Are PTs Stealing Chiropractic?

This is a great read from Planet Chiropractic discussing the perceived looming threat that physical therapists have become for the chiropractic profession. This individual makes the case that the chiropractors should give up on the inevitable - 1) Physical therapists will be Doctors of Physical Therapy and 2) Physical therapists already and will continue to utilize spinal manipulation. Although I agree with many of these viewpoints, here is the author's solution to differentiate chiropractic from allopathic medicine:

"It’s time we start educating the public that what we do is not spinal manipulation and what we do is 'specific scientific chiropractic adjustments.' It is also time we start educating the public that these adjustments are for correction of vertebral subluxations, and it is time to educate the public as to what subluxations are and what they can do."

Unfortunately for the chiropractic profession, they have a major problem on their hands because of severely misguided logic. They have backed themselves itself into a corner by attaching the entire rationale for the effectiveness of manipulation to the elusive “subluxation”. Althugh many questions remain regarding underlying mechanisms, we do know with some degree of certainty that the concept of a subluxation is probably more a figment of one’s imagination. Even presuming that something resembling the idea of a subluxation exists, no one can reliably identify it. As Josh pointed out a few days ago, the chiropractors are not alone in their well-intended, but fanciful biomechanical decision-making strategies requiring painstaking mental gymnastics.

Based on the conflicting results of clinical trials, the evidence is clear that not all patients with back and neck pain need to be manipulated. Patients are not well served by health care professionals (whether they be chiropractors, physical therapists, DOs, etc.) who cling to fanciful explanations and indiscriminately use manipulation procedures repeatedly for extended periods of time on almost every patient. The unfortunate situation for the chiropractic profession is that the physical therapy community appears to be doing the lion’s share of the credible research in this area and is quickly becoming recognized for its more judicious use of manipulative interventions.

To be frank, having close colleagues who are chiropractors makes a part of me almost feel sorry for the profession. Persistent efforts to limit their scope of practice to essentially one intervention, claim this intervention as their exclusive domain, and link the target of this intervention to elusive biomechanical constructs that have no basis in science will only accelerate the rate at which the profession backs itself into a corner from which it cannot escape. In my opinion, although intended to protect the chiropractic scope of practice, efforts such as the one advocated in this article are misguided and will ironically have the unintended consequence of differentiating physical therapists as the evidence-based practitioners of spinal manipulation.

This is why I repeatedly assert that our best days as a profession remain ahead. Thoughts?

John

Comments

[Carina Lowry]

John,

I find this commentary and the discussion generated by Josh's post interesting. I still find great resistance to utilizing manipulation in the PT community where I work, and frankly I'm tired of the same lame argument that only DC's manipulate. A manipulation when appropriately applied is the BEST thing we can do for our patients. I also enjoyed the prior article posted about subluxation theory, specifically the "Save our Subluxation" button.

My two main points are this:
1. My colleague actually learned a few manipulations in coursework however was never allowed to use them in her clinicals. In fact, the clinical instructor performed an elbow manipulation and then told her "you should never do this." WHAT?? Are we giving our students the message "do as I say not as I do?" Are we letting them practice on the clinical? Are we giving them critical feedback they need? I just don't see how we can expect our students to be confident in manipulation skills if we are not reinforcing it.

2. As another previous post pointed out, patients equate manipulation with chiropractic care. I have to constantly educate my patients why we are different, ie we are trying to get the joint to move; trying to get some type of relaxation response to increase movement at the joint, etc. Not that I'm putting them back "in" after they mysteriously slipped "out." Not only patients but colleagues also need consistent winning over to start implementing manipulation into practice when needed and decrease the perception that we are just manipulating everything that walks in.

I find it humerous that this commentary states that we are able to manipulate in a few states, YEAH I think something like 46? Also I think it's interesting that he describes PT's as DPT's like this is the turning point. PT's have utilized manipulation for longer than 10 years for the transition to DPT. It's just now that we don't expect only experts can do it! Which may be a benefit in my novice case.

Carina

[Jason Silvernail]

It's really funny how American culture is fixated on this doctoral degree thing. Looking at it this way, it's kind of sad that the PT profession didn't get more attention and a fairer remuneration system for our work until we crossed that mystical line into being a "doctor", a term which has less and less meaning as the years go on.

Our PT colleagues in other countries, especially commonwealth countries, have had direct access and no practice restrictions for several generations, and they usually enter the field with a Bachelor's degree.

I'm afraid the chiropractic ship has sailed. I hope in the coming years that the sensible DCs out there providing appropriate care (several of which we are lucky to have post here) don't suffer for the direction it's headed in.
J

[Jon Newman]

I posted this some time ago at RE

http://www.chiroandosteo.com/content/13/1/17

The only problem with positing a theory in my opinion is being unwilling to revise it so as to better explain our observations or to make it more consistent with other areas of study. Equally bad, in my opinion, is an unwillingness to attempt to explain our observations in the first place. I think this is not unlike that peanut butter and chocolate thing Brit mentioned in another post.

[Jon Newman]

Opps. I didn't realize that Josh had already referred to the above paper in another post.

[Brian Pease]

Let's not spend too much time and effort celebrating the impending demise of Chiropractic when we have considerable work to do on improving the overall quality of decision making and care within our ranks. For every EB practitioner that I encounter, there are 5-10 others supervising home exercise programs with no scientific merit, inappropriately advancing basic exercise progressions without the slightest insight into inflammation and repair constraints, or simply giving every patient the blue plate special. Some wise person (I am supposing) once said "when you only have a hammer, everything looks like a nail." We need to be diligent so that this becomes less and less true of many of our colleagues in addition to the DC community.

[Britt Smith]

John,
Whoa, those boys have circled the wagons around! I don't know how many chiropractors would agree with the view point expressed, but, wow, this group has slipped in the world of the Amish: reactionary to an extreme!I agree with the comments above about we need to continue to get our house in order, including getting PTs on board with manipulation.
Two vignettes from yesterday: I evaluated a 14 yo girl, volleyball player in an MVA at thanksgiving. She has been treated by a chiro (continues) and the mom asked me if I minded. I said, no, I just won't manip., to be fair to the girl, the chiro and myself. I did add that I have frequent situations of 'co-treatment' and occasional referrals from a chiro or two. My only beef with this particular chiro was that he advises parents against vaccinations for their children (I know 3-4 parents who take their kid to this guy for care). This view falls in with the Luddites (thanks Jason), you mention above.
The second scene: I got a call from a colleague who is an osteopath asking to treat him after work. He's a great guy: 5/5 on the CRP, no problem with manip. Afterwards, we had a nice chat about the CPR, the Flynn et al 2002 and Childs et al 2005 studies and the classification system. He was impress. I have presented at the Family practice residency in two, where he may be involved in a sports med. fellowship.
Both vignettes illustrate teaching opportunities: one to the public and one to the medical profession. Look for the oasis in the desert and keep reminding yourself that somewhere in the wilderness, a group of chiros have circled up and are waiting for the barbarians at the gate...could be a long wait.
Britt