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American Chiropractic Association National Chiropractic Leadership Conference

McAndrews Lecture “Challenges of the Past, Challenges of the Present” Washington DC February 28, 2015

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January, 1962 Davenport, Iowa

Setting 1

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• Director of Clinics, Palmer College of Chiropractic, 1961 to 1963

• Chairman, Division of Chiropractic Sciences, Palmer College of Chiropractic, 1964 to 1966

• Coordinator, Principles and Practices Division, Palmer College of Chiropractic, 1963 to 1964

Jerry McAndrew Davenport, Iowa

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Status

• Enthusiasm for the profession

• Lyceum and other meetings drew 4000 chiropractors

• In South Africa the members of SACA met every month for an education symposium and personal interaction

• Philosophy dominates discussion although varies between institutions

• Research: BJ osteology lab, radiology, Carl Cleveland animal models, JC Watkins clinical research - all philosophy driven research

• Most chiropractors had a cash practice

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• BJ Palmer had just died

• AMA Committee on Quackery established in 1963

• Formation of ACA from NCA, ICA separates

Events 1960s

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• Isolation • Principles based on clinical experience and belief • Philosophy is either a strongly held belief or basis for ridicule

• No significant research culture • No consistent education curriculum • Divided profession • No Clear or consistent Identity (Straight or mixer)

Challenges 1960s

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January,1973 Vancouver, Canada

Setting 2

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Status

• AMA actively changes ethics – contain and destroy chiropractic

• Chiropractic being attacked all over the world, licensure rare outside North America with Commissions of enquiry in New Zealand, Australia, South Africa.

• Chiropractic not licensed in Louisiana and Quebec in North America

• Virtually no research and no qualified researchers

• No chiropractic textbooks by major commercial publication companies

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The Iowa Plan’s section (1962) “What Medicine Should Do About The Chiropractic Menace”

• Encourage ethical complaints against doctors of chiropractic;

• Oppose chiropractic inroads in health insurance;

• Oppose chiropractic inroads in workmen’s compensation;

• Oppose chiropractic inroads into labor unions;

• Oppose chiropractic inroads into hospitals; and

• Contain chiropractic schools.”

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• Executive Vice President, International Chiropractors Association, 1971 to 1979

• Executive Vice President, Foundation for the Advancement of Chiropractic Tenets and Science (FACTS); Washington, DC, 1977 to 1979

Jerry McAndrew

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• 1973 - The University of Colorado, Chung-Ha Su research.

• 1975 – NINCDS Conference on Spinal Manipulative Therapy

• 1977 – FCER and FACTS begin to fund research

• 1977 – proposal for an interdisciplinary conference on “Modern Developments in the Principles and Practice of Chiropractic” 1979 conference draws 500 paricipants

• 1978 – New Zealand Commission of enquiry into Chiropractic

Events 1970s

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• Open hostility (containment) and ethical enforcement by AMA • NINCDS - “There are little scientific data of significance to

evaluate this clinical approach to health and to the treatment of disease”

• Early recognition of the importance of research but minimal research culture or support

• Divided profession • No Clear or consistent Identity (Straight or mixer, chiropractic

medicine, named technique practitioners) • Professional led primarily by technique or practice building

gurus

Challenges 1970s

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1981 Chicago, Illionois

Setting 3

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• George McAndrews – attorney with pashion for chiropractic

• Wilke et al verses AMA et al – 1981 Antitrust trial

• Wilke et al verses AMA – 1987 Appeal Antitrust trial

Events 1980s

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• Publication of first chiropractic text book by medical publishing house

• World Federation of Chiropractic established

• David Cassidy awarded Ph.D. under Bill Kirkaldy-Willis

• North American Spine Society and American Back Society formed

• Manipulation clinical trials. UCI, Hadler, Palmer

Events 1980s

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• “The plaintiffs clearly want more from the court,” Judge Getzendanner pronounced.

• “They want a judicial pronouncement that chiropractic is a valid, efficacious, even scientific health care service.”

• “I believe that the answer to that question can only be provided by a well designed, controlled, scientific study.”

Challenges 1980s

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• Engagement with the research and medical community

• Change medical and hospital attitudes • Training of chiropractic researchers • Develop of standards of care • Divided profession, lack of consensus of how

chiropractors should practice • No Clear or consistent Identity for chiropractic • Lack of participation in spine and public health

deliberations and societies

Challenges 1980s

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1992 Washington, DC

AHCPR

Setting 4

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• Chairman, National Task Force on Managed Care, American Chiropractic Association, 1991 to 1994

• Vice President for Professional Affairs, American Chiropractic Association, 1992 to 1995

George and Jerry McAndrews

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• 1992 - House Subcommittee on the military Commissions Bill

• 1992 – AHCPR Guidelines on Acute Low Back Pain

• Guidelines for Chiropractic Practice Parameters and

• Formation of the World Federation of Chiropractic

• North American Spine Society, ABS and ISSLS includes chiropractors

• Quebec Task Force on Whiplash Related Disorders includes manipulation as one of few EB treatments

• Second Edition of Principles and Practice of Chiropractic

Events 1990s

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• Chiropractors do not participate in hospital and multidisciplinary health delivery systems

• Lack of engagement with medical profession or the spine or public health societies

• No distribution of chiropractic research breakthroughs or communication between scientists and clinicians

• Philosophical purists become more aggressive • Divided profession • No Clear or consistent Identity (Straight or mixer)

Challenges 1990s

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2000 Saskatoon, Canada

Setting 5

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• 2001 - Duke Evidence Based Practice Center – Behavioral and physical treatments for tension and cervicogenic headaches

• Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Associated Disorders

• Third Edition of P& P of Chiropractic

• Evidence Based Management of Low Back Pain

Events 2000s

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Perceptions of effectiveness of conventional care and CAM for specific ailments

(Eisenberg et al, Ann Intern Med 2001;135:344-351)

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• Finding and training of chiropractors interested in reseach

• Finding and training of chiropractors to serve in multidisciplinary centers including hospitals, VA and Military

• Distribution of chiropractic research breakthroughs or communication between scientists and clinicians

• Defining the role of chiropractors in health care • Lack of participation in professional societies by practicing chiropractors

Challenges 2000s

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March 23, 2010 Washington DC

Affordable Care Act PICORI

Setting 6

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December 2010 Lancet

Global Burden of Disease

Setting 7

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Global Burden of Disease 2010 Report Key results – spinal disorders:

• Low back pain is the leading cause of disability worldwide (YLDs) contributing 10•7% of total.

• Neck Pain is the fourth leading cause of disability worldwide

• Low back pain is the sixth most important contributor to the global burden of disease (death YLLS and disability YDLS)

• It has a greater impact on global health than: - malaria or tuberculosis - preterm birth complications - COPD - diabetes or lung cancer.

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Global Burden of Disease 2010 Report Key results – spinal disorders

• When combined with neck pain (#21 on this list) back pain and neck pain are second only to ischemic heart disease in its impact on the global burden of disease

• Back and neck pain combined have a greater impact on global health than –HIV/AIDs -- Alzheimer’s Disease

-- Diabetes –Lower respiratory infections -- Depression –Stroke -- Traffic injuries –Breast and lung cancer combined

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World Report on Disability 2011 WHO and World Bank

• Back problems, arthritis, and rheumatism were the most common health conditions related to disability

• People with disabilities have generally –poorer health –lower education achievements –fewer economic opportunities and higher rates of poverty

than people without disabilities.

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April, 2012 Durban, South Africa Mahalapye, Botswana

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Surgeon Attitudes Toward Nonphysician Screening of Low Back or Low Back–Related Leg Pain Patients Referred for Surgical Assessment

A Survey of Canadian Spine Surgeons Busse JW et al. Spine 38:E402. 2013

• Survey to all 101 surgeon members of the Canadian Spine Society

• A majority of respondents (75.3%) agreed that they would be comfortable not assessing patients with low back–related complaints referred to their practice if indications for surgery were ruled out by an NPC.

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JAMA PATIENT PAGE Low Back Pain

1738 JA M A, April24, 20l3-Vol309, No 16

• Many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture. Sometimes medications are needed, including analgesics (painkillers) or medications that reduce inflammation. Surgery is not usually needed but may be considered if other therapies have failed.

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October, 2014 San Francisco, CA

NASS Annual Meeting

Setting 9

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February 2015. Washington DC

• JAMA Forum: Payment Reform Is About to Become a Reality • Secretary Burwell’s proposal calls for 30% of Medicare

payments to be based on non–fee-for-service models by the end of 2016, and 50% to be so by the end of 2018.

• Such payments did not exist in 2011. • The Secretary intends to have 85% of Medicare fee-for-

service payments tied to quality or value in some fashion by the end of 2016.

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February 6, 2015 Washington DC,

NCCAM to NCCIH

Setting 10

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February 26, 2015 Palm Springs, California

Palmer Board of Trustees

Setting 11

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Palmer College Identity statement The primary care professional for

spinal health and well-being

CMCC Mission Statement An academic institution recognized for

creating leaders in spinal health

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February 28, 2015 Washington DC,

ACA/NCLC Conference

Setting 12

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February 25, 2015

State professional boards controlled by active market participants must be

supervised by state government to avoid federal antitrust scrutiny

US Supreme Court Ruling North Carolina State Board of Dental Examiners v Federal Trade Commission

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Current Status

• Chiropractic care is one of the few accepted Evidence Based Treatments for spinal pain

• Chiropractic theory has a solid but incomplete body of scientific experimental support

• Chiropractors are invited to participate in most spine and public health policy conferences, meetings and discussions

• Chiropractors are now serving on the interdisciplinary teams at the VA, Military Health Care, increasing numbers of hospitals and interdisciplinary spine centers

• There is growing support for a primary spine care identity for the practice of chiropractic amongst the non-chiropractic community

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I used to be asked: How could chiropractic possibly work?

Then: Is there evidence that it helps people?

Now: How can I find a good chiropractor?

Christine Goertz at NCCIH

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• How to counter the continued effort to redefine primary general practice physicians to include chiropractic

• Failure to participate in recognition programs such as URAC and NCQA, registries, PQRS

• Poor participation at national and international forums discussing spinal disorders

• Continued claims of chiropractic cures without evidence • Poor support and participation in state and national societies • Inadequate continuing educational to prepare profession for the new

reality • Threats from other health professions to protect their turf or to

challenge chiropractors role in states with low professional participation or leadership understanding of the new world

Challenges 2015

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Pitfalls of Clinical Experience

In 2005, in a paper in the online journal PLoS Medicine, Ioannidis laid out detailed mathematical proof evaluated studies in different fields of medical research that 80 % of non-randomized studies turn out to be in error

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• Promotion of a condition-based identity that follows the data • Stop trying to redefine primary care physicians to include

chiropractic or chiropractic as a non-spine care profession • Participate in recognized programs such as URAC and NCQA,

registries, PQRS etc. • Increase professional participation in the major chiropractic and

spine societies • Ensure chiropractic institutions train for the new reality • Ensure current practicing chiropractors understand and are able

to practice within the new reality

Addressing the Challenges 2015

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• Jerry and George McAndrews have had marked impact in changing the scientific, legal and professional opportunities for chiropractors and created an environment that allows for unimpeded inter-professional cooperation and professional advancement

Knights in Shining Armor

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Essential elements to ensure the future

•Identify and recognize the gender neutral knights who are currently representing the profession

•Train more gender neutral knights (researchers, policy authorities, instructors0

•More support of these Knights – armor and weapons (research support, travel and salary support, political support, publicity)

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An Example of What Chiropractic can do and the role they can play Improving the lives of people in underserved communities through sustainable, evidence-based spine care

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Supported by The Bone and Joint Decade, An initiative of The World Health Organization

A non-profit charity registered in the United States and Canada with the goal of helping

people with spinal disorders in under served communities throughout the world.

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Archbishop Emeritus

Desmond Tutu Nobel Peace Prize laureate Member, Advisory Council, World Spine Care

Elon Musk Board of Directors, World Spine Care CEO and CTO of SpaceX CEO and Product Architect of Tesla motors Chairman of SolarCity Co-founder of Paypal

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Professional and institutional endorsements

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Collaborating institutions

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Major financial sponsors

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International volunteer advisors

Charles Branch Neurosurgeon

Eric Hurwitz DC, PhD

Bjorn Rydevik MD, Ph.D Orthopedics

John Mayer DC, Ph.D

Don Powell MIPM

Carolyn Wilson, Vanessa Beyleveld

Premiere consulting Reginald Engelbrecht, DC

Paul Bishop DC, MD, Ph.D

Eduardo Bracher DC, MD, Ph.D

Lindsay Rowe Radiologist

Emre Aceroglu - Spine surgeon

Norman Fisher-Jeffes Neurosurgeon

William Watters Spine Surgeon

Christian Etter - Spine Surgeon Jan Hartvigsen DC, PhD Max Aebi MD

Eurospine

Deborah Kopansky-Giles DC MSc

Paul Hodges Physiotherapist

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A BILLION PEOPLE

WORLDWIDE SUFFER FROM

SPINAL PAIN

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Spinal disorders have a greater impact than:

• HIV/AIDs • Depression • Malaria • Breast & lung cancer

combined • Stroke • Diabetes • Alzheimer’s disease • Traffic injuries • Lower respiratory

infections

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The prevalence of spinal pain

is 4 times higher in developing

countries

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World Spine Care is the only

organization worldwide that is

tackling this global health crisis in an inter-professional, evidence-based, sustainable way

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Clinical program

• Low cost, low tech • Evidence-based • Fully integrated into local health care infrastructure

• Long term presence • Inter-professional and collaborative

• Measured clinical outcomes

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Clinical team

1. Primary spine practitioner • Screen for serious pathology • Timely referral when appropriate • Offer Evidence-based interventions:

o manual therapy o exercise o education (including psychosocial) o occasional mild analgesics

2. Surgical Specialists 3. Rheumatologists

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Prevention

• Scoliosis screening • Exercise programs

o “Straighten Up” program o WSC Yoga project

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Capacity building

• Patient/community education • Front line health care worker training/education • WSC spine conferences and professional

development • Student Scholarships • Advanced surgical training

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Sustainability Elements

• Volunteer clinic supervisor • Short term volunteer clinicians • Integration into the existing health care system • Spine care Clinician training – Education of local clinicians – Scholarships – Fellowship training

• Transition to local control

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Secondary Care Facility

Mahalapye District Hospital, Botswana

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Moca Project Dominican Republic

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Providing care for 500,000 people

Magu Project Tanzania

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“The Global Spinal Care Initiative”

•“The Development and Evaluation of an Innovative, Integrated Model of Care to Improve the Management of Spinal Disorders with the Goal of Reducing the Associated Global Disability and Burden of Disease.”

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Global Spine Care Initiative • Develop and disseminate an effective, low-cost spine care model that

can be sustainably implemented in communities with limited resources.

This 6-year Initiative is being launched in 2014, and it involves four phases:

• Develop a universally acceptable model of care for spinal disorders;

• Implement and test the model in 5 carefully chosen countries, with it modified to address prevalent language, culture, resources, and other local factors.

• Measure the impact of the model on the burden of disease in these communities

• Disseminate the results through WHO, and government and academic channels

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SCIENTIFIC SECRETARIAT

Scott Haldeman, DC, MD, Ph.D., FRCP(C), FAAN USA (Neurology, chiropractic) Margareta Nordin, Dr. Med. Sci., PT, CIE. France (Rehabilitation, EB Medicine, Implementation, Physical Therapy) Roger Chou, MD, FACP USA (Internal Medicine) Eric Hurwitz, DC, PhD USA (Epidemiology, DC) Pierre Cote, DC, PhD Canada (Epidemiology, DC) Emre Acaroglu, MD Turkey (Orthopedic surgery) Christine Cedraschi, Ph.D Switzer land (Psychology) Federico Balagué, MD Switzerland (Rheumatology) Damian Hoy, BAppSc (Physio/PT),MPH, PhD Australia (Epidemiology, PT) John Mayer, DC, PhD USA (Exercise physiology, DC) Rachelle Buchbinder, MBBS (Hons), MSc, PhD, FRACP Australia (Rheumatologist) Norman Fischer-Jeffes, MC, CHB, FCS South Africa (Neurosurgeon) Arthur Ameis MD Canada (Physcial Medicine and Rehab Deborah Kopansky-Giles, DC, FCCS, MSc Canada (Chiropractic) Claire Johnson, DC, MSEd, USA (Ethics and policy, DC) Geoff Outerbridge, DC, MSc Canada (chiropractor) Maria Hondras, DC, MPH, PhD Fellow USA Denmark (Epidemiology, DC) Christine Goertz, DC, PhD USA (Research methodology, DC)

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ADVISORY COMMITTEE

• Robert Dunn, MBChB (UCT) MMed (Orth) South Africa (Orthopedic surgery)

• Julie LaPlante Ph.D. Canada (Anthropology)

• Jean Moss, DC, MBA Canada (Administration, policy)

• Jan Harsvigsen DC, Ph.D. Canada (Epidemiology)

• Christoph Siepe, MD, PhD Germany (Orthopedic surgery)

• Gerold Stucki MD, MS Switzerland (Physical medicine)

• William C. Watters III MD, MMS, MS USA (Orthopedic surgery)

• Antony Woolf, BSC, MBBS, FRCP United Kingdom (Rheumatology)

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Conclusion

• The next 5 years will be the most dramatic and exciting in health care policy evolution and, in particular, spine care and the role of the chiropractic profession

• The challenges of the past are not the challenges of today

• The chiropractic profession is being asked to participate in all spine related health care issues

• The chiropractic organizations, educational institutions, researchers, policy experts and clinicians will have to understand what is happening and assume a leadership role

• Chiropractors must commit to helping people with spinal disorders throughout the world irrespective of their ability to pay

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www.worldspinecare.org

“Do a little bit of good wherever you are;

it’s those little bits of good put together

that overwhelm the world.”

Archbishop Emeritus Desmond Tutu Member of WSC Advisory board

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Thank you! Re a Leboga!