April 2004

Physical therapists and chiropractors ‑‑ creating the future

 by Dr. Christopher Kent

A visit to the website of the American Physical Therapy Association [1] should be required of every DC. This is a profession that has determined the direction it plans to take into the 21st century.

One of the most striking proposals is making the entry‑level degree for physical therapists a professional doctorate. The website describes the rationale for the entry‑level Doctor of Physical Therapy (DPT) degree:

"(S)ocietal expectations that the fully autonomous healthcare practitioner with a scope of practice consistent with the Guide to Physical Therapist Practice be a clinical doctor; the realization of the profession's goals in the coming decades, including direct access, 'physician status' for reimbursement purposes." [1]

What will the new "doctor" be offering in the way of services? An article in the journal Physical Therapy [2] is instructive. "Many interventions used by physical therapists in the management of patients with low back pain (LBP) lack evidence supporting their effectiveness. For example, interventions such as thermal modalities, electrical stimulation, and biofeedback have not been studied sufficiently, whereas interventions such as transcutaneous nerve stimulation, mechanical traction, and ultrasound have been studied and found to be ineffective... Spinal manipulation is one intervention for LBP that is supported by evidence."

Ironically, while physical therapists are achieving direct access, our ACA member colleagues seem quite content to abandon direct access, with chiropractic services by referral or consultation only in the DoD and VA. Under the proposed regulations, a physical therapist could determine the appropriateness of chiropractic care ‑‑ a chiropractor could not. Even stranger is the committee recommendation that the equipment provided at VA sites include electrical stimulation and ultrasound, described as "not studied sufficiently" and "ineffective" for LBP by the physical therapists! Keep this in mind the next time you hear someone promoting "evidence‑based" practice.

What is a physical therapist to do when treating LBP? Embrace manipulation, of course. And if anyone still equates spinal manipulation and chiropractic adjustment, this excerpt describing the procedure employed in a recent PT study may be instructive:

"If the subject could not identify a more symptomatic side, the therapist flipped a coin to determine the side to manipulate... After the initial manipulation attempt, the physical therapist recorded whether a 'pop' was heard or felt by either the therapist or the subject. If a pop was heard or felt, the therapist proceeded to the other treatment components. If no pop was heard or felt on the second attempt, the therapist next attempted to manipulate the other side. A maximum of 2 attempts per side was permitted. If no pop was heard or felt after the fourth attempt, the therapist proceeded with the other treatment components." [2]

What about subluxation? The PTs are treading carefully, but with resolve. Here is what their website says: "With the filing of a 'Stipulation of Dismissal,' Medicare's recognition of physical therapists as providers of manipulation services is no longer under challenge. The Federal Government and the American Chiropractic Association (ACA) have agreed to the dismissal of Count II of the ACA's suit (American Chiropractic Association, Inc v Tommy G Thompson, Secretary of Health and Human Services), which sought a ruling from the Court that physical therapists could not perform manual manipulation of the spine as a Medicare covered service. With dismissal of Count II, the government's long‑standing policy of treating manipulation of the spine provided by a physical therapist as a Medicare covered service remains in effect. This policy frequently was affirmed in the Government's pleadings to the Court. In one instance, the Government wrote that 'a physical therapist may provide, and be reimbursed by Medicare for, the services of manipulative treatment of the spine as long as that service is appropriate and within the scope of the physical therapist's license.' And in another, while affirming that manipulation of the spine to correct a subluxation is a physician service, the government went on to say that 'this reading of the statute does not, however, preclude physical therapists from providing whatever services they are authorized to perform under the scope of their licenses.'" [3]

All that is necessary for the PTs to be able to offer "manipulation of the spine to correct a subluxation" is for such to become one of the "services they are authorized to perform under the scope of their licenses." This is our wake up call. Physical therapists are implementing a first professional doctorate. They have passed legislation providing direct access in most states, and are aggressively working to see that manipulation is included in their scope of practice. It is imperative that the distinction between spinal manipulation and chiropractic adjustment be preserved. Furthermore, we cannot permit chiropractic care to be a "by permission only" service in the VA, DoD, or anywhere else.

References

1. www.apta.org

2. Fritz JM, Whitman JM, Flynn TW, et al: "Factors related to the inability of individuals with low back pain to improve with spinal manipulation." Physical Therapy 2004;84(2):173‑188.

3. www.apta.org/Advocacy/chiro_challenge/dismissal

(WCA Vice President Dr. Christopher Kent, president of the Council on Chiropractic Practice, is a 1973 graduate of Palmer College of Chiropractic. The WCA's "Chiropractic Researcher of the Year" in 1994, and recipient of that honor from the ICA in 1991, he was also named ICA "Chiropractor of the Year" in 1998. He is director of research and a co‑founder of Chiropractic Leadership Alliance. With Dr. Patrick Gentempo, Jr., Dr. Kent produces a monthly audio series, "On Purpose," covering current events in science, politics and philosophy of vital interest to the practicing chiropractor. For subscription information call 800/892‑6463.)