February 2004

PT Assn. sides with CCE on 'physical therapeutics' issue

Wants to trade 'physical devices' for manipulation

The recent proposal considered by the Council on Chiropractic Education (CCE) to mandate courses in "physiological therapeutics" was remanded to the CCE Executive Committee at a recent meeting of CCE Board of Directors. The Executive Committee, if it so chooses, can act on the proposal without a board vote. The proposal may have backfired by giving physical therapists greater leverage to make spinal manipulation an integral part of their profession.

In a letter to the CCE dated Jan. 5, 2004, Ben F. Massey, Jr., president of the American Physical Therapy Association (APTA) said his organization has no problem with the CCE's proposal as long as D.C.s don't present themselves as physical therapists and don't try to prevent physical therapists from offering spinal manipulation.

"We do not deem it appropriate to attempt to control any other discipline's body of knowledge including use of physical agents any more than we would accept another profession limiting our body of knowledge, for example, in the use of manipulation and manual therapy," Massey stated (emphasis added).

The implication was clear: we won't try to prevent you from incorporating physiological therapeutics, if you won't try to prevent us from incorporating spinal manipulation. Massey emphasized this point in the letter, saying, "... it is not unusual for professions to overlap in their use of interventions, even though separate professions may have distinct perspectives on the nature of the patient's problem.  Therefore, the Association believes that each profession, and only that profession, can define its scope of practice and requisite body of knowledge."

The APTA president did suggest, however, that the CCE change its terminology, "We would encourage the Council on Chiropractic Education (CCE) to adopt mainstream terminology in its requirements. As described, 'physiological therapeutics' is not a commonly used, or widely understood, term," Massey advised. "Instead, we would recommend that the Council use terms such as 'physical agents,' 'mechanical modalities,' and 'electrotherapy' as these terms are broadly understood and used in the literature. 'Physiological therapeutics' is a nearly whimsical phrase without clear denotation and unfortunate political connotations as it might be abbreviated as 'PT' or interpreted as 'physical therapy/physiotherapy.'"

The "whimsical" phase "physiological therapeutics" has been in widespread use in the chiropractic profession for years, most notably as part of the title of the Journal of Manipulative & Physiological Therapeutics (JMPT).

For several years, physical therapists have attempted to edge into chiropractic territory by demanding reimbursement for spinal manipulation. Although the chiropractic profession has fought those attempts, certain elements in the profession simultaneously have tried to expand into physical therapy. The APTA letter is a challenge to chiropractic to decide on the rules of the game. Chiropractic either supports the idea of each profession retaining its unique character and domain, or it permits other professions to define their own scope. We cannot, they suggest, have it both ways by deliberately pushing into physical therapy's province while fighting PT incursion into chiropractic.

The CCE's proposed change to its educational standards would have mandated that all chiropractic colleges -- in order to quality for CCE accreditation -- include courses in "physiological therapeutics." Another term suggested by the CCE Planning Sub‑Committee on Physiotherapy was "Non‑adjustive therapeutic procedures."

Although the CCE did not detail what would be included in that category, the varied and non‑specific range of therapies that can be encompassed by the term is evident in the class offerings at several chiropractic colleges. The University of Bridgeport's College of Chiropractic's two courses cover "the physics and clinical use of heat, cold, high volt galvanism, interferential current, low volt galvanism, ultrasound, electrical muscle stimulation, diathermy, and paraffin," as well as "the rehabilitative management of injuries to the spine and extremities common to the practice of chiropractic."

At Western States Chiropractic College, the list includes "thermotherapy (hot packs, paraffin baths, heating pads, diathermy, ultrasound, etc.), cryotherapy (cold packs, ice massage, etc.), hydrotherapy (whirlpool baths, sitz baths, hand and foot baths, etc.), electrotherapy (low volt galvanism, high volt galvanism, low frequency alternating current, TENS, microcurrent, interferential current, Russian Stimulation, electrodiagnosis, etc.), phototherapy (infrared, ultraviolet, etc.), massage, traction and gait appliances."

The courses offered at Northwestern College of Chiropractic offer an even broader range of topics. Students enrolled in Physiological Therapeutics I are expected to "understand the principles, effects, indications, contraindications, and applications of the following modalities:

*** Alternating Heat and Cold

*** Cold Packs 

*** Fluidotherapy

*** High Volt Galvanic 

*** Hot Moist Packs 

*** Hot Packs and Electrical Stimulation 

*** Ice Bath 

*** Ice Massage 

*** Ice Packs and Electrical Stimulation (Low Volt EMS, Interferential, High Volt) 

*** Infrared 

*** Interferential 

*** Intersegmental Traction 

*** Laser 

*** Long Axis Traction 

*** Low Volt Electrical Muscle Stimulation 

*** Low Volt Galvanic 

*** Microcurrent

*** Microwave Diathermy 

*** Paraffin Bath

*** Qi Gong

*** Russian Stim 

*** Short‑wave Diathermy

*** T.E.N.S. 

*** Ultrasound 

*** Ultrasound and Electrical Stimulation 

*** Ultraviolet 

*** Vapocoolants 

*** Vibration" 

In addition, the website for the Council of Chiropractic Physiological Therapeutics and Rehabilitation, affiliated with the American Chiropractic Association, lists articles on such topics as ankle sprain management, the diabetic patient, preventing leg injuries, and managing shoulder sprain/strain injuries.

Although current CCE rules do not prevent schools from offering courses in physiological therapeutics, the proposed change in standards would have forced colleges to add such training to their curriculum, although the CCE didn't specify what that training would have to encompass. Some critics say the CCE would have the power to interpret such a standard and decide what "non‑adjustive therapeutic procedures" would be required.  It wouldn't be long, they say, before licensing boards likewise required training and competence in those non‑adjustive procedures.

The willingness of the APTA to permit such a change in chiropractic education without a protest may indicate their recognition of the dubious benefits of such training. According to Christopher Kent, D.C., president of the Council on Chiropractic Practice, "A growing body of scientific literature reports that passive physical modalities are of little or no value in addressing musculoskeletal pain, and may actually prolong disability. Evidence for this conclusion was provided in the Clinical Guidelines for the Management of Acute Low Back Pain, produced by the Royal College of General Practitioners in Great Britain and The AHCPR Guideline for Acute Low Back Problems in Adults." 

Even many of those who argue for the effectiveness of physiological therapeutics are adamant that it is not chiropractic. In Nov. 1990, Dr. Rory W. Pierce wrote, "Physical medicine works; we have no problem with that. I believe in the use of physiological therapeutics as an adjunct to the practice of chiropractic. I even wrote and published a reference textbook on physiological therapeutics. This, however, is NOT chiropractic, but is only an adjunct or a tool for use by chiropractors."

By mandating the teaching of physiological therapeutics, however, the CCE is, in essence, making it an integral and essential part of chiropractic. If it does so, it will be giving implicit approval for physical therapists to lay claim to manual therapy and manipulation. In time, they could conceivably market those services for subluxation correction as well as rehabilitation and therapy.

"That's definitely trading our chiropractic jewels for their medical garbage," commented Terry A. Rondberg, D.C., World Chiropractic Alliance president. "Current CCE standards and licensing laws permit D.C.s to obtain training in non‑chiropractic adjuncts such as physiological therapeutics, and in most states, to offer those extra‑chiropractic services to patients. There is no reason for making such courses or competency a requirement for accreditation or licensure. Doctors should be given the freedom to choose for themselves whether they wish to expand beyond chiropractic into the area of physical therapy. CCE shouldn't impose its definition of chiropractic on all chiropractors."