacy of physiotherapy for musculoskeletal disorders: what can we learn from the research?" Br J Gen Pract 1993;43(367):73.
7. Gibson T, Grahame R, Harkness J, et al: "Controlled comparison of short-wave diathermy treatment with osteopathic treatment in non- specific low back pain." The Lancet 1985;1(8440):1258.
8. Waterworth RF, Hunter IA: "An open study of diflunisal, conservative and manipulative therapy in the management of acute mechanical low back pain." N Z Med J 1985;98(779):372.
Second Sample Letter:
Dear Doctor,
Please download my attached letter as a template for your own and then FAX it to this Executive VP Dr. O'Connor at the CCE
FAX: 1-480-483-7333.Sincerly,
Don Harrison, PhD, DC, MSE
Martha S. OConnor, PhD November 8, 2004
Executive Vice-Pres.
CCE
8049 W. 85th Way
Scottsdale, AZ 85258-4321
FAX: 1-480-483-7333RE: Comments needed by Nov 15th on Proposed Revisions of CCE Standards per CCE
Policy BOD-22, specifically Lecturers for Radiology Courses in Chiropractic Colleges.Dear Dr. OConnor:
I was very surprised to see an obvious conflict of Standards in your new Proposed Revisions for CCE Standards. Specifically pages 18 and 19, Sec. 2.111.E.1.a&b. See copy below:
All chiropractors have the same education in radiographic anatomy, imaging physics, and x-ray positioning. All chiropractors are licensed by all State Boards to determine the need for x-rays, taking of x-rays (including positioning, shielding, machine factors of MAS & KV, processing of films), interpretation of films, and geometric analysis of the bony structures.
In fact, in most States, whether by licensure or by in-office training, CAs (Chiropractic Assistants) may position the public for x-rays, determine the penetrating factors, take the x-rays, and develop the x-rays.
To designate a DACBR or DACBR trainee as the only persons certified to teach these items in Chiropractic Colleges is absurd and directly in conflict with existing State Laws.
DACBRs are NOT trained in Universities with a degree in such topics. They have a few extra weekends of rehashing what all DCs learned about x-ray projection, x-ray positioning, and x-ray physics. A DACBRs extra training is confined to looking at radiographic contours (hard tissue and soft tissue) for abnormalities. This training is NOT in x-ray physics, nor projection, nor positioning. In fact, I have had a lot of university courses/degrees in mathematics, physics, and mechanical engineering. I have had graduate courses in Projection Geometry; I have exact knowledge that DACBRs are NOT trained in these fields above any other graduated DC.
I have had past debates in JMPT with DACBRs on these exact topics, see (1) DG Hariman JMPT 1995; 18(5): 323-324 and (2) DD Harrison et al. JMPT 1995; 18(5): 324-325. Whenever a DACBR gets out of the realm of radiological contours (normal and abnormal), they step totally out of their field into other fields in which they have absolutely NO education and NO expertise.
I have personally published studies, which have shown that many long-time held DACBR OPINIONS are false; these false opinions have been perpetuated in Chiropractic Colleges for at least 3 decades. These false opinions, held by all DACBRs, point to the inadequacies in the DACBR weekend certification courses. Such courses are absolutely NOT equivalent to a university education. If such topics were taught in a University and not by DACBRs, such false information would not be perpetuated. Some of these false opinions are:
1. Normal spinal position does not exist,
2. Variations in x-ray positioning simulate subluxation or correction,
3. Posture and biomechanical analysis are not repeatable phenomena,
4. slight head nodding/flexion creates kyphosis in the cervical spine,5. acute muscle spasms cause cervical and lumbar kyphosis or hypo-lordosis,
6. normal anatomic variants cause the spine to appear to be subluxated,
7. x-rays should not be taken for biomechanical or postural screening and post x-rays are not warranted, and
8. radiographic line drawing for measuring spinal displacements are not reliable.
Contrary to DACBR personal opinions (#1-#8 above), the following references show some of the facts:
1. Harrison DD, Troyanovich SJ, Harrison DE, Janik TJ, Murphy DJ. A Normal Sagittal Spinal Configuration: A Desirable Clinical Outcome. J Manipulative Physiol Ther 1996; 19(6):398-405.
2. Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of Lordotic Cervical Spine Curvatures to a Theoretical Ideal Model of the Static Sagittal Cervical Spine. Spine 1996;21(6):667-675.
3. Harrison DD, Janik TJ, Troyanovich SJ, Harrison DE, Colloca CJ. Evaluations of the Assumptions Used to Derive an Ideal Normal Cervical Spine Model. J Manipulative Physiol Ther 1997;20(4): 246-256.
4. Troyanovich SJ, Cailliet R, Janik TJ, Harrison DD, Harrison DE. Radiographic Mensuration Characteristics of the Sagittal Lumbar Spine From A Normal Population with a Method to Synthesize Prior Studies of Lordosis. J Spinal Disord 1997;10(5): 380-386.
5. Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DE, Holland B. Elliptical Modeling of the Sagittal Lumbar Lordosis and Segmental Rotation Angles as a Method to Discriminate Between Normal and Low Back Pain Subjects. J Spinal Disord 1998; 11(5): 430-439.
6. Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE. Can the Sagittal Lumbar Curvature be Closely Approximated by an Ellipse? J Orthop Res 1998; 16(6):766-70.
7. Harrison DE, Janik TJ, Harrison DD, Cailliet R, Harmon S. Can the Thoracic Kyphosis be Modeled with a Simple Geometric Shape? The Results of Circular and Elliptical Modeling in 80 Asymptomatic Subjects. J Spinal Disord Tech 2002; 15(3): 213-220.
8. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Haas JW. Do Alterations in Vertebral and Disc Dimensions Affect an Elliptical Model of the Thoracic Kyphosis? Spine 2003; 28(5): 463-469.9. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Haas JW, Ferrantelli J, Holland B. Modeling of the Sagittal Cervical Spine as a Method to Discriminate Hypo-Lordosis: Results of Elliptical and Circular Modeling in 72 Asymptomatic Subjects, 52 Acute Neck Pain Subjects, and 70 Chronic Neck Pain Subjects. Spine 2004; 29(22): in press for Nov 15th.
10. Harrison DE, Harrison DD, Colloca CJ, Betz J, Janik TJ, Holland B. Repeatability of Posture Overtime, X-ray Positioning, and X-ray Line Drawing: An Analysis of Six Control Groups. J Manipulative Physiol Ther 2003; 26(2): 87-98.
11. Jackson BL, Harrison DD, Robertson GA, Barker WF. Chiropractic Biophysics Lateral Cervical Film Analysis Reliability. J Manipulative Physiol Ther 1993; 16(6): 384-391.
12. Troyanovich SJ, Robertson GA, Harrison DD, Holland B. Intra- and Interexaminer Reliability of the Chiropractic Biophysics Lateral Lumbar Radiographic Mensuration Procedure. J Manipulative Physiol Ther 1995;18(8):519-524.
13. Troyanovich SJ, Harrison DE, Harrison DD, Holland B, Janik TJ. Further Analysis of the Reliability of the Posterior Tangent Lateral Lumbar Measuration Procedure: Concurrent Validity of Computer Aided X-ray Digitization. J Manipulative Physiol Ther 1998; 21(7): 460-467
14. Troyanovich SJ, Harrison SO, Harrison DD, Harrison DE, Payne MR, Janik TJ, Holland B. Chiropractic Biophysics Digitized Radiographic Mensuration Analysis of The Anterioposterior Lumbopelvic View: A Reliability Study. J Manipulative Physiol Ther 1999; 22:309-315.
15. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ. Cobb Method or Harrison Posterior Tangent Method: Which is Better for Lateral Cervical Analysis? Spine 2000; 25: 2072-78.
16. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Centroid, Cobb or Harrison Posterior Tangents: Which to Choose for Analysis of Thoracic Kyphosis? Spine 2001; 26(11): E227-E234.
17. Harrison DE, Harrison DD, Janik TJ, Harrison SO, Holland B. Determination of Lumbar Lordosis: Cobb Method, Centroidal Method, TRALL or Harrison Posterior Tangents? Spine 2001; 26(11): E236-E242.
18. Janik TJ, Harrison DE, Harrison, DD, Payne MR, Coleman RR, Holland B. Reliability of lateral bending and axial rotation with validity of a New Method to determine Axial Rotations on AP Radiographs. J Manipulative Physiol Ther 2001; 24(7): 445-448.
19. Harrison DE, Holland B, Harrison DD, Janik TJ. Further Reliability Analysis of the Harrison Radiographic Line Drawing Methods: Crossed ICCs for Lateral Posterior Tangents and AP Modified Risser-Ferguson. J Manipulative Physiol Ther 2002;25:93-8.
20. Harrison DE, Harrison DD, Janik TJ, Holland B, Siskin L. Slight Extension Head Nodding: Does it reverse the cervical curve? Eur Spine J 2001; 10: 149-153.
Important Political Component
Requiring a political group, such as ACAs DACBRs, to be the only persons qualified to teach radiology courses in chiropractic colleges is bordering on a possible lawsuit. The Diplomats in American Chiropractic (Association) Board of Roentgenology are ACA members. DACBRs, DACBNs, DACBOs were sanctioned by the ACA in the beginning. Recently, to try to look independent, they are trying to have outside sponsorship. However, I believe it is a requirement that they have to be members of the ACA. To have a political group influencing education is a no-no in accreditation. The ICA has their counterparts in Radiology. Will they be acceptable teachers?? I think not, in the way you have worded this standard of politics.In summary, DACBRs are subject to incest learning because they continually teach themselves and other trainees without an outside influence from the literature or university setting. They are members of a political organization, ACA. To decide that only DACBRs are qualified to teach anything more than radiographic pathology courses is false.
Sincerely,
Donald D. Harrison, PhD (applied mathematics), DC, MSE (Mechanical Engineering)
Additional Suggestion:
One final suggestion...a letter would be good, attending the meeting in Phoenix and testifying would be even better--especially if the person
represented a defined constituent group.Gerard W. Clum, D.C.
President
Life Chiropractic College West
Blessings to all of you for who you are and what you do!!
Jeanne Ohm DC
ICPA, Executive Coordinator
www.icpa4kids.com
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