A Chiropractic Perspective

I have not chimed in very often to this website, but John knows me rather well from our interactions at the University of Pittsburgh (PITT) where I am completing my PhD in rehabilitation science. When I read that bizarre "article" (or whatever one might call that futuristic rambling) about the future where only one DC is left standing, I felt that I needed to give a lengthy commentary on what I feel is the likely future for both DPTs and DCs. Tony Delitto and I have often discussed the future possibilities for the chiropractic and physical therapy professions, and have come to similar conclusions about what the future holds for our respective professions. But first a little bit of background information.....

I believe that chiropractic is in the midst of a downward spiral due to a failure to establish any unified professional identity. There are four basic subdivisions of the chiropractic profession (1) musculoskeletal specialists who are only interested in treating the spine and extremities (2) "holistic" or "functional medicine" specialists who like to treat functional internal disorders with nutrition, dietary interventions, homeopathy, etc. (3) DCs who consider themselves to be "alternate primary care physicians" and (4) the "subluxation" based DCS who promote spinal manipulation as the panacea for all mankind's illnesses. There are no hard data on what percentages of DCs fall into these 4 categories, but my main point will be focused on TYPE 1...i.e. the musculoskeletal specialist....while at the same time recognizing that the other 3 types are constantly fighting each other as to what the "real message" of chiropractic should be, ad nauseum.

The DC who practices as a musculoskeletal (MSK) specialist is typically one who has embraced the principles of evidence based care, has learned active care techniques such as spinal stabilization exercises and other rehab protocols, knows several "PT techniques" such as the protocols promoted by McKenzie, Mulligan, Butler, Maitland, Cyriax, and others. This DC practices a combination of manual methods, teaches his/her patients how to care for themselves at home, and does not promote chiropractic as a panacea for all illness. S/he has a very fine understanding of musculoskeletal diagnosis and conservative treatments, as well as a good sense of when other medical interventions are required, such as injections and surgery. His/her diagnostic skills are the envy of most medical physicians, who are extremely unqualified to perform musculoskeletal diagnosis that requires mechanical reasoning and provocative physical examination procedures that logically deduce which tissues are the pain generators.

This sounds a lot like a description of the current DPT graduates that I have encountered. And therein lies my point....I believe that we will see a certain segment of the chiropractic profession gravitate toward the version of clinical practice that looks very much like the practice of physical therapy. And we have already seen the PT profession gravitate toward improving its manual skills, especially thrust manipulation (oh, I meant to say Grade V mobilization) and integrating those skills along with traditional rehab and active care protocols. So the chiropractic and physical therapy professions are on a collision course wherein MSK based DCs are not content with manipulation only and are embracing rehab priniciples, whilst MSK based DPTs are not content with rehab and exercises only and are embracing more manipulation and manual therapy principles.

In the past, some people like Dick Erhard who were excellent clinicians and superb at differential MSK diagnosis became frustrated as PTs, and obtained a DC degree in order to become a "physician" and break free from the MD referral nonsense. Now with the DPT program and direct access, the need for PTs to obtain DC degrees is going away. Instead, the reverse situation has started to surface...i.e. some DCs who are gravitating in this MSK specialist direction are interested in obtaining a DPT degree, to complete their understanding of all aspects of rehabilitative care and to potentially practice under a different license/profession. They are becoming disenchanted with all of the nonsense espoused by the "subluxation removing" DCs who claim to treat all sorts of non MSK conditions. They are ready for a split from the remainder of their colleagues who can not seem to make any stand on who they are and what they do. And sliding over to the PT profession may become a future trend for a select group of DCs.

The DC who now obtains a DPT degree is no longer "stepping down" from "doctor" status to "therapist" status. It can be considered a lateral move. Tony Delitto and I have met with a few DCs in the Pittsburgh area who are planning to apply to the DPT program at PITT, in order to make this very lateral move a reality. I believe this could be the beginning of a long term trend, if those MSK specialist DCs can not find any voice of reason within the American Chiropractic Association or other national organizations. I am committed to stimulating more like minded DCs to consider enrolling in DPT programs, and would like to see other institutions besides PITT offer such programs to DCs. Of course, many of you know that Stanley Paris was the first person to make a DPT program available to DCs in a mostly online format. I have met with Stanley and found that he too senses a great potential demand in the future by DCs to take DPT programs, which explains his rationale for taking the risk of an outcry from his own profession to make this bold move.

It is my personal opinion that the chiropractic MSK specialists and PT profession have so much in common, that the synergistic relationship of having them blend together into some new type of hybrid clinician that possesses the best of both worlds would be an awesome combination. This is likely to happen, if a substantial subset of MSK specialist DCs decide to bail out of the chiropractic profession, and make a lateral move over into the PT profession. I  have stated publically at chiropractic meetings and conventions that it is wrong for the chiropractic associations to be suing PTs over the right to perform spinal manipulation. I think this only serves to divide our professions further, and must make a lot of AMA delegates quite pleased when our two professions waste precious economic resources on legal fees, fighting each other instead of them. We should be pooling resources to improve NIH funding for MSK conditions that are treated by both of us, and fostering more evidence through clinical research...for the ultimate benefit of the patients we treat...and not to protect professional economic territories.

So now we come full circle...back to the futuristic article that started this discussion. That DC's opinion piece represents (in a distorted way of thinking) the opinion of a large segment of the chirorpractic profession which feels threatened by the emerging DPTs who they feel will "take away manipulation". Hence the legal battles to save manipulation as the exclusive domain of chiropractic. Without exclusive rights to the one thing that defines the chiropractic profession, DCs feel they will become irrelevant and expendable. And you know what...this is probably correct! What future thinking DCs envision is a day where DPTs who are skilled at manipulation will become the one-stop shopping center for patients with spine pain. DPTs have full integration within the medical community, and the chief reason for chiropractic's survival over the years has been the fact that we were the only ones performing manipulation....no one else really cared to provide this service, and when nothing else worked....manipulation often gave dramatic results.

But that all can change when DPTs are able to see patients without medical referral, provide manipulation as well as rehab exercises, and insurance starts to reimburse them via direct access. The corrollary fear is that insurance companies will some day see PT and DC services as mutually exclusive or redundant, and because there are twice as many PTs as DCs, we will loose the battle due to a shear numbers game. So all of these fears are wrapped into one bizarre story by a DC who is probably trying to scare his colleagues into taking some sort of action. Some DCs will take action by contributing money to lawsuits that attempt to block PTs from manipulating the spine, and others like me will take action by trying to stimulate DCs to get a DPT degree and practice as a MSK specialist. I hope that this information is useful for stimulating some further debate and discussion about the respective futures of our professions.

Mike Schneider, DC, PhD (c.)

Comments

[Jeff Hebert]

Mike,

I was happy to see your post here and believe that you have summed up the situation quite well. Our profession will either be forced to change, assimilate or be overrun. I wish you all the best in your endeavors at PITT.

Jeff

[Britt Smith]

Mike,
Excellent summary of the the chiropractic (and DPT) situation. Interesting development. Some of my friends in manual therapy became DCs in the 1980's for 2 reasons: 1. get out from under referrals and 2. learn more manipulation than was being taught in CEU courses. They are excellent practitioners functioning as what you have called 'MSK specialists'. I remember discussing with Dennis Morgan PT,DC in the late 1980's the possibility of a convergence of the professions. I don't recall the details of the conversation, but the direct access issue was a giant barrier for PTs, in Dennis' opinion.
Thank you for the clarity of commentary.
Britt

[Dave Morrisette, PT, PhD, OCS, ATC, FAAOMPT]

Do any of the "elderly"PT's who read this blog remember the arthropractic movement that was so diligently promoted by David Lamb in the 80's? At the time, a group of PTs and chiropractors were working together to start a "new profession" that would combine the best of both worlds. The current discussion sounds very much like David's vision. I believe David would have agreed with Dr.Schneider's comments and would have promoted the collaboration in training / education between these groups of musculoskeletal specialists.

I am not sure why anyone would object to a chiropractor becoming a PT. I am more concerned with what I perceive as what the majority of PTs are not doing.

Dave Morrisette

[Peter Huijbregts]

Hi Mike,

Like you, I have been thinking a lot about the current interaction and future relationship between chiropractic and PT. I have read an abundance of chiropractic texts and have become quite familiar with the history and theories of the profession, all as part of me teaching an online course (yes, in Stanley Paris' program) that includes a section on the history of manual medicine. You may have read my musings on this in the form of an editorial on the chiropractic subluxation and its relevance to manual medicine at large (available full-text at http://jmmtonline.com/past/vol13no3.php)...

As the editor of an evidence-based manual medicine journal that caters to all professionals active in this area, I am very interested in getting a dialogue going between the two professions. So my question is, would you be interested in writing an opinion piece on this topic? I am sure it will stimulate some discussion...

Regards,

Peter

[Scott Newton, PT, DPT, OCS, CWS]

Mike, Thanks for the insight into the DC profession. Any suggestions for dealing wtih the fears you mention in the last paragraph? Last legislative session we attempted to remove many of the restriction to our state's direct access bill. The ortho's, and the medical association agreed to the changes but the DC's were opposed because of the "safety of the patients" PT's can not perform "X-Rays" thus we might miss a DX. The bill had safeguards for patients that were not improving that the majority of the medical profession felt comfortable with(along with explaining the extent of PT's current training). The DC association did not wish to discuss the bill with us until the morning of a committee vote at which time they offered to remove their opposition in return for changes to the defination of manipulation in our bill. In the end the bill was pulled. As it stands we will prove your comments correct--both sides will spend a lot of money. Any suggestions or insight would be greatly welcomed.
Scott

[Mark Boncser]

I appreciate Mr.Schneider's comments and his openness to this discussion. I honestly would be worried about being associated in any form with the chiropractic profession at this time. I believe that there is a public perception that the majority of chiropractors are "quacks". I have worked hard to maintain a personal and professional reputation of integretity and I believe as a whole our profession has as well. I don't want to be anywhere near something that would taint my profession. At this point and time I believe the chiropractic profession needs to address the issues that cause the some of the public to believe they are quacks. Then and only then do I believe the PT profession can risk be associated in some way.

[Chris Baker]

Well said Dr. Schneider. I could not agree with you more. Here I am, in my last clinical prior to graduation with MSPT, and am excited about what the near future holds for me. DPT next I presume.

I have practiced for almost 16 years as a DC, and have practiced from a evidence-based position. Unfortunately, not much evidence has been promoted via Chiropractic which has been disheartening over the years. Yet, in spite of low evidence, my manual-based chiropractic practice has done very well, seeing patients an average of 3 visits per incident. We all know the manip works, and recently the evidence supports its use in specific situations.

I see the movement exactly as you have described, those evidence-based chiros moving towards DPT and manual-oriented PTs moving towards a "chiro"-based approach ("chiro" meaning "hand-on manual.") Having a research background, I am impresed with the quality and evidence associated with the teaching of manual techniques within the PT profession right now.

Now, a very interesting thing happened yesterday in the clinic where I am completing my final clinical. A patient shared some of her concerns with me regarding her care. Keep in mind, she does not know that I am a practicing DC completing my 3rd clinical.

She (call her name "Mary" thought she needed to see a chiropractor for additional care. I asked her why, and she explained that she thought a chiro could help improve her symptoms better(history of MVA with multiple site spinal strain, general deconditioned, depressed). She admitted that she was improving since injury, ie increasing her cardio with aquatics, active rehab, and manips. However, her concern was whether it was legal or not for "us" (referring to clinic DPT's and me as an intern) to manipulate. She said it scared her becasue chiro's were trained to manip, not PT's. "Mary" and I further discussed what could a chiro do that was different than our clinic, and her response was that she thought she would be safer with a chiro manip and maybe get better faster.

After further discussions Mary stated that "you guys" probably do not get along with chiro's. I felt it time to "spill the beans" and share with "Mary" that I was a practicing Chiro since 1991, and that frankly, I do not see any difference in one manipulation from another referencing practitioner type. I explained to her that the goal of the manip is to restore the dysfunctional movement patterns, and that the techniques used by our DPT's or my DC were very similar if not the same. In fact, due to my involvement in teaching with Texas State University, I can vouch that the methods taught to the students are very sound and same as those taught to me as a DC.

Funny how her attitude changed and she could not wait to tell all her friends that this clinic utilized both Chiro and DPT in the treatment approach to MSK disorders. Interesting patient perception and importance to educate our patients regarding the manual treatment approach.

In summary, Dr. Schneider, good comments. Our profession in in for some serious changes, and those not evidence-based may have some difficult times ahead supporting why they need to treat the subluxation or other "mankind illnesses" in their practice.

More later, as my CI is in looking for me :).

Christopher Baker, MS, DC, DACBN, CCN, SPT

[Cameron MacDonald]

Mike & All,

This is certainly an interesting discussion. The 'trend' of DC's enrolling in DPT programs has been noted by others, and also by myself. I personally see this as the MSK DC's attempting to be able to redefine themselves as evidence-based, and more mainstream than the stand-points taken by many of their colleagues who would fall into groups 2-4 that Mike listed.

As it takes a lot of personal effort, expense and time for a DC to complete a DPT program, these practitioners appear to be putting considerable effort into expanding their education and changing their status. I give these DC's a lot of credit, but what is driving this change??

I feel we all have some ideas as to this: professional disatisfaction, a desire to be able to base practice on research not simply what they were instructed in school, a resentment to the negative asscoiations of quackery which is sometimes associated with the chiropractic profession or other reasons which escape me.

I personally do not wish to see the DC and PT professions form an alliance. I would prefer the DC's who wish to be recognised as MSK specialists to go the DPT path. As EBP DPT's develop entry-level skills which embrace the utilization of manual PT skills as needed, in combination with good differential diagnostic skills, is another type of MSK provider needed?

The growth of the PT profession through the DPT, the work of AAOMPT, residencies and fellowships in orthopedic/manual PT will generate a direct access provider that encompasses all of the needs of a patient with MSK dysfunction, including referral for non-mechanical presentations. I suspect many in the DC professions see the extensive overlap, and are looking to protect a niche in this market in holding onto manipulation.

The kicker in all this is that the research generally does not support manipulation in islolation (unless you want a life long patient........), manual PT based patient managemnt requires in-depth MSK evaluation, differential diagnosis, an exercise intervention program (nearly always), and a path to patient independence. This is the outpatient OMPT at work. For those who wish to own manipulation in isolation, and provide only manipulation, isolation from clients may be what you get.

It is possible that the growth of the DPT will be a catalyst for change in the DC profession, and it probably already is, but this is not likely to be a major change. I feel that there are to many deeply entrenched beliefs which will not change. I still have many clients who present receiving ongoing subluxative intervetnions, and it is difficult to see any real positive client management occuring in a lot of these individuals. I do also see clients who I feel have received very good prior care with a DC, but the care given certainly sounds like OMPT to me; including all the billing.

We shall see what the future doth bring.
Cameron

[Jon Newman]

The MSK specialist is being bandied about lately on a number of discussion forums. I was originally attracted to PT "to help people". My education made it more clear as time went on that I was trying to decrease disability and improve QOL. To my mind an MSK specialist is too specialized for that purpose. Actually MSK specialists already exist in my opinion--orthopedic surgeons and rheumatologists.

What we have a dearth of are pain specialists. Especially those describing and prescribing science anchored non-pharmalogical approaches to pain relief. I think this is ironic since it is the primary presenting complaint as well as a significant player in disability.

I don't see how a marriage of PT and DC is going to change things much as far as that is concerned as they are largely redundant, especially as it pertains to relevant MSK knowledge. The diversity of opinion on this topic leads me to believe that such a move would have to be an arranged marriage with the wishful thought for something wonderful in the future.

People will profession hop as they feel they must and for their own unique reasons. I'll try my best to make this the profession to hop to and not from.

[Leigh Langerwerf]

Dr. Schneider,
Your response to the article was phenomenal. I didn't know that there was such a lack of unity in the chiropractic community. Additionally, it was very interesting to hear your prospective on the two professions going on more similar paths. We shouldn't be at odds with the MSK DC's, we should be working together, as you seem to suggest. I actually was talking with a DC the other night at my fantasy football draft and when I told him I was a PT, he kind of gave me a weird look. I told him that I wasn't a chiropractor hating PT, on the contrary, I think that they do a lot of good. Anyway, glad to have read your post and really looking forward to sharing ideas with you and your colleagues in the future.

Sincerely,
Leigh Langerwerf, DPT

[CHris Baker]

I do not think the two professions of DC and PT will merge. Having studied both professions, I think the health models are different.

Chiro is more patho-anatomically based, ie disease, subluxation, diagnostic whereas PT is functionally oriented. These are two different paradigms. As DPT approaches direct access, I do think that it is important to diagnose and differential diagnose which certainly includes blood work, imaging, etc. Of course I am influenced by prior training as a diagnostic doctor. I have experienced multiple occassions where I have received a referral of back pain, and thankfully my ability to refer for advanced imaging, proper bloodwork enabled me to properly diagnose cancer, missed fracture, etc.

I digress though. It is challenging to be working with a patient on my clinical and know that there are some unanswered questions which I could resolve with a proper diagnostic work-up, however hands tied as a PT. Yet if my goals are to restore functional use, I really do not concentrate on the pathology, as my goal is to restore functional use and meet the patient's goals regardless of the patho-anatomical diagnosis.

Said another way, as a chiropractor, I diagnose and "fix" the patho-anatomical problem with the manipulation. Unfortunately, with the absence of traditional rehab and active patient participation, the patient will most likely be manipulated over and over due to lack of stability or lack of addressing the deficits of the other bodily systems. As a manually oriented DPT, you would still address the structural (joint) dysfunction (probably resolved within 2-3 visits) yet address the functional deficits as well, ie stabes, conditioning, HEP, independence. I think chiro in general tends to promote patient dependence where-as the DPT approach promotes patient independence.

My reason to incorporate PT into my DC practice is simple. The only profession to offer manual approaches in the 1980's was chiro. It was the alternative non-surgical approach to correct dysfunctional problems. Functional rehab was not a part of the education. I have practiced EBP, though not to the detail as taught in EBP DPT programs. I personally really like the evidence, and have really had my eyes opened to true EBP model with this MSPT education.

Summary, PT is different than chiro and I think will remain so because the emphasis on the educational model is different -- patho-anatomical on the one hand and functional model on the other.

My thoughts, would love to hear others. Great post.

Chris

[Louie Puentedura]

Chris:
I was more than a little perturbed to read that you considered yourself to be a "diagnostic doctor" presumably courtesy of your prior training as a DC. You went on to say that you had had "multiple occassions where I have received a referral of back pain, and thankfully my ability to refer for advanced imaging, proper bloodwork enabled me to properly diagnose cancer, missed fracture, etc."
Now, as a student completing your MSPT you mention that there are times where you feel a "proper diagnostic workup" would resolve some unanswered questions but you feel your "hands are tied" as a PT.
Here's my question to you. When you graduate with your MSPT and then, presumably go on to get your DPT, will you support the idea of DPT's being able to order some of these extra diagnostic work-ups or should that be a special perk only available to dual degree (DC/DPT) MSK specialists?

[Michael Schneider]

Louie,

You bring up a very interesting point about a major difference between chiros and DPTs...at least at the present time.

DCs have extensive differential diagnosis coursework in chiro college, including lots of skeletal radiology. This comes from a history of being required to be portal of entry providers, in which we would see patients right off the street without the luxury of having them pre-screened for red flags by a medical physician.

The history of PT has followed a different path. PTs have always been part of the mainstream medical system, and traditionally have required referral from MDs who supposedly pre-screened patients and found they had a MSK lesion requiring PT services.

Now the emerging DPT program may change the old ways of doing business in PT. With direct access will come new the responsibilities of more serious differential diagnosis, referrals to other specialists, and referrals for diagnostic imaging and lab work.

From what I see in the present DPT curricula that I have reviewed, there is not an intensive array of such diagnostic coursework. Are there plans to incorporate more differential diagnosis into the DPT curriculum of most PT schools?

Mike Schneider, DC, PhD (c.)

[Louie Puentedura]

Michael:
Thanks for your post. From a personal experience as an Australian trained PT, where we are portal of entry providers and do see patients off the street, I can fully appreciate the need for differential diagnostic abilities. I certainly felt well prepared to handle those situations when I practiced there for 15 years as a direct access provider for musculoskeletal disorders.
I recently completed a Post Professional DPT program and, yes, there was a significant component of differential diagnosis for physical therapy. I believe that all Post Professional or Transitional DPT programs have that as a requisite component.
I am also a clinical instructor for several of the DPT schools in AZ, NV and CA, and from what I see from the students I have had, they are getting some very good differential diagnosis skills to use as PTs. The greatest emphasis really is to be alert for those red flags that could signal more serious medical pathologies and referring them back to their physician (MD/ DO), but what I am wondering is what EIM bloggers think about us (PTs) being able to order diagnostic tests. I'm not talking about blood work or other medical tests, but simple plain films, diagnostic ultrasounds and maybe CT/ MRI scanning as a prelude to working in a collegial manner with our patient's physician or surgeon.
And of course, the other question that I'd like us to discuss/ debate is whether a dual professional DC/DPT should have any significant right to feel better qualified to differentially diagnose musculoskeletal disorders than the DPT.

[David Browder]

I think differential diagnosis is a bit of a misnomer here. In the case of pathology that mimics musculoskeletal complaints my experience has been that both DCs and PTs in direct access roles (such as the Military) do not differentially diagnose outside the neuromusculoskeletal arena. If a DC suspects a non musculoskeletal lesion do they take the steps to diagnose the lesion? I think in most cases they (should) refer back to a physician. What direct access physical therapists must be able to do is recognize red flags and be able to recognize when a condition is not consistent with a musculoskeletal condition. In addition to this PTs must be able to recognize when consultation or referral to another provider (or back to referring physician) is indicated.

As far as concerns of delayed diagnosis due to patients seeing therapists as a portal of entry- most clinical practice guidelines for physicians do not recommend radiographs/ESR labs until 30 days from initial evaluation.
Most practice acts also still require a patient to see a physician if they fail to improve.
In LBP, for example, failure to improve with conservative care (LR=3) (in this case physician care (nada) but no reason it could not apply to physical therapy intervention) was shown by Deyo and Diehl (J of Gen Int Med, 1998) to be more discriminatory than any finding other than previous history of cancer (LR=14.7). I think the idea that an active cancer screening process is missed if the patient does not see their physician with acute LBP is probably not reflective of reality.
The previous post included this sentence "With direct access will come new the responsibilities of more serious differential diagnosis, referrals to other specialists, and referrals for diagnostic imaging and lab work." I disagree- Screening for conditions not appropriate for physical therapy treatment is already an integral part of practice. Musculoskeletal differential diagnosis/classification is an everyday part of practice for the orthopedic physical therapist. Differentially diagnosing (as opposed to screening for) conditions outside our scope of practice is umm, outside our scope of practice - and direct access does not need to change that.

Several other comments have been made in this discussion about the model of PT health care being different (non patho-anatomically based?) than chiropractic and another about we need to be pain management specialists because the orthopedic surgeons and rheumatologists are already musculoskeletal specialists? I take exception to the parts of that I could understand. Physical therapists have an integral part to play: WE are the experts in non-surgical management of musculoskeletal conditions. We have the appropriate knowledge base (Childs et al. BMC Musculoskeletal Disorders, 2005) and Military PTs have been seeing patients in direct access roles since the 1970s without problems. EVS.

[Ben Hando]

I've been following this post with some interest and have been disappointed to see the chiropractic input mischaracterize PT's skill-set and scope of practice.

Here is a quote from Chris that I think needs vetting:

"Chiro is more patho-anatomically based, ie disease, subluxation, diagnostic whereas PT is functionally oriented".

My experience with Chiro is that they indeed do use a patho-anatomic model. Unfortunately, when this model has been subjected to the rigors of scientific inquiry, it has been shown to be an unreliable, invalid, and an overall ineffective paradigm for evaluating msk diseases.

PT's certainly evaluate a patient's functional status in their evaluation, as well as address patient's functional limitations in their plans of care. But this doesn't mean we neglect other areas of the evaluation that would lead us to an accurate diagnosis. To the contrary, investigating the functional aspect of a patient's presentation can provide valuable insight into a diagnosis.

Here's another of Chris's comments that I took issue with:

"Said another way, as a chiropractor, I diagnose and "fix" the patho-anatomical problem with the manipulation".

After studying manipulation for years and years; the scientific and healthcare community is not any closer to understanding the underlying mechanism of manipulation and why it "works". Said another way: if you're under the impression that you're diagnosing and "fixing" a patho-anatomical problem with your manipulation, you are simply mistaken.

Here's one from Mike that I wanted to comment on:

"DCs have extensive differential diagnosis coursework in chiro college, including lots of skeletal radiology".

I didn't go to Chiropractic school, but I have worked fairly closely with more than one chiropractor. So I can only comment on the ones I've worked with, but my impression is that their idea of "diagnosis" is often a pathoanatomic description i.e. a subluxed segment. This extends to radiology, where patients are told over and over again that their spine is "out of alignment". This again, is an inaccurate statement for many reasons that have been well covered on this blog.

I'd like to address more of the comments from our chiro friends, but I'll stop for now.

I'd also like to point out that PT's have been seeing patients w/out physician referral for years, with great success. As a physical therapist in the military, I see a bulk of my patients without physician referral. I certainly feel my education prepared me well to do this. I do utilize my imaging privileges on occasion to rule in or rule out a diagnosis, but I would refer readers to the recent Deyle editorial in JOSPT to address Chris's comments about "diagnosing cancer".

One last point. There is emerging evidence in peer reviewed medical literature that physical therapists possess a better musculoskeletal knowledge base than our colleagues in medicine (with the exception of Orthopedic surgeons). There's also evidence that our ability to order accurate and appropriate imaging studies is second to none in the healthcare community. To my knowledge, Chiro's have not subjected their musculoskeletal competency to scientific scrutiny. Maybe the chiro comments on this post would hold more sway if they had.

Ben

[Chris Baker, MS, DC, DACBN, SPT]

Sorry I have been away from this post recently to miss some of the exciting posts made. For clarity, I think that some of my comments are misinterpreted. Recognize that I am a DC who has practiced 15 years MOVING in the direction of a DPT - My comments are intended to be constructive, not devicive. My comments, firstly, are about our two professions in general.

I do think that those of us who read and post here are like minded in that we have some concerns with how and where our professions are sometimes headed, ie chiro being less "competent to scientific scrutiny" as Ben has said.

Louie, who is a "little perturbed" at the "diagnostic doctor" comment. My intent is to state that my DC training prepared me to be a patho-anatomical diagnostician, rather than a functional provider as in PT. Having completed both training paradigms, I can assure you that DC is more diagnostic oriented, and PT more functional treatment oriented. There is some differential diagnosis emphasized to enable the PT to "recognize red flags" as David says.

David, I DO agree with you that as PT, "WE are the experts in non-surgical management of musculoskeletal conditions." I DISAGREE with you in that a DPT merely "recognize"; you SHOULD be "differentially diagnosing outside the neuromusculoskeletal arena" if you are portal of entry and have direct access. Once you diagnose the problem, THEN refer to proper clinician. I feel the DPT will be more than adequate to diagnose, rather than "recognize" that a red flag is present and thus a need to refer. I prefer the route of diagnosing the problem and making the responsible correct referral to our peers who more correctly treat the problem.

My intent is to state that although DC's (I can speak for myself) diagnose, PT's (contrast to DPT) "recognize" red flags. My feeling is that the DPT WILL bring this together to differential diagnose and treat whether manips or functionally which is why the DPT will have such an advantage. I can see that with the development of the DPT programs, the importance of diff diagnose is being emphasized as well as radiology.

Yes, Louie, the DPT should be able to have all the access a DC does (probably more due to the extensive acute care training) to imaging, portal of entry, etc. This is what I am trying to portray and why I support the move to DPT. I sense that some of the comments posted take issue with the comments I have made by misinterpreting them as I may be suggesting DC to be better clinically than a PT. Quite the contrary. MOST DC's are better diagnosticians than BsPT or MSPT's. I do not think that of DPT's. This is why I think that the previous BSPT and MSPT will need to have some approriate diagnostic and radiological training to become proficient as a direct access provider.

Louie, you state "And of course, the other question that I'd like us to discuss/ debate is whether a dual professional DC/DPT should have any significant right to feel better qualified to differentially diagnose musculoskeletal disorders than the DPT." No, I do not think that.

David, I disagree with you on "I disagree- Screening for conditions not appropriate for physical therapy treatment is already an integral part of practice." While "screening" is an integral part of a PT's practice, it is not what a DPT does. A DPT will be a doctor (physician status) and you will be one of the best diagnostician's there is, especially for MSK issues. You will be able to diagnosie and recognize the various arthritides, cancers, blood disorders, etc. That is what you will do, and you will need to do that as a portal of entry, direct access provider which many families will put faith in you to do. I do not imply that DPT's will have problems doing that, I just am stating what I have seen as the facts, that BsPT and MSPT will need to learn how to better diagnose, and the DPT has learned how to do that.

Ben, you state "I've been following this post with some interest and have been disappointed to see the chiropractic input mischaracterize PT's skill-set and scope of practice." I need you to clarify where you see this. Understand, I am completing the MSPT program because I see the deficits in my DC training in the field of EBP functional therapy.

You state that "Unfortunately, when this model has been subjected to the rigors of scientific inquiry." I disagree with you. The model of diagnosing is well proven. Maybe you refer to the practice of adjusting the subluxation as not well proven with which I would agree with you. Is "a subluxed segment" on a radiograph questionable? yes. What I refer to is scientific diagnosing utilizing blood, imaging, etc - not the search for the ever alluding subluxation. You state, "if you're under the impression that you're diagnosing and "fixing" a patho-anatomical problem with your manipulation, you are simply mistaken." This is correct. This is why is use quotation marks. The comment is that where I think a DC is an excellent diagnostician (not merely find the "subluxation"), the DC falls short in the functional model. Where the PT is an excellent functional provider, they fall short in the diagnosis department (which the DPT makes up.) You are correct stating "To the contrary, investigating the functional aspect of a patient's presentation can provide valuable insight into a diagnosis." However, this is not diagnosing. But the info you state (functional) is what makes the DPT diagnosing more accurate than the provider making a diagnosis without functional info, much like received from many DC's and MD's.

Ben when you state "To my knowledge, Chiro's have not subjected their musculoskeletal competency to scientific scrutiny." This is partly true. We actually have same and more of the textbooks used in PT school, so the competency is well proven, maybe the treatment techniques are not.

I fail to see the connection to your comment of " Maybe the chiro comments on this post would hold more sway if they had." Overall, with the improved communication and understanding of the two professions, these many misconceptions will continue to resolve, so that judging one's "comments" will be by merit and the evidence, not merely by the pre-conceived misunderstood degree.

Hope this clarifies some intent of my posts.

Chris

[Jon Newman]

What MSK diagnosis are people making when the they manipulate someone?

[Michael Schneider]

Chris,
Thank you for your comprehensive explanation of the chiropractic perspective on the DPT program. I would concur with everything that you said.

I do feel that some additional commentary is necessary to clear up some misconceptions.

1. Direct access in the military setting may not generalize to direct access in the civilian population...I don't know for sure...but it is an important concept. As a DC, patients come to me "off the street" without any referral from MDs. I still see patients who do not have a family physician and when I see red flags, the buck stops here. Meaning, I become the physician in charge of ordering diagnostic work-ups to find the pathology. I don't like being in that role...but that is the reality of real direct access in the civilian population. I agree with Chris that the emerging DPT model willl prepare DPTs for this type of practice scenario, but at present the BsPT and MSPT level graduates are probably not prepared for full diagnosis under the type of direct access I mentioned. Are DPTs ready for the challenge of being in a position where no MD is in charge, and all the responsibility falls onto the DPTs' shoulders? Does this happen in the military population?

2. I think the point Chris makes about the differences in the PT programs and DC program is critical to this discussion. Chiropractic colleges were designed to produce "alternative physicians". PTs were trained to be "therapists" who worked under direct order of a supervising MD. Of course the DPT model is changing this older model, but none the less, the historical model of PT education was to "screen" for red flags not to "differentially diagnosis for pathology". This is not meant to be a criticism, but rather a point of distinction between our respective educational backgrounds.

As such, DCs' education included a full coursework of all body systems and full differential diagnosis. We were being prepared for the true "direct access" of being an alternative physician to MDs. This means a hell of a lot of responsibility, to truly hold yourself out as an alternative to the MD. This is one of the 4 models of chiropractic I discussed in my first post, still being promoted by people like Jim Wintersteing, the president of National College of Chiropractic.

3. The question was asked "should a dual DC/DPT give that person any sig. right to feel better qualified in differential dx of MSK problems". I agree with Chris, NO.

4. Another comment was made that orthopods and rheumatologists are already MSK specialists. I would disagree with that comment. Most of us know that these MDs are not very well trained in FUNCTIONAL MSK diagnosis. They can find MSK pathology, but very often they do not have the mechanical reasoning skills that DCs and DPTs possess with respective to selective tension testing, repeated movement testing, nerve mobilization testing, etc.

5. We seem to be tip-toeing around a really big question...that is, how will the physical "therapist" morph into the "doctor" of physical therapy role? Chiropractors already have the "doctor" title, which has put us in a different light within the health care industry. I am in full support of the DPT program and seeing PTs move in this direction... but I wonder if your profession understands the long road ahead to gain cultural and professional authority as "doctors".

The real gatekeepers are the patients out there in the general public. As long as they continue to view PTs in the "therapist" role...the longer they will continue to seek out an MD for a diagnosis.

I don't know about this group, but I find the terminology "Doctor" of physical "therapy" to be somewhat oxymoronic. What I mean is that in the same title you are holding yourself out to be both a doctor and a therapist. Which is it? This is what I am hearing from some of my patients when they ask "what is this DPT thing?"

6. The idea of blending the best attributes of both chiropractic and physical therapy is the wave of the future. I think that Chris is a fine example. He recognized the limitations of his DC education and now seeks to fill in the gaps with the PT education. I think that PTs should recognize that DCs like Chris and I have a lot to offer the PT profession. We were trained in a slightly different model, and have a lot of experience to bring to the table. We are trying to find common ground and improve MSK care for our patients.

[Jason Silvernail]

I would like to thank our chiropractic colleagues for posting.

I have a question. Mike mentioned that "...DCs' education included a full coursework of all body systems and full differential diagnosis."
Do you mean that, as a portal of entry practitioner, you are fully diagnosing a nonmusculoskeletal problem if the patient does not have a family physician? I wonder how your DC education can qualify you for that, since MD/DOs who are board certified in family medicine don't do that. They order what tests are in their scope of responsibility, make what preliminary diagnosis they can, and then they refer to the relevant specialist.

I think this "primary care provider" thing is completely overblown. There is no need, and in fact a significant risk to patients, for a PT or DC to be attempting to work up a nonmusculoskeletal problem. Screening and referral yes, diagnosis no. The purpose of any diagnostic tests that may be ordered would simply be to determine if there was suspicion of a condition outside the scope of expertise. And if such is found, to REFER IT to the appropriate provider. NOt attempt to work up something one doesn't have the education to approach. It's the same basic scheme that those in family medicine use.

When Chris mentioned he is a "diagnostic doctor" I hope (for his patient's sake) he was referring to conservative musculoskeletal diagnoses only. Is this right, Chris?

I am a military therapist and have imaging and limited prescription rights. I have not found a great use for those privileges in most cases, though they are critical for direct access. I have found in the medical system a lack of understanding of pain and poor managment of chronic musculoskeletal pain syndromes, as Jon Newman mentions. I have not found a lack of diagnostic tests and differential diagnosis labels.

J

[John Ware]

Michael,
You may hear "what is this DPT thing" from your pt's. What I hear from my pt's about chiropractors I'll refrain from repeating on this blog out of respect for you participation in this discussion. Generally, and this has been referred to already, the perception of chiropractic as quackery is widespread. The fact that PTs are referred to as "therapists" does not mutually exclude us from becoming a "doctoring" profession. It just depends on how you define "doctor". Chiropractors view themselves as "alternative" to allopathic physicians, whereas PT's view themselves as having a specific role within the healthcare system. We're not trying to break off into some sect or alternative group of practictioners. We're just trying to make the whole system better. And that includes a lot of cooperation with our physician colleagues. By and large, I have a tremendous amount of respect for MDs and DOs. For the most part, they're very well-trained, intelligent, hard-working people. Furthermore, medicine is a profession that's grounded in science, not fanciful theories about "subluxations" and "nerve flow."
As far as our role in diagnosis goes, I think what's being talked about here by my PT colleagues is differential diagnosis of conditions which may mimic or present initially as a musculoskeletal syndrome. We don't aspire to diagnose conditions outside of the movement system. Perhaps that's why I just don't understand chiropractic-what is the foundational science of your profession?
John

[Chris Baker]

Jason -

"Do you mean that, as a portal of entry practitioner, you are fully diagnosing a nonmusculoskeletal problem if the patient does not have a family physician? I wonder how your DC education can qualify you for that, since MD/DOs who are board certified in family medicine don't do that. They order what tests are in their scope of responsibility, make what preliminary diagnosis they can, and then they refer to the relevant specialist."

Asking how a DC education can qualify us to do that is similar to asking how can a PT education qualify you to gait assess? Diagnosing is an inherent component of Direct Access. Having a detailed understanding of appropriate blood work, advanced imaging, nuclear studies, stool sampling, etc. is so critical for Portal of Entry, unless you restrict your practice to MSK disorders as John says as "We don't aspire to diagnose conditions outside of the movement system." If direct access means only diagnosing "movement system" ICD's, then one definitely does not need the other diagnostic tools to do such. However, I was trained to be portal of entry direct access - and diagnose. Part of that responsiblity is to make the appropriate referral to a specialist for the appropriate treatment. Our patients trust our thoroughness. Probably the most frequent "missed" diagnosis I find is cancer. I am simply stating that when you accept the responsibility of direct access, you accept the current standard of care to perform as such. And a major component of that standard of care is to ensure a correct diagnosis.

"NOt attempt to work up something one doesn't have the education to approach. It's the same basic scheme that those in family medicine use." I would disagree somewhat with your perspective. I think we may in many ways be saying something along the same lines, Jason, however, maybe wording it differently. In no way would I ever condone "attempt to work up something one doesn't have the education to approach." Yet I continue to be baffled why many on this post feel that DC is "uneducated" to diagnose anything BUT MSK, and is not a "very well-trained, intelligent, hard-working people." as the MD and DO. I would like to see what source you gain your info from. I can recall my 3-day National Board exam and 2-day State Board exam in which I was required to diagnose many non-MSK ICD's, and to determine which approriate testing to perform to confirm and diff diag from other potential ICD's.

"When Chris mentioned he is a "diagnostic doctor" I hope (for his patient's sake) he was referring to conservative musculoskeletal diagnoses only. Is this right, Chris?" Absolutely not Jason, for my patient's sake and especially those who had a late-stage cancer. Example, Friday, new patient admitted for symptoms diagnosed by her Family Physician as asthma. Recognizing that the symptoms were rather excessive for only asthma, the proper diagnostic workup revealed she actually had Streptomyces workup from the appropriate testing (local lab, etc.) Did this come from "subluxations" and "nerve flow" as John seems to think DC's can only do? Or did this come from a "lack of diagnostic tests and differential diagnosis labels" as Jason states? (Yes, on the part of the Family PCP.) Or maybe I should not "aspire to diagnose conditions outside of the movement system" as John states and continue to treat her for functional deficits of asthma. Absolutely not...I should diagnose her, and soon, so she can seek the necessary care from a Specialist since this specific diagnosis is outside my scope of treating.

Jason, you state "I am a military therapist and have imaging and limited prescription rights. I have not found a great use for those privileges in most cases, though they are critical for direct access. I have found in the medical system a lack of understanding of pain and poor managment of chronic musculoskeletal pain syndromes, as Jon Newman mentions. I have not found a lack of diagnostic tests and differential diagnosis labels." If that is all DPT does, I would agree. My opinion is that the DPT is far better than that, and if to successfully gain Direct Access in the civilian environment, it WILL be much more than that if true Open Direct Access. Every Tom, Dick, and Harry will come in your office and being able to utilize every avenue you have available to assist in the proper diagnosis will only make one a better diagnostician. I do not imply that I am only a diagnostic doctor, however that IS how I was trained with the emphasis on neuro-musculo-skeletal. Therefore, those endless classroom hours on dermatology, internal, micro, pathology, genetic, etc. were critical to round out the educational preparation for diagnosing.

If PT is to continue to seek Open Direct Access, then to be successful, we will need to demonstrate that we meet the Standard of Care for that responsibility prior to being accepted by the public at large, I think.

John, as you have so eloquently stated, what you hear from your disgruntled patients pales to what we hear from ours about the medical model. We all have our skeletons, unfortunately we do seem to have our large share in chiro. "We're just trying to make the whole system better." Again, not speaking for Michael, I am headed for the DPT becaue of the exact comments you make. But isn't it ironic how that the new "manual therapy" boom in PT is so progressive, utilizing the very same method of treatment which originally DO and recent hundred years the DC uses, and quite well, to be so effective in patient care? I am not sure that I have not met a DPT who was not first influenced by one or the other originally. It is unfortunate for the treatment method (maipulation) to only recently have received the accolades it deserves by a group of hard working determined researchers. All of us who utilize the manipulation in our practices are indebted to folks like Wainner, Flynn, Childs, etc. who have finally provided the necessary "pudding" showing just how effective the manip really is. I should not matter if you are a DC, DPT, PT, DO, MD - if you manip and do it EBP as your "profession that's grounded in science," you should be applauded for your progressive thinking. But if you perform ANY procedure based upon "fanciful theories about "subluxations" and "nerve flow," (whether it is manip, decompression, laser therapy, US, etc) then I think ALL of one's practices will definitely be criticized, questioned and judged as to its validity as Jason exemplifies so well.

Back to diagnosing. Lets not forget that even as a PT, we use the ICD code book and utilize patho-anatomical diagnoses, with few exceptions like gait imbalance, muscle fatigue, postural changes, etc. Do we, as PT's, not use degenerative changes, or sprain/strain, or hip replacement diagnoses? Absolutely we do.

In like manner, are we to treat Streptomyces with manips or functional care? No - but since we can diagnose, the patient is now receiving appropriate medically necessary sulfamethoxazole/trimethoprim, rather than an inhaler for her "asthma." You see, if we are to be Open Direct Access, then we will be expected to step up to the plate and take our job seriously and professionally...and do so according to the accepted Standard of Care required of us as Portal of Entry provider....if we are to be respected by the field of docs we so "have a tremendous amount of respect for..."

Chris

Chris

[Jason Silvernail]

Chris-
Thanks for your post. In no way was my post meant to criticize the DC education or your practice. I find PTs and DCs I've worked with to be every bit as intelligent and hardworking as medical physicians.

I think that while we fundamentally disagree on the diagnosis issue, we agree on most other things.

I do not think the APTA's current vision, nor clinical reality, supports the paradigm of "diagnose it all - then treat only MSK" as I gather from your posts. I do think both clinical reality, long history in the US military and Commonwealth countries, and the APTAs vision supports the "open direct access, unlimited MSK treatment, screening and referral as needed" paradigm that I mentioned.

I think it's impressive for you as a practioner to use diagnostic tools to fully medically diagnose a patient without the benefit of medical school, clinical training and hospital rotations that a medical doctor has. It is my understanding that Chiropractic school does not have the clinical internships or a residency program in hospitals managing sick patients and using these diagnostic tests and clinical reasoning under supervision. If the MDs and DOs seem to think it takes 4 yrs med school and 3 yrs residency (family medicine) to do these things, I wonder what your assessment is of your training in comparison to theirs. Based on time in training alone, it seems you got a much better deal, don't you think? Especially since no MD or DO straight out of med school is considered to be qualifed to practice without at least an internship, and almost always a residency.

I wonder how common this diagnostic confidence is among your colleagues. I also wonder regarding consequences of missed diagnosis, especially when working up a condition that is outside the MSK/movement system area (which is what I believe both DCs and PTs are primarily trained in).

Thanks for the courteous and informative exchange on a hot button issue between two professions with a history such as ours.

J

[Carina Lowry]

Chris,

Thank you for the clarification. To me, you are making medical diagnoses and are managing them as such instead of referring back to an MD or DO. Maybe I am just unaware of the extensive education that chiro receives to be able to medically diagnose and manage medications to treat medical diagnoses.

I was just wondering a few poignant questions:

1. I am not asking you to pump your school, however how do you think your schooling as a DC compares nationwide? Do you feel all chiros are able to make medical diagnoses like this? Do you feel that your schools are standardized throughout the country to prepare you for medical diagnosing?

2. Did you also receive extensive training in pharmacological management to be able to manage all of a patient's medications? Do you think this is standard across the DC profession as well?

3. Do the DC schools have a governing body overseeing the curriculum of their programs to prepare DC's to be medical managers?

4. Does the practice act of each state vary as far as DC and practice of medicine? I know that in Minnesota, there is a very clear distinction that a DC cannot make a medical diagnosis. Is the DC profession working to change this to allow unrestricted medical diagnosing for all DC's?

I am not disputing your points that entry level providers should be able to identify and differentially diagnose. However, I am not sure if anyone should be managing the medications and medical diagnoses other that a medical doctor--MD or DO. This should be the standard for referring out.

Carina

[Michael Schneider]

John, Chris, and Carina,

I think this dialogue about the role of diagnosis is very important and certainly a healthy discussion. Let me chime in on a few points made by all:

1. There is a clear difference between the amount of diagnosis coursework taught in DC vs. DPT curricula. This is a fact...not an opinion or criticism. All of the chiro colleges teach a wide variety of differential diagnosis in their curricula, as mandated by the Commission on Chiropractic Education (CCE). CCE is the chiro equivalent of CAPTE. Unlike PT curricula, which I understand to vary substantially from school to school, chiro colleges must adhere very strictly to the diagnosis courses as mandated by CCE.

2. Regardless of the fact that all chiro colleges mandate a full diagnosis coursework, the two corrollary questions that arise are: (a) Is all that coursework really necessary? and (b) Do all DCs upon graduation possess excellent differential diagnostic skills?

My answer to (a) is "probably not". I think that the ability to perform full diagnosis (which I believe I possess) is a nice attribute to possess, but it is not absolutely necessary for the version of MSK care that DPTs desire as their specialty.

I too, like Chris, routinely make a "medical diagnosis", but I would not care too much if MDs really did their job properly and I never had to do it again in my life. But the reality is such that all of us, DCs and DPTs alike, will see a number of patients off the street who think they have a MSK lesion when in fact they do not. John Mennell during his lifetime used to quote the statistic that about 20% of the patients he saw in a strictly MSK specialty practice had internal disease that was mistakenly diagnosed as MSK disease.

Should the DPT program offer a full array of medical differential diagnosis? No, in my opinion. Should it be more extensive than the present coursework. Probably yes. There needs to be some compromise on how much diagnosis is "enough"..how much is "too little"...and when "overkill" is happening. I suspect that chiro schools are overkilling the situation.

3. Are all DCs excellent diagnosticians? Absolutely not! The vast majority of DCs (in my opinion) are fair to mediocre at differential diagnosis. Chris and I probably represent outliers in our profession, but we are examples of how the system works properly.

The biggest missing link in chiro education is the lack of any meaningful residency or internship. Carina is correct to point out this deficiency. It really makes the DC inferior to the MD or DO, with respect to real experience with illnesses in the clinic while having a diagnostic mentor teaching you the ropes.

4. The issue of variation between states...wow...you are right on with that comment Carina. Each of the 50 states has different practice acts with respect to chiropractic, with Illinois at one end of the spectrum allowing DCs to basically act like MDs doing full differential diagnosis. There is no consistency between states, and this is a huge problem for the general public who are confused about the scope of chiro practice.

5. Carina also asks if we have Pharm training...only a cursory knowledge with one course in chiro school. I think it is fair to say that the majority of DCs have not recieved any formal training in pharmacology. But we don't prescribe..nor do we advise patients about their medications directly.

6. Lastly, John mentions the fact that most DCs are percieved as quacks. Well, I can not argue completely with that comment because there certainly are a lot of quacky chiros. Yet I have seen many PTs take the John Barnes myofascial release and Upledger Institute craniosacral therapy courses (just to name a couple) and they seem rather quacky to me as well.

I think the point of distinction here is that in the chiropractic profession we clearly tend to attract more "fringe" folks to our colleges, which are completely tuition dependent and accept basically "all comers", and therefore we wind up having a larger percentage of "quacks" in practice. I would expect that the PT school do not attract as many fringe folks, would screen them out during the application process, and thereby wind up with less "quacks" in practice.

Naturally it is harder to rid your profession of quacks once they have a license, than to screen them out before they ever get a license. But I must lower my head and admit that the chiropractic profession has way too many quacks who give us a collective bad name. Yet I would urge the PT profession to consider that these quacks still represent a minority, and the majority of DCs are decent folks trying their best to help sick patients get well. Quacks in any profession are not representative of the profession itself.

--------------------------

In summary, I think that the DPTs should look at the chiro curricululm and our present situation in private practice as a good example of what happens when you try to become an alternative physician. Learn from our successes and learn from our mistakes. My suggestion is not to reinvent the wheel...there should be enough diagnosis in the courseload to make the emerging DPT an excellent MSK diagnostician, rule out red flags of pathology, and also to know enough about general systems diagnosis to converse and interact with PCPs and other MDs. There is probably a need for more courses on diagnostic imaging, especially skeletal radiology, MRI, etc.

It seems to me that this is the direction the PT profession is taking, to add more diagnosis to the DPT curriculum, but to stay shy of going so far as to attempt to become full fledged physicians.... and I think it is the correct path. Just my two cents again.

Mike Schneider, DC, PhD (c.)

[Jason Silvernail]

Mike-
I find it hard to argue with anything you've said. I think that underscores my point that there is a place for as you say "full fledged physicians" - medical school of the MD/DO type. There is also a place for a conservative musculoskeletal and chronic pain specialist - DPT (DC?).

I find it rather silly to have access to a vast array of diagnostic tests if I can't actually DO anything about the results. To say that training to achieve such a situation is a waste of time is obvious.

I still think the role of the DPT or DC should be that of screening and referral for non-MSK conditions, rather than diagnosis of them. I agree that more training in the area to fully understand the systemic nature of disease and improve those skills is an admirable goal.

J

[Christopher Stuart, DC]

The radiology diagnosis aspect is probably one of the few remaining defining differences between the DC and the DPT as far as education and training

But that will probably change unless it is going to be the sole m.o. of the DPT profession to just "order" but not "interpret" radiographs. That's certainly a possibility and probably most likely.

I don't see too many DPT's going out and purchasing a 30K x-ray unit, processing films, and interpreting. They would have to become a "mini-tech", learning KvP and maS dosages, protection, appropriate views, of which I have already caught a DPT on another forum with his pants down on knowledge of this.

I would say they are about 10-15 years behind DC's on this body of knowledge but quite capable of "catching up" if they feel interpretation and performing is needed. (judging an adequately technical film is an art all of it's own).

I also think an emergent difference in chiropractic practice and DPT practice will be chronic vs. acute and has been over the years.

This is a generalized statement of course; both professions see both types of pain and learn to manage.

But DC's manage chronic pain patients (and beleive me, it's harder than it looks, you just don't say, "Come in 1x/month" and you got yourself a little annuity.").

PT's generally speaking cure acute pain and attempt, being the operative word, to empower chronic pain patients.

They don't have experience in long term management.

But mine is a chronic pain practice, probably like over half of the DC's out there.

Because of this, I am drawn to a statement made by a colleague 20 or so posts back where he wrote:

"I averaged 3 visits."

Really?

I imagine he didn't see any patients with 20 years of chronic back pain attributed to DDD.

Frankly speaking, chronic patients need "management approach" vs. a "treat and street" type of a treatment plan and I question any "positive outcomes" he may have had on these types of patients.

It's no wonder he gravitated towards a DPT/PT degree and license. Chiropractic practice simply isn't a match if you want acute, uncomplicated LBP. Really. . .for those pts., an aspirin is better than PT or chiropractic.

I know every chiropractor beleives they have good outcomes, especially the low visit ones, but I don't understand how you can arrest and control 20 years of chronic pain in 3 visits.

As much as "maintenance care" is villified by MD's, DO's, PT's et al., I am not aware of any alternatives other than "Vioxx 2x daily" (maintenance meds) or a month or two of "self-empowerment" from the PT to the typical chiro. "maintenance" approach.

If you have any suggestions, I swear I'll present them to my patients with a straight face.

In fact, I often suggest a couple of months with the PT to "self-empower" them but I am often met with a "Nah. . ." Even with pt.s who have past experience with PT's.

PT's just don't have the confidence rating on pain management that DC's have at this point in time and probably, with good reason, some of it.

In fact, it is my theory as DPT's and DC's cooperate, if it does, you will see DPT's manipulating for maintenance.

No, they won't say, "Gee, you were right all along. . ." (as they have not said with manipulation). They'll just slowly start adopting this paradigm for the chronic pain patient. They'll use fancier words and terms (probably alienating the pt. somewhat) of why they are doing a "monthly alignment" but it is my prediction you will see the practice become mainstreamed. They'll say something like, "We are doing this for mobility management."

The pt. will say, in Charlie Brown fashion: "?"

In fact, maintenance care, even though not reimbursed, has become mainstreamed IMO by the public. I don't even have to bring it up. PPatients are now asking for it. Political medicine/PT is just lagging.

So, this is something chiropractic brings "to the table." When you breed with us, if you are going to, this in an evitable outcome. As another poster put it, it will remain to be seen if DPT's will tolerate this.

He doesn't want it but frankly, if a newbie DPT were to do a rotation through my vanilla chiropractic practice, he would probably see the reasoning and benefits of "maintenance" chiro. care.

For $35.00/month. . .you get all of this.

I think the American Academy of Pain Management, which has both PT's and DC's in it's organization, could be a neutral meeting ground if you will on this contentious issue.

Of course, politicians will play politics. PT's will continue to say, "Once you go to DC's, they keep you coming back." and DC's will say, "Don't have a PT manipulate your neck. That's for pros, not amateurs."

I do think a merger would make sense but dont' think it will happen. If a merger happened and prescriptive powers were obtained, physiatry would be a thing of the past as a specialty IMO.

I just don't think either profession has the wit to swallow some pride and do this.

[David Browder]

It seems that this conversation has drifted away from our commonalities and degenerated into a free for all. We've gone from a DC who acknowledges the evidence base and can probably work quite well within the medical community... to others who believe that PTs cannot be portal of entry providers because of our inability to diagnose non-musculoskeletal disorders and now we cannot be portal of entry providers without ordering an x-ray machine and diagnosing the causes of LBP off of plain film radiographs. This discussion is really getting strange. I am a DPT, direct access provider who worked with a DC/PT for several years. The wide range of practice patterns in the DC community is obvious just within this post, not that PTs don't have our own variations of practice. The fundamental difference in the discussion of direct access here is scope of practice. Physical Therapists have a very defined scope of practice. We do not, should not and cannot diagnose outside of the neuromusculoskeletal realm. This does not mean that we cannot be portal of entry providers - it just means that we cannot be all things to all people. We should recognize that this limitation is actually a strength. This is why we can function within the medical community - we do not step beyond our bounds and even with direct access have close relations with MDs who can take over the care of the nonmusculoskeletal patient. The surest way to have direct access slip through our grasp is to let this differential diagnosis question be misunderstood by the medical community. One final thought - this thread started nicely with a great post - and I hope that more MSK DCs post on this site. With that being said - physical therapists are not asking the chiropractic community for permission/approval to have direct access priveleges. 47? states now have direct access as part of their practice act. Similar to chiropractic's attack on physical therapists performing manipulation - the one profession does not have the right to police the other. I could care less what the DC community thinks of my credentials to practice. It is the MDs and DOs that I am concerned with - and the surest way to lose their support would be to start diagnosing non-musculoskeletal conditions.

[Carlos Estevez]

I think theres a big misconception from our Chiropractor friends who have been bloggin here, as to what the DPT will mean to our profession and how it will impact our future practice. I will ask you to log on to the APTA.org for more info, heres a piece from the APTA vision 2020.

"APTA Vision Sentence for Physical Therapy 2020
By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health."

As David pointed out our job as DPT's is not to be the cure ALL, see ALL type of practicioner, but rather continue to be part of a multi-disciplinary team, and in doing so will deliver the greatest care within our scope of practice, which has been already been emphasized by several previous posts.
It is this mutual relationship with the medical community that has been and will continue to be the catalyst of our PT profession. It is obvious that what PT's are doing in terms of advancing our profession and increasing our Evidence Based Practice has stirred the Chiropractic community, otherwise we would not have Chiropractors posting on multiple PT forums/blogs.

In my opinion Chiropractors can work and be part of the medical community, but before that happens I believe they must humble themselves and accept the fact (like other Chiropractors have pointed out!)that the Chiro profession is in need of an overdue tune-up, primarily with the Chiropractors who practice like the #3 and # 4 (Initial post).

To the fellow who feels that he could only diferentially diagnose a pnt, thanks to his DC education, all I have to say to you sir, is perhaps is to go and get your money back! sounds like you didnt recieve a quality education. Physical therapy is FAR more than functional testing.

On the flip side PT's as a whole can and need to police our entry level PT requirements, unfortunately even with DPT's theres a B-I-G disparity with the PT's that are coming out of schools!. Ive met PT's both exp. and inexperienced who have no clue as to what EMB practice is!!.
Along w our vision 2020, there needs to be a standardization of PT education w an emphasis of Evidence Based Practices. It is due to this variability in PT education, that we cannot generalize all PT's level of practice. Simply b/c someone has "Experienced" the PT education doesnt qualify him/her to generalize on what a PT can/cannot do.

Thankfully it is the efforts such as web blogs like this one, as well as vision 2020 that will eventually tie any loose ends our profession may have.

[John Ware]

Michael,
I didn't say that "most DCs are percieved as quacks." I said that "the perception of chiropractic as quackery is widespread." Those are two very different statements. I do not believe that there is a widespread perception of PT as quackery; though, I will certainly acknowledge that there is some "quackiness" in our midst. That's one of the reasons I participate in this blog.

I am still curious what the chiros think is the foundational science of their profession. As far as DCs going the DPT route: come on in the water's warm-and the theory is sound.
John

[CHris Baker]

I think the posts above continue to illustrate how diverse our two professions are, as well as how different our professions are within themselves.

Lots of misconceptions continue to circulate with many comments taken out of context, ie Jason states ,"I find it rather silly to have access to a vast array of diagnostic tests if I can't actually DO anything about the results" when in fact you do actually do something with the results, you recognize that there is an existing ICD and make the appropriate referral to the MD/DO for medical care. Think about it Jason, if you do not have the tools to recognize and diagnose, then how will you be able to refer back to appropriate provider? As admirable it is to "recognize" that something is not MSK and warrants a referral back to PCP, I just think again that the DPT is better than that. It is better to recognize and diagnose empowering us to appropriately refer which is safer to the public at large and further limits inappropriate care and missed diagnoses under our care. I don't think this steps on any MD/DO toes, but it certainly improves our credibility and Open Direct Access Docs.

After some discussion with a DPT peer, I recognize that experiences in a military setting do differ from those in civilian environment, and that our terminology does vary. I am continuing to learn appropriate usage of some of the terms so that I can communicate better with my PT peers. Example is, I was educated in DC training that "neuro" really means the neuro-sciences; however in PT "neuro" means functional (ie ADL's, hygiene, "pulling on pants"...etc. What I am referring to above as "functional" may be better described as "addressing the impairments associated with the ICD." Much of the above is talking in circles due to terminology, something I recognize because of experiencing both educational models.

Now take Carlos who criticizes his very own educational model by stating that "Simply b/c someone has "Experienced" the PT education doesnt qualify him/her to generalize on what a PT can/cannot do." Carlos, what can I say? Does this not incriminate yourself and further diminsh your credibility of DC comments unless you have completed the DC 4-yr education and followed this up with a specific number post-grad practice experience? Does this mean that then and only then you would become qualified to render an opinion and thus "hold more sway" as Ben stated earlier?

Take Chris Stuart who thinks that because "I averaged 3 visits" he thinks "I imagine he didn't see any patients with 20 years of chronic back pain," so he "questions any "positive outcomes" he may have had on these types of patients." Dr. Stuart, 20 years of back pain seeking chiro care monthly for "$35.00/month. . .you get all of this" is not "long term management" in my book, and certainly not "positive outcome" either. Neither is "Vioxx 2x daily" (maintenance meds)." In fact, both of these models promote dependence in my view.

It is becasue of this mentality of DC promoting long term dependent care that I chose to "gravitate towards a DPT/PT degree and license" which is showing a great combination of both manual manipulative methods in the management of the condition as well as the therapy benefit for correction of the orthopedic/neuro impairments...and EBP as well.

I will continue to promote the understanding of both professions to recognize "our commonalities" as David says with the hope of limiting further degeneration and "free for all" as we see in these posts.

Again, these posts continue to emphasize that our two professions are different. Even though both professions use the successful manipulation, the paradigm taught is different for both.

[Christopher Stuart, DC]

"Take Chris Stuart who thinks that because "I averaged 3 visits" he thinks "I imagine he didn't see any patients with 20 years of chronic back pain," so he "questions any "positive outcomes" he may have had on these types of patients." Dr. Stuart, 20 years of back pain seeking chiro care monthly for "$35.00/month. . .you get all of this" is not "long term management" in my book, and certainly not "positive outcome" either. Neither is "Vioxx 2x daily" (maintenance meds)." In fact, both of these models promote dependence in my view."

I chose to challenge your proclamation of 3 visits in pride because you forward a common emotion that ebased DC's have about maintenance care - "I'm embarrassed."

They throw the baby out with the bath water. Yes, some DC's abuse the maintenance care thing. But it's a perfectly acceptable form of management in some patients.

You don't like maintenance chiropractic care because well. . .the patient is dependent.

You don't like maintenance Cox-2 inhibitors.

So, what do you suggest for this subset of patients? A month or two of self-empowerment from the DPT? OK fine, let's say just for argument's sake, your beacon of wisdom imparted to them in 12 visits doesn't work? What then?

Just live with it?

Here's a $1 pamphlet?

Yes, if a pt. comes in once/month and exacerbations are controlled and less severe, the pt. lives a more functional life, complains less about pain, even if he has some daily. . .that's a positive outcome.

I don't care if it is for 20 years at $35/month. Using the PT/ebased chiro value system, every diabetic patient who takes insulin is "dependent" and a failure and the internist deserves to be criticized.

I think the obvious needs to be said here for the ebased geniuses - FOR A LOT OF SPINAL PAIN, THERE IS NO CURE. And that includes "self-empowerment" regimens consisting of exercise.

The spine is a different set of anatomy and neurology than the ankle or the hip or the elbow.

A negative outcome is seeing the patient 3 times for self-empowerment, discharging the patient (treating and streeting), the pt. scratches their head 3 weeks later and says, "Well, gee tnat was a waste."

I am pointing this out here because there is a fundamental value difference between DPT's and DC's.

DC's (ususally, not you) value long term relationships with patients and see it as a good thing.

DPT's really do not. Yeah, they'll pay some lip service to it but all in all, that's not who they really are. Their goal is to return to functional status (that plateau we all reach with a patient) and discharge.

There are positives and negatives to both and IMO, the DC is better suited to manage chronic pain. It's just the way they are disiplined.

I don't mean to distract from the current subject but globally, this is about transitioning from a DC to a DPT. I think the two providers are disiplined differently, for better, for worse.

I don't think I would adjust well in a transition because once I saw a pt. with chronic pain who improved and then plateaued, I would probably consider "chiro maintenance care" in the algorhtim.

Whether the DPT Board would tar and feather me, I don't know.

I actually suspect not.

Like I said, as manipulation becomes part of their armamentum, you'll see them change their tune. It will be funny to hear what they have to say when they do.

(BTW, how do you turn off this center thing and left jusifty - it's annoying)

[John Ware]

Chris S.,
You are making a lot of assumptions about how PT's treat pt's with chronic spinal pain- and most of them are just wrong. In our profession, we set goals for each episode of care, once the goals are met, the pt is discharged. This does not mean that the pt will not be seen again for another episode. At that time, new goals will be set based on the current level of impairment in function, which includes function limited by pain. We use a variety of tools to assess return of function, we do a lot of measuring and observing, and we use outcome measures like the Neck Pain and Low Back Pain Disability Indexes. I, and all the the PT's I work with, have seen pt's over the course of years for treatment related to the same spinal condition. I certainly don't schedule them once a month ad infinitum.

I don't know what you mean by "self-empowerment." You seem to be using it disparagingly, as if it is not a good thing to help someone help himself recover function after an episode of spinal pain. I don't buy the diabetic analogy either. A diabetic will die if he doesn't take insulin, and then the physician would be sued out of business if he failed to renew the prescription. Secondly, responsible internists are continually enjoining their diabetic pts to diet and exercise in order to reduce their dependence on insulin. Chronic pain due to a degenerative spinal condition is just not even in the same ballpark. About the only comment of yours I agree with is that there is no cure for many spinal conditions. PT's know this- and, oh, BTW, we also know the difference between the spine and the extremity joints- but thanks for the update.
John

[John Ware]

"Quack Alert"
I just had a chiropractor call me about a pt we are seeing concurrently. He started out sounding reasonable by stating that he doesn't just "crack backs" but strives to get to the "source" of the pt's problems. When I mentioned that I use the manipulation judiciously in practice based on current best evidence, he proceeded to tell me that he has "found" a way to "float" the SI joint back into place by merely placing his thumbs in certain places on the pt's sacrum and ilium. He stated that he can perform this technique on a 90 y/o woman sitting in a chair. On the remote chance that the SIJ of a 90 y/o women moves, how could one even tell?
He wanted to have lunch and "share" some exercise techniques. I declined.
John

[Michael Schneider]

I believe that the recent postings by Chris Stuart only confirm the comments I made in my original post "A Chiropractic Perspective". In that post, I discussed 4 basic subsets of DCs:

1) Wellness DCs - who consider "maintenance care" to be essential for all people to maintain optimum health. They believe the spinal subluxation can be an asymptomatic "lesion" that blocks the flow of nerve energy to the various tissues of the body and therefore this "lesion" must be corrected in order for people to stay functioning at optimal levels of health.
2) Alternative PCPs - these are the DCs who believe that they can differentially diagnose all diseases and act in the capacity of a PCP.
3) Functional or Holistic specialists - these are the DCs who treat all sorts of health problems with herbs, vitamins, nutrition, etc.
4) Musculoskeletal (MSK)specialists - DCs who believe their role is limited to the spine and extremities.

Chris S. represents the "wellness" subset of DCs...whereas Chris Baker (DC-DPT) and myself represent the "MSK" subset of DCs. I would suggest that only MSK specialist DCs will be able to engage in reasonable discussions with the PT profession. The other 3 subsets are thinking outside of the PT paradigm.

This somewhat bitter exchange between John and Chris S. is not very productive and is reflective of the chasm between wellness DCs and the PT profession. There is clearly a huge difference in philosophy between PTs, who believe in empowering patients and moving on....and wellness DCs who believe that routine manipulations must be rendered to asymptomatic patients on an ongoing basis to prevent disease and/or optimize function. This difference can not, and will not, be resolved by discussions on this blog.

It is detracting us from discussing more important issues like the role of full systems diagnosis versus MSK diagnosis and screening for red flags.
Or the future of DPT and "MSK specialist" DC relationships. How about the role of spinal manipulation within PT and how MSK specialist DCs can help ease the tensions between the chiro world and the PT world?

I would respectfully request that we ignore extraneous commentary and negative jabs, and instead focus the discussions back to these more important subjects. I want to see more MSK specialist DCs post comments on this blog and open up a bigger dialogue on these important issues...including the idea of more DCs getting DPT degrees and making a lateral move into the PT world.

Michael Schneider, DC, PhD (c.)

[Jon Newman]

I'm not sure why people want to limit themselves to being MSK specialists. Even in the WI practice act they acknowledge the existence of a nervous system.

“Diagnosis” means a judgment that is
made after examining the neuromusculoskeletal system
or evaluating or studying its symptoms and that utilizes
the techniques and science of physical therapy for the
purpose of establishing a plan of therapeutic intervention,
but does not include a chiropractic or medical diagnosis.

[John Goodrich]

Jon, I honestly have no idea what point you are trying to make, at least in the context of this thread, and Michael's post. Am I missing something? Please be specific.

[John Ware]

Michael,
I wish we could all just get along as you suggest. But the fact is, our profession has been under assault by chiropractic for at least as long as I have been practicing. While remaining civil and articulating facts, I'm going to call a spade a spade when I see one. And I may use some tongue-in- cheek "jabs" to demonstrate the weakness in another's argument. In my opinion, and I think many of my peers would agree, PT's have been meekly accepting their subsidiary role in the health care system for way too long. We stand by while chiros, like Chris S, make erroneous assumptions about how we practice, and post it on a PT blog, of all places. I'm not going to sit back and take that. I'm passionate, not bitter. There's a big difference.
And that recounting of the conversation I had with a chiro actually did happen today, about a pt I treated in the clinic yesterday. This is what many PT's working in the orthopedic setting have to deal with on a regular basis: pt's coming in saying, "Well my chiropractor told me to do your exercise like this," or "My chiropractor said I needed to give him $4000 up front for 6 months of traction," or "my chiropractor told me my spine is out of alignment." My job is difficult enough without having to compete with the propagation of ignorance masquerading as health care.
Bottom line: I'm all for DC's "seeing the light" and going the DPT route, but I'm not going to shy away from the controversy. The bitterness between PT's and DC's is already there-it's the proverbial elephant in the living room. This blog is about evidence in practice-it's about finding the truth. That process is not always genteel.
John

[Jon Newman]

Hi John G.,

I wasn't addressing Michael's post exclusively but rather the trend in comments. Not that this particular thread has one tight topic to focus on in the first place.

A quick look through the many posts reveals a wide variety of types of diagnoses: MSK dx, differential dx, pathoanatomic dx, full systems dx, functional msk dx, medical dx and radiology dx.

At one point it was suggested that there are essentially two kinds of dx: MSK and everything else and the word specialist seems always to be preceded by MSK.

Yet the very definition of diagnosis used to define and guide PT practice (at least in WI) seems to recognize that there is more to diagnosis than the musculoskeletal system. While this may seems obvious the banter here never reflects this fact. It may even turn out that manipulation/manual therapy gets explained in terms of its neurological affect making me wonder what importance being an MSK specialist will be. And I want to clarify that I'm not suggesting the musculoskeletal system should be ignored, rather I'm asking that the rest of the person be included.

[John Goodrich]

Thanks, Jon. So maybe it's a question of semantics. For clarification, if we go back to Carlos' reference to the APTA vision2020 statement earlier, is there anything there that you take exception to? Or does that accurately sum up where we're headed? I have to say that, even if I fall under the category of orthopaedic physical therapist or musculoskeletal physical therapist, or just plain physical therapist, or if I were a DC who wanted to embrace evidence based practice, I find it hard to imagine that I would ignore the nervous system, lymphatic system, integumentary system, cardiovascular system,etc. I think Michael makes a very valid point, that when we drift into DC vs PT, there is no place to stop. I also appreciate John W's frustration. But no DC or anyone else can go through a DPT program and just skip everything but the musculoskeletal system. I took Michael's statement to mean that, whatever else chiropracice holds itself to be, its only valid impact is on what is commonly known as musculoskeletal disorders. I wonder how many of us appreciate what a huge leap this is for DCs, or how big a shift has taken place in just the past 5 years in terms of the relative standing between the two fields.

[Jon Newman]

Hi John,

I have little to disagree with in Carlos' post. The statement regarding vision is not at odds with the definition of "diagnosis" I posted.

I wonder if the disparity he speaks to is a disparity in what programs are teaching or simply what one would expect from the variety of people going to PT school. Ideally, the boards would weed out any significant outliers. If someone is frankly incompetent in an elemental area, they shouldn't be able to pass the exam.

I think your summary of Michael's statement--"I took Michael's statement to mean that, whatever else chiropracice holds itself to be, its only valid impact is on what is commonly known as musculoskeletal disorders."-- likely identifies the motivation for my questioning the hip hip hurray for the MSK slant. I asked earlier what MSK disorder is being treated by manipulation (the defining act of chiropractic)? To my lights, the single most compelling piece of evidence for predicting success with manipulation does not include a musculoskeletal diagnosis nor does it implicate the MSK. And it shouldn't need to in my opinion as it is consistent with operational definition of "diagnosis" that I posted.

[Carlos Estevez]

Jon,
I meant the disparity stemming from what programs are teaching, it seems that there is a clear difference b/t PT students coming from a reputable institution vs one that is not.
I am detracting from the main topic here, but id like to know what PT's opinions are of co-treating pnts w Chiropractors. Im seein a pnt, who has a hx of chiropractic visits most of her life, and has begun to see one in the middle of my care.
This is a bit frustrating as I am treating this lady for Lumbar instability.Personally i think the multiple adjustements/conflicting diagnoses are only retarding any positive outcomes. Chiro bashing is not my thing, so when my pnt asks me about why the different Dxs, all i can say is "every clinician is different" although i felt more compelled towards the bashing when she came to me and...well he said:...uh .."subluxed segment, ....per x-ray" or something to that nature, at that point i just kept shaking my head inside.

Its funny how after a Hx of Chiro care, most pnts will "self-diagnose" and feel that if they get adjusted this will somehow translate to a better feeling, or a cure for whatever condition theyre having.
Im not shooting down, manipulation, as it is one of my most consistent interventions, but I feel that making a pnt dependent on my skills for their ability to function, is doing a diservice to the pnt population, although i guess its good for $$$$.
Any thoughts on dealing w this?
BTW the pnts Sx's did not improve after the "adjustment", despite of this, the pnt feels that more adjustments is what she needs.
hmmmm...., im not a genius here, but she has received Chiro adjust most of her life, pain has never subsided, and yet this is what she needs, do we see a trend here??.
Personally i am almost compelled to not treat a pnt if they are receiving Chiro interventions.

[Donald R. Murphy, DC]

Carlos,

I guess your experience with treating a patient who is also treating with a chiropractor who has convinced her that she needs endless adjustments is similar to my experience with treating a patient who is also seeing a PT in which I am trying to get them active but the PT is just lying them on a table with hot packs, e-stim and US. Or the patient with whom I am trying to deal with their fear-avoidance beliefs, but they are all freaked out because every time they see their PT they are told that their "pelvis is 'out' again".

What we need is to promote evidence-based, patient centered care, regardless of who the professional is. And it is my experience that non-evidence-based care is rampant in both the chiro and PT professions. We can take the tact of just refusing to treat a pt who is also treating with the "other" profession, or we can rise above this and work together for the betterment of all patients.

I am enthusiastic about the possibilities of closer collaboration between the professions, provided chiropractors can move beyond manipulation and embrace the funcional model, and PTs can improve their DDx skills. But I think that this can only involve a relatively small portion of each profession, as the professions as a whole are not ready for it.

[Donald R. Murphy, DC]

Carlos,

I guess your experience with treating a patient who is also treating with a chiropractor who has convinced her that she needs endless adjustments is similar to my experience with treating a patient who is also seeing a PT in which I am trying to get them active but the PT is just lying them on a table with hot packs, e-stim and US. Or the patient with whom I am trying to deal with their fear-avoidance beliefs, but they are all freaked out because every time they see their PT they are told that their "pelvis is 'out' again".

What we need is to promote evidence-based, patient centered care, regardless of who the professional is. And it is my experience that non-evidence-based care is rampant in both the chiro and PT professions. We can take the tact of just refusing to treat a pt who is also treating with the "other" profession, or we can rise above this and work together for the betterment of all patients.

I am enthusiastic about the possibilities of closer collaboration between the professions, provided chiropractors can move beyond manipulation and embrace the funcional model, and PTs can improve their DDx skills. But I think that this can only involve a relatively small portion of each profession, as the professions as a whole are not ready for it.

[Donald R. Murphy, DC]

Carlos,

I guess your experience with treating a patient who is also treating with a chiropractor who has convinced her that she needs endless adjustments is similar to my experience with treating a patient who is also seeing a PT in which I am trying to get them active but the PT is just lying them on a table with hot packs, e-stim and US. Or the patient with whom I am trying to deal with their fear-avoidance beliefs, but they are all freaked out because every time they see their PT they are told that their "pelvis is 'out' again".

What we need is to promote evidence-based, patient centered care, regardless of who the professional is. And it is my experience that non-evidence-based care is rampant in both the chiro and PT professions. We can take the tact of just refusing to treat a pt who is also treating with the "other" profession, or we can rise above this and work together for the betterment of all patients.

I am enthusiastic about the possibilities of closer collaboration between the professions, provided chiropractors can move beyond manipulation and embrace the funcional model, and PTs can improve their DDx skills. But I think that this can only involve a relatively small portion of each profession, as the professions as a whole are not ready for it.

[John Ware]

Mike Schneider asked if I would copy his comments he sent to me in a private email regarding my query of the foundational science of chiropractic. Here are those comments:

Unlike the PT profession, which was founded upon movement science in
cooperation
with standard medical practice....the DC profession was founded as an
alternative to standard medical practice. And we still see vestiges of this
"alternative provider" mentality today. DD Palmer started out as a "magnetic
healer" before he founded the chiropractic profession, and as such he believed
that the human body had electromagnetic energy fields flowing through it
(sounds like the meridians of acupuncture theory) that could somehow become
impeded by "blockages" of the spinal segments. He purported to treat all sorts
of ailments with spinal manipulation, which he believed to free up nerve
channels and allow nerve energy to flow normally.

The early DCs worked with the same principle that the early osteopaths also
embraced...i.e. the idea that human health was related to proper flow of "nerve
energy" through the body. The DCs used the term "spinal subluxation" and the
DOs used the term "osteopathic lesion" to describe basically the same
entity....a dysfunctional segment of the spine that they believed caused not
only local pain, but a host of other health problems. Hence the belief by many
DCs (and still some DOs) that spinal "subluxations" cause health problems
beyond local pain and joint dysfunction.

It seems that over time, a certain segment of DCs went way beyond the spinal
subluxation concept and began to incorporate other "natural healing" methods
like acupuncture, physiotherapy modalities, nutrition, colonic irrigation,
vitamins and herbs, homeopathic remedies, etc. This is where two of the subsets
I mentioned in my original posting came from; the holistic DCs and the
alternate PCP-DCs. The DCs who still hold fast to the original premises of
Palmer are the wellness/subluxation DCs.

Chiropractic education always focused on making the DC an independent clinician
who could provide portal of entry care for any human disease. As a result,
differential diagnosis courses became an essential part of all chiropractic
curricula. Some schools stayed true to the original premise that spinal
manipulation had profound effects on all bodily systems, and these schools
produced "straight" DCs who used manipulation exclusively in their practices.
Other schools blended in the other methods noted above and produced "mixer"
DCs, who used manipulation as just one tool in their bag of clinical tricks.

X-ray diagnosis became an essential part of the chiropractic education as well,
because DCs were trained to take and interpret their own x-rays. This expanded
the number of differential diagnosis courses, because DCs had to learn how to
read x-rays not just for detecting "misalignments", but for full differential
diagnosis purposes to screen for pathology in any internal structure.

Yet as time went by further, a group of DCs abandoned these old Palmer
philosophical belief systems and saw manipulation in a more simplistic
manner...i.e. as a form of manual therapy to treat joint pain and dysfunction.
This group of DCs became interested in biomechanics, rehabilitation and active
care, and any manual non-surgical techniques to treat muscles, tendons, joints,
discs, and nerves. This is what I loosely call the MSK-specialist DC. DCs in
this category do not fit into the original model of chiropractic as espoused by
Palmer, and actually fit more nicely into the human movement science model
which is the foundation of PT. They do not prefer to remain seperate and
distinct from standard medicine, and seek more integrated clinical settings.
They consider themselves specialists in the diagnosis and treatment of MSK
conditions. They do not purport to treat internal disorders with manipulation,
but also recognize that there may be central nervous system effects of
manipulation that are yet to be discovered.

With respect to the osteopathic profession, they went through an analgous past
history...they started off as "alternative doctors". Recall that craniosacral
therapy has its roots in the osteopathic profession. However, as time went by
the DOs saw themselves more as primary care physicians than MSK specialists,
and found common ground with standard medicine. In fact, DOs have basically
morphed themselves into PCPs and largely have abandoned their manipulation
skills to others, chiefly DCs in years past.

That is why this type of DC may have more in common with the PT profession than
is generally recognized. The foundations of our two professions are vastly
different, yet one subset of the chiropractic profession has embraced most of
the foundational concepts of the PT profession and abandoned the Palmer
concepts. This subset is finding that manipulation is a nice tool for relieving
pain and restoring function, but other methods are also important...especially
active rehabilitative care. Those DCs who take the road to obtaining a DPT
degree will become an excellent hybrid clinician, with both the manipulation
and rehabilitation skills that it takes to provide the best quality care to
patients.

Does this help to clarify your question?

Mike

My response:
In fairness to the DO's, I believe they preceded the chiros by a couple of decades. In fact Palmer was a former patient of Andrew Still, the founder of Osteopathic medicine. My understanding is that the DO's based they're osteopathic lesion on the "Law of the Artery", not so much the "nerve flow" theory espoused by the chiros (many to this day). From what I can tell, the osteopathic lesion differed significantly from the chiropractic subluxation in that it was based on then current knowledge of the inflammatory response due to a disruption in blood flow. In a way, the osteopathic lesion theory was prescient, as we now know that the inflammatory response plays a very large role in a certain subset of pt's with acute LBP due to HNP. In short, the osteopathic lesion was, at least, based in sound biological plausibility and keen understanding of human physiology. I don't think Palmer's "nerve flow" theory was based on nearly as solid a footing.
Further, I would argue that the reason osteopaths have largely abandoned using manipulation is based more on the economics of health care in the US than because their theory is flawed.

Finally, as I told Mike in our private correspondence, I am not inclined to cooperate with the chiros on any legislation or public effort to legitimize the use of manipulation. I used the phrase "dine with the devil" as a figure of speech, as I do not think DC's are evil. However, I do think they are by and large adversarial to our profession, and I am confident that APTA and AAOMPT are committed to Vision 2020. Soon, we will have the unimpeded right to manipulate- with or without the blessing of the chiros.
John

[John Raymond DC]

My first post here, so hello everyone. Stumbled upon this site and like what I have read so far.

Anyway, to the subject, I believe the APTA talked with some chiro org. with the possibilty of combining the two, but the DCs disliked the idea. Too bad, now I doubt the PTs would like it. It would, in my opinion, created a great profession.

[John Raymond]

The statement that DD Palmer was a pt of Andrew Still is speculation at best. I have yet to any evidence to the fact, but makes for a good story. Manipulation was performed long before either took credit.

I also doubt, with the science of the times the DOs understood the inflammatory response as you imply, at least no writing attest to this fact.

The Palmer therory of nerve flow implied simply that a "bone out of place puts pressure on a nerve causing an interference in it's "flow". Although a rare event (where actual bone hits nerve causing a disruption in nerve function), the idea was just as plausable as the "blood flow therory" IMO, considering the level of science at the time.

As far as being adversarial I never thought of the relationship as that way, except that we treat many of the same type of pts., but so do many other fields (LMTs, Accupunture, DOs). Hence, a competative situation may exist.

I don't think that every PT becoming a DPT will be all that compatable for evryone. You'll not get reimbured anymore (are more expensive treatments/analysis available?), and have to deal with the higher overhead of running a clinic, not to mention higher insurance possibly. Some may fit into this model, others may prefer to stay where they are and avoid the extra "hassels" that come from private practice.

Having an MD screen all my pts, then referring most of them, not having to deal with marketing, employees, and the extra hrs sounds kinda nice to me, but that's just me.

I may be way off base here, and I admit I have no real knowledge of your (a PTs) situation, conceding that this is just opinion/specualtion.

In addition, though you may have the right to manipulate, DC will always be known for that, at least for sometime, and not every doctor (DPT or DC even) is adept at adjusting skills, and may find it's not in thier ability.

That's why you have some DCs doing everything but manipulating IMO. They graduate college just to find out they have no skill at adjusting and so need to do whatever to pay off thier student loans. Sad, but true I think.

Thanks, John.

[Sean]

If they have no skill at mainipulating, how did they graduate from an accredited program?

[John Ware]

John R.

Here's an original letter from DD Palmer, himself:

D. D. PALMER
SCHOOL OF CHIROPRACTIC
PERSONALLY CONDUCTED BY THE ONE WHO DISCOVERED THE BASIC
PRINCIPLE OF CHIROPRACTIC, DEVELOPED ITS PHILOSOPHY,
ORIGINATED AND FOUNDED THE SCIENCE AND ART OF CORRECTING
ABNORMAL FUNCTIONS BY HAND-ADJUSTING, USING THE VERTEBRAL
PROCESSES AS LEVERS.

D.D. PALMER gave CHIROPRACTIC to the WORLD.
___________________

Santa Barbara,
Cal., May 4, 1911.
P.W. Johnson, D.C.;

Yours of April 26th at hand. It contains an interesting and financial question, one which I think Old Dad hold the key of.
Stop right now and read two sections in this enclosed circular, on pages 2 and 8 marked, and see if you cannot grasp the way out,
that which I see that we are coming to. I want you to study those two items marked. The same ideas are in my book, altho not
put out quite so plain as found in these two sections.

I occupy in chiropractic a similar position as did Mrs. Eddy in Christian Science. Mrs. Eddy claimed to receive her ideas from
the other world and so do I. She founded theron a religioin, so may I. I am THE ONLY ONE IN CHIROPRACTIC WHO CAN
DO SO.

Ye, Old Dad always has something new to give to his followers. I have much new written for another edition, when this one
is sold. It is STRANGE TO ME WHY EVERY CHIROPRACTOR DOES NOT WANT A COPY OF MY BOOK.

You write as tho you did not know of my change of location. I lived in this city nine years ago and have always had a
hankering for its climate, fruits and flowers. I can edit, publish and place my book on the market as well here as elsewhere. I
have not been teaching or practicing since leaving Portland, but have today placed an add in the city paper, of which I am
sending you a copy, and will instruct by book or in person as the way opens.

I have been and continue to watch your rights with "The American Octopus". I want you to STUDY the religious move.

California has an organization with Miss Michelson as our attorney.

Please drop me a few lines as soon as your trial is over, so that I may know how matters proceed.

You ask, what I think will be the final outcome of our law getting. It will be that we will have to build a boat similar to
Christian Science and hoist a religious flag. I have received chiropractic from the other world, similar as did Mrs. Eddy. No
other one has lad claim to that, NOT EVEN B.J.

Exemption clauses instead of chiro laws by all means, and LET THAT EXEMPTION BE THE RIGHT TO PRACTICE
OUR RELIGION. But we must have a religious head, one who is the founder, as did Christ, Mohamed, Jo. Smith, Mrs. Eddy,
Martin Luther and other who have founded religions. I am the fountain head. I am the founder of chiropractic in its science, in
its art, in its philosophy and in its religious phase. Now, if chiorpractors desire to claim me as their head, their leader, the way is
clear. My writings have been gradually steering in that direction until now it is time to assume that we have the same right to as
has Christian Scientists.

Oregon is free to Chiropractors. California gives Chiropractors only one chance, that of practicing our religion.

The protective policy of the U.C.A. is O.K., but that of religion is far better. The latter can only be assumed by having a
leader, a head, a person who has received chiropractic as a science, as an art, as a philosophy and as a religion. Do you catch on?

The policy of the U.C.A. is the best that B.J. can be at the head of, BUT THE RELIGIOUS MOVE IS FAR BETTER, but we
must incorporate under the man who received the principles of chiropractic from the other world, who wrote the book of all
chiropractic books, who today has much new matter, valuable, which is not contained in that book.

If you will watch my book closely as you read, you will find it has a religion contained in it, altho I do not so name it.

If either of the Davenport schools would take advantage of practicing our religion founded by D.D. Palmer, it will make the
way of chiropractic as easy as it was for the S.C.'s.

I have given you some special hints on the question which is uppermost in your mind, will you please give it consideration --
never mind if it is new.

Truly,
(Signed) D.D. Palmer.

Copyright by Joseph C. Keating, Jr., Ph.D

Palmer was not a man of science or evidence. In contrast, Andrew Still was a medical doctor before he founded osteopathy. And while he eschewed many of the practices of physicians of the time, he did believe in the science of medicine. The following is from Still's "Philosophy of Osteopathy":

WHAT I MEAN BY ANATOMY.

I will now define what I mean by anatomy. I speak by comparison and tell you what belongs to the study of anatomy. I will take a chicken whose parts and habits all persons are familiar with to illustrate. The chicken has a head, a neck, a breast, a tail, two legs, two wings, two eyes, two ears, two feet, one gizzard, one crop, one set of bowels, one liver, and one heart. This chicken has a nervous system, a glandular system, a muscular system, a system of lungs and other parts and principles not necessary to speak of in detail. But I want to emphasize, they belong to the chicken, and it would not be a chicken without every part or principle. These must all be present and answer roll call or we do not have a complete chicken. Now I will try and give you the parts of anatomy and the books that pertain to the same. You want some standard author on descriptive anatomy in which you learn the form and places of all bones, the place and uses of ligaments, muscles and all that belong to the soft parts. Then from the descriptive anatomy you are conducted into the dissecting room, in which you receive demonstrations, and are shown all parts through which blood and other fluids are conducted. So far you see you are in anatomy. From the demonstrator you are conducted to another room or branch of anatomy called physiology, a knowledge of which no Osteopath can do without and be a success. In that room you are taught how the blood and other fluids of life are produced, and the channels through which this fluid is conducted to the heart and lungs for purity and other qualifying processes, previous to entering the heart for general circulation to nourish and sustain the whole human body. I want to insist and impress it upon your minds that this is as much a part of anatomy as a wing is a part of a chicken. From this room of anatomy you are conducted to the room of histology, in which the eye is aided by powerful microscopes and made acquainted with the smallest arteries of the human body, which in life are of the greatest known importance, remembering that in the room of histology you are still studying anatomy, and what that machinery can and does execute every day, hour, and minute of life. From the histological room you are conducted to the room of elementary chemistry, in which you learn something of the laws of association of substances, that you can the better understand what has been told you in the physiological room, which is only a branch of anatomy, and intended to show you nature can and does successfully compound and combine elements for muscles, blood, teeth and bone. From there you are taken to the room of the clinics, where you are first made acquainted with both the normal and abnormal human body, which is only continuation of the study of anatomy. From there you are taken to the engineer's room (or operator's room) in which you are taught how to observe and detect abnormalities and the effect or effects they may and do produce, and how they effect health and cause that condition known as disease.

I apologize for the long post, but I believe these contrasting letters from Palmer and Still are very illuminating.
John