Chiropractor.
What was your immediate reaction to this word?
The general public usually responds with either "Quack," or, "I couldn't survive without my chiropractor." There seems to be little middle ground. Unfortunately, for far too many personal injury plaintiffs, their investigator's reaction is all too often the same as that of much the general public: "Quack!"

It is vital that the personal injury investigator understand the history and use of chiropractic treatment. Old wives tales and myths handed down from the days when the American Medical Association (AMA) was deliberately targeting chiropractors and chiropractic care, have no place in a professional investigation. This is true for both the plaintiff's investigator and the defense investigator. An investigation is an investigation. An investigator's knowledge and opinions should be based on provable facts.

A brief history of chiropractic
In a timeline of world history, chiropractic may appear to be "new"---but only the word is actually new. Spinal manipulation has been mentioned throughout the history of mankind.
Although there are recorded uses of spinal manipulation by the Chinese, as early as 2700 BC, it was Hippocrates who first emphasized the importance of the nervous system to our general health. During the Dark Ages, however, manipulative therapy suffered a setback, often being referred to as part of the occult. The art of "bonesetting" then began to be handed down from parent to child in most European and Asian communities, much as the Native Americans of this continent handed down their knowledge of herbal medicine.
The website of the American Chiropractic Association (www.amerchiro.org)
reports that during the colonial days of our nation, the majority of doctors were without any formal medical education and practiced their healing art along with other occupations. Apprenticeship or self-training was the usual and almost exclusive path to becoming a doctor, even in the 1880's. A medical school was not part of Columbia University until 1860. And, it was not until the 1880's and later that states considered passing laws licensing practitioners of medicine.
A former grocer and teacher, Daniel Palmer, is credited with "creating" the practice of chiropractic in the United States. In 1895, Palmer, who was interested in the healing arts, performed an "adjustment" on a misplaced vertebra in the upper spine of a janitor, causing the man's hearing to improve. Interest in the new science then began to develop among the prominent medical men of the time.
The word "chiropractic" derived from the Greek words "cheir" and "praktikos" meaning "done by hand," has been used in the United States since that time.
Finally, in 1913, (just thirty plus years after the medical doctors were first licensed), the first state law to license chiropractors was passed. Today chiropractic is recognized in all fifty states, Puerto Rico and the District of Columbia, as well as in Canada and throughout much of the rest of the world.

What are chiropractors?
Chiropractors are physicians who consider man as an integrated being, giving special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, nutritional, emotional and environmental relationships.
They include adjustment and manipulation, particularly of the spinal column, in their treatment of patients. These treatments are often referred to by patients as "manipulations," or as "getting an adjustment."
Chiropractic treatment is drug-free and non-surgical. Chiropractors are the only doctors who are trained to treat the entire human body, understanding that its parts are interrelated. Though the spine and nervous system are the primary focus of treatment, that treatment is done with a full understanding of, and concern for, the complete human.

Training the doctor of chiropractic
"He's not a REAL doctor!"
This seems to be the favorite saying of the uninformed who want to argue about the validity of chiropractic care. In fact, those chiropractors with a sense of humor are often teased by their staff with just those words. But there's no truth in the statement. In fact, chiropractic physicians receive more training in human anatomy than those perceived to be "real doctors"---the MDs who for so long refused to acknowledge the expertise of chiropractors.
Students pursuing a career as chiropractors are subjected to some of the most stringent educational requirements of any health care professionals. Following successful completion of four years of pre-medical training, with emphasis on advanced sciences, the future chiropractor faces four or five more years of study. Much of that time is spent in clinical training.
The ACA points out that these doctors undergo rigorous education in the healing sciences, similar to that of medical doctors. "In some areas, such as anatomy, physiology, rehabilitation, nutrition and public health, chiropractors receive more intensive education than their MD counterparts," the ACA reports. Usually, a chiropractic student must also complete clinical-based programs dealing with patient care.
Upon completion of a doctor of chiropractic degree, a student will have completed a minimum of 4200 hours of classroom, laboratory and clinical experience in a course approved by an accrediting agency that is fully recognized by the U.S. Department of Education. This is not a new situation---it's been true for more than twenty-five years.
Fully accredited chiropractic colleges are strategically located across the United States. The ACA reports that the Council on Chiropractic Education and its Commission on Accreditation are recognized by the U.S. Department of Education as the sole authority on training offered by these colleges. The colleges also undertake research projects and offer teaching, graduate and residency training agreements to state universities.

What are these graduates called?
Graduates of chiropractic colleges may be called "Doctor of Chiropractic" or "Chiropractic Physician." Thus, it is appropriate to call them "Doctor." The generally accepted professional designation is D.C, or DC, following the doctor's name. For example, Janice C. Meisenheimer, D.C.

Required continuing education
The profession has long supported continuing education as a yearly requirement for relicensing, leading the medical field in recognition of its importance.

Who are those "CAs?"
"CA" is the name commonly given to the chiropractic assistant. There are no national licensing provisions for a CA, although some states may have, or may be considering, registration or licensure. Several chiropractic and liberal arts colleges have developed an educational curriculum for their special training. There are also seminars and other educational opportunities available for continuing education. Most chiropractors are dedicated to ensuring that their staff is fully informed about, and supportive of, chiropractic care and philosophy.
A well-trained and experienced CA can provide valuable background and interpretative information for an investigator seeking to gain knowledge about a plaintiff's care.

"Bonecracking" and other ugly words
Much of the misunderstanding of chiropractic treatment has resulted from incorrect information disseminated by other medical groups, unethical and unprofessional chiropractors, and a general lack of public education regarding the truth about treatments.
Words such as "bonecrackers" and "crunching," combined with the oft-held belief that once a person has a spinal manipulation, they will have to keep returning to the chiropractor forever, has given the profession a black eye that can only be overcome by truth.
The professional investigator must learn to recognize these biases within him or her self, and to eradicate them, so that there is no interference with understanding the client's need for professional care. However, knowing that these biases still exist, and that there are still some unethical and unprofessional "doctors" practicing chiropractic, just as there are similar problems in every branch of medicine, will also help the investigator identify potential problems with a client's case.

Modalities
State law determines the kinds of treatments, known as "modalities," that chiropractors can perform. The main modalities include chiropractic manipulation, dietary advice, nutritional supplementation, physiotherapeutic and supportive measures, and professional counsel.
Actual modalities vary from state to state, but might include such treatments as ultrasound, hot or cold compresses, foot stabilizers, hydrotherapy, or galvanic currents.
The professional investigator should review the appropriate state law, comparing the approved modalities to those provided to the plaintiff, to avoid surprise testimony at trial.
The various treatments have assigned billing codes called Chiropractic Manipulative Treatment (CMT) codes. Insurance companies, government agencies, and others who might be involved in paying for chiropractic treatment universally recognize the codes. CMT codes are a part of the medicine section of the Current Procedural Terminology (CPT) Code system developed by the AMA in 1966. It is updated annually.
For example, if 98940 is listed as the treatment code, one knows that the billing is for "Chiropractic manipulative treatment (CMT); spinal, one to two regions," whereas 98941 is "CMT, spinal, three to four regions."
Investigators who must review chiropractic records should obtain a complete listing of CMT codes and their definitions.

Beware of the "others"
It is important that all investigators working with a client who has had, or is having, chiropractic treatment understand that bias against chiropractors still exists in the medical community, especially among some of the older doctors and nurses.
As an example, last year, while visiting a professional (non-medical) office, I noticed that their receptionist, an older, white-haired woman, seemed to be in great pain. When I inquired, she told me that she had a "pinched nerve" and that the resulting leg pain was almost unbearable. However, when I offered to give her my chiropractor's name and phone number, she haughtily pulled herself upright and announced very loudly, "I am a retired NURSE!" Such ignorance keeps a lot of people in pain.

Tips for the investigator
The following list of investigative tasks may help to develop important facts about your case. Read them carefully and develop your investigation plan. Not all tasks will be necessary in every case, nor will they always be done in the order listed here. These are suggestions and guidelines only.

1. Be sure that your attorney/client has sent a letter to all treating medical professionals requesting notification if the opposing party requests copies of your client's medical file. (In some states, the patient may instruct that no records are to be released without their express permission, but some medical providers-and especially their staff---are intimidated by attorneys. They may release the records simply because they were requested by an attorney).

2. Review the billing statements provided by the patient, or the insurance company. Note any unusual charges or unusually frequent treatment visits. Note: It is not unusual for a patient to see a chiropractor for three visits per week in the beginning stages of treatment, especially following a motor vehicle or other serious accident. If the patient continues to have three times weekly visits after seeing the physician for six to twelve visits, however, questions should be asked. This is the first area of inquiry that will be made by the defense team, so the plaintiff's team must be prepared to justify the continuing treatment.

3. Compare the CMT code definitions with the actual chart notes for any discrepancy that may be questioned by the opposing experts.

4. Watch for evidence of the "practice management" concept of running a chiropractic business office. The concept itself may not be faulty, but the way in which it has been used by many practitioners and their staffs has caused considerable problems for injured patients trying to collect insurance payments, or to win an award of damages in a courtroom! Some few chiropractic offices reportedly have the new patient sign a contract for a certain number of visits, and to schedule those visits, sometimes for several months in advance, before the patient has seen a doctor! This, added to the insurance industry's ingrained bias against chiropractors, has caused even more problems for those who abide by the rules, treating and billing only for what is necessary for the well being of their patients. What may appear to be excessive treatment may actually be provably necessary to your client's recovery. But if the investigator doesn't recognize the potential problem and bring it to the attorney's attention, the plaintiff's medical expert may not be prepared to justify it. (Review the information in Tip #2).

5. Visit the office.
Pick up a copy of any brochures or other chiropractic literature available in the waiting room.
Ask for a tour of the facility.
Observe whether equipment is actually available to do the work listed in the chart notes and billing statements. (For example, if the billing statement lists x-rays, is there a room and equipment for taking x-rays?)
Ask your attorney-client if experts in their trial testimony will need positives of the x-rays for use.

6. Don't ask, or rely on, your client to obtain a copy of his/her file from the chiropractor's office. Go to the chiropractor's office with your subpoena duces tecum, or letter of authority from the client/patient, and ask to review the file before it is copied for you. Don't forget to include the billing statements, x-rays and other test results in the request, and in your review. Make a list of the contents of the file.

7. If your client has a common name, check other identifiers to make sure you were given the correct records

8. Be sure you have the complete chiropractic file. It's not unusual for the office to routinely remove letters from insurance companies, subpoenas from the opposing party, reports prepared specifically for another insurance company or attorney, and other documents, before copying the file to fulfill an attorney's or investigator's request. Compare the copies received with the list that you made. (See Tip #6)

9. Review the file. Look for the following kinds of information.

Does the injury incident information match what you have been told by the client?
Does the date of injury and first treatment match what you have been told?
Is this the first treatment for this injury?
Were there prior injuries of which you were unaware?
Look for notation of other diseases and injuries.
Compare test dates with reports to make sure all of the information is included.
Was this client/patient seeing more than one doctor at this office?
Have other attorneys, insurance adjusters, or investigators requested records or reports? Do you have copies of those reports?
Has anyone else met with the doctor, or the staff, regarding this client/patient?
Does the prescribed treatment fit within the usual methods for this type of injury?
Are the treatment modalities consistent with state law?
Are there "warning signs" of over treatment or malingering?
Are there names/addresses in the file for other medical providers? (Get their files!)

10. X-rays:
Check x-ray dates with the actual x-rays. Are any missing? (State laws usually determine the length of time x-rays must be retained.)
Who took them?
When?
Why?
Is that person licensed according to the laws of the state?
Was he/she licensed at the time the x-rays were taken?
Check with the appropriate state licensing agency.
If not taken in-house, obtain the records from the other facility
11. Request a transcription of the chart notes, if one is not provided with the file. Be sure that the doctor who wrote or dictated them certifies the transcription. Only that professional will know the correct, exact, original wording. (There will probably be a charge for transcribing.)

12. If there are prescriptions for other health care professionals in the file, such as massage therapists, orthodontists, or orthopedists, request those records, as well.

13. Obtain the doctor's curriculum vitae and verify everything listed!

14. If the litigation team includes a chiropractic or other medical expert, it may be
necessary for you to prepare an investigation report, notebook, or some other package
of materials for the expert's review and analysis.

15. IMPORTANT: Be sure to discuss your investigation plan with your attorney-client
before proceeding. In most states, anything that you request or acquire in a personal injury case will most likely be discoverable. Make sure the attorney has given you
instructions, or at least agreed to your plan, IN WRITING. You may have to do a letter
documenting the meeting or phone conference in which the plan was discussed and
agreed upon. When something goes awry in a personal injury investigation, some attorneys
are quick to deny prior knowledge. It's important to remember to protect your own business, while working to protect the rights of the plaintiff.

I hope that professional investigators will use the information in this article as an incentive to become fully informed on this much-maligned medical treatment, thus assuring that the client who chooses to see a chiropractor will receive fair treatment in the legal system

Further educational sources
www.amerchiro.org
"The American Chiropractic Association (ACA) is a professional organization representing Doctors of Chiropractic. Its mission is to preserve, protect, improve and promote the chiropractic profession and the services of Doctors of Chiropractic for the benefit of patients they serve. The purpose of the ACA is to provide leadership in health care and a positive vision for the chiropractic profession and its natural approach to health and wellness."

Gomez, Mark A., Ph.D; Biomechanics of Soft-Tissue Injury
© 2001 Lawyers & Judges Publishing Company, Inc. This book is an excellent source of information regarding soft-tissue injury.

www.clevelandchiropractic.edu

www.chiropractic.org
International Chiropractic Association. Established in 1926 by B.J. Palmer

www.worldchiropractic.alliance.org/tcj
The Chiropractic Journal

www.cjnetworks.com/~kca
Official website of the Kansas Chiropractic Association. Includes links to state licensing information and chiropractic colleges.

Disagreement over the validity of chiropractic continues to plague the profession. In fairness to those who might want to read "the other side," the following website and information is included: www.chiromed.org "The National Association for Chiropractic Medicine (NACM) was founded in consumer advocacy. Most professional associations are formed to further the interests of the professional individuals forming the organization. Members of the NACM believe that the interests of the public must come first over the interests of the professionals making up the association. Associate members believe that, in serving the public interest, they will be working toward a better profession, which, ultimately, will further their professional/personal goals. The first and foremost requirement for membership in the NACM is that a Doctor of Chiropractic Medicine renounce the chiropractic hypothesis and/or philosophy; that is, the tenets upon which their scope of practice is based"

Endnotes
1 The history, training and education information in this article was obtained from the American Chiropractic Association (ACA), including their website (www.amerchiro.org) and/or communication with Felicity Feather Clancy, ACA Vice President of Communications. Much of it is directly quoted to assure accuracy, but due to limited space, the author is using only one endnote for attribution. Please refer to their website for additional, useful information

©Grace Elting Castle

Prior to becoming a professional investigator, and a long time before becoming editor of PI Magazine, and Cluesonlinethe original online newsletter for professional investigators™, Grace Elting Castle, CLI®, was a chiropractic assistant in Newport, Oregon. Contact her at gecastle@cluesonline.com.