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Re: A novel approach to the DC/(D)PT relationship
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Re: A novel approach to the DC/(D)PT relationship - March 26, 2007 11:28:00 AM
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jlharris
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I agree with proud. PT researchers like Childs, Fritz, Cleland, Wainer, Jull, the great Erhardt PT/DC, and the Canadian Dellito are producing practice oriented research that is giving us guidelines that allow us to accurately make clinical decisions on who will benefit from what specific rehab treatments.
This is not ignoring the greats like Maitland, McKenzie, Cyriax and more, but instead of being one treatment for all, we are becoming capable of providing pt specific treatments with literature on that population showing significant change over "standard PT" and optimizing pt recovery.
This is the future of PT and we all need to be able to accept that if the literature is not supporting what we are doing (eg CST, massage, Estim), and more importantly giving us treatments proven to produce great outcomes, we need to change our way of practicing. Plain and simple.
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My PT Blog
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Re: A novel approach to the DC/(D)PT relationship - March 26, 2007 1:57:00 PM
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proud
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Jason,
Yes, it's a move away from "guruisim". That time has come after decade after decade of the same old...
There is no "great" technique. Nothing we do really requires magical hands( eh ehm...manipulation, myofascial release, CST, ART, training Tra/multifidus).
The magic so to speak is the research. Then the mastery is applying that research. And anyone can really do it if they read...and understand(key)... the literature.
I was thinking about how much information exists nowadays. It's amazing how much effort is required to remain current.
The good news is PT's are really advancing the NMSK knowledge base now. Particularily in the US.
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Re: A novel approach to the DC/(D)PT relationship - March 26, 2007 2:23:00 PM
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nari
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Jason, you are quite right, in implying the move away from guruism is essential for progress.
As for differences in practices between countries; this is a boggy area, because every country has its share of not-so-good PTs. The UK has leaped ahead of Oz in some ways, with extended scope practice, therapy for the larger animals and attitudes in general. Canada has some great research going, and the USA seems to be on that route as well.
We still have to be careful with all that information, though. PTs are notorious for making clinical practice complicated; we often do not see the wood for the trees.
Concentration on the neurosciences makes for better management of pain, which is primarily a neural affair, rather than separate efforts directed towards very specific orthopaedic conditions. Resolution of pain results in improvement of function, which is evidence-based, and many techniques could be a matter of over-kill, or even worsening of pain.
I realise this is not accepted by many PTs, but the future may reveal otherwise.
Nari
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Re: A novel approach to the DC/(D)PT relationship - March 26, 2007 3:14:00 PM
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ginger
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overcomplications are usually the province of the inexperienced. Though we must be a little on guard with oversimplifications too. I'm not sure I agree with Proud on the notion that there is no "great" method , though I'm going to leave it unsaid as to what that method might be.
Clearly some things work better than others.
I'm spending some time in another victorian country hospital, where I've learned that the local private physio provides patients with, are you sitting down?, cupping , bowen "therapy" and aura analysis. It takes all kinds.
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Re: A novel approach to the DC/(D)PT relationship - March 27, 2007 2:07:00 AM
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Sebastian Asselbergs
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ginger, don't knock "aura analysis". It makes me frown at my brothers after they've had beans for supper....
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 5:10:00 AM
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rwillcott
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Thanks to the cpr's for manipulation of the lumbar spine my outcomes have improved considerably when treating acute low back pain. This is the direct result of the research performed in the US by Flynn and Childs.
Prior to using the cpr's I would spend time performing unnecessary PIVMs and PAVMS etc. Now a patient with acute LBP is provided with relief after one session rather than say 5-6.
I am amazed at the number of PT's that are not familiar with recent cpr's for LBP, cervical rediculopathy, mechanical neck pain etc. You don't have to be a Part B manual therapist (highest level of manual therapy in Canada) to apply this knowledge and manipulate the right patients.
There has been recent efforts in Canada to present this information in undergraduate programs. Also, it is suggested that more emphasis wll be placd on the teaching of manipulation in undergraduate programs in Canada. The need to undertake years of training following graduation in order to manipulate is ridiculous. However, those with an invested interest in teaching these courses would argue otherwise.
Rob
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 1:37:00 PM
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Marc Bronson
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Rob,
Nice to see the PT programs want to incorporate manipulation into their curriculum.
Just out of curiosity, if all PT's were to manipulate, do you think the DC profession would die off, in Canada?
M.
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 2:34:00 PM
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ginger
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Marc , interesting that you would equate manipulation with chiropractic, as if the same thing.
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 3:24:00 PM
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ONstudentPT555
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Marc,
Also find your comment interesting...
RWill,
You mean incorporate it into the Masters program..not many undergrad physio programs left.
Has anyone heard about the new Masters of Manipulative therapy program that is going to be offered .. I just got an E-mail about it.
MASTERS OF CLINICAL SCIENCE IN MANIPULATIVE THERAPY
School of Physical Therapy
University of Western Ontario
Do you want to:
- Earn a Masters degree in Manual and Manipulative Therapy
- Qualify to be a Fellow of the Canadian Academy of Manipulative Therapists
- Complete a program in one year with primarily distance learning
The School of Physical Therapy at Western is the first university in Canada to offer a clinical masters program in Manipulation designed to foster advanced clinical skills, and professional and research competencies. This one-year program will be offered primarily by distance learning with eight weeks of on-site intensive manual and manipulative training spread out over the year.
For the 2007-2008 academic year, on-site dates are September 10-28, 2007, Feb 4-22, 2008 and July 7-18, 2008 (subject to change). The clinical skills component of the masters program will be taught by Bev Padfield, FCAMT, along with other FCAMT instructors in the London area. Other Western faculty members contributing to the program include Bert Chesworth, PhD PT, FCAMT, Trevor Birmingham, PhD PT, Canada Research Chair in Musculoskeletal Rehabilitation, and Dianne Bryant, PhD, Director of the Facility for the Advancement of Musculoskeletal Health Research.
The program consists of six courses, see https://nts-e2036-sowa1.fanshawec.ca/exchweb/bin/redir.asp?URL=http://www.uwo.ca/fhs/pt/ for description.
Candidates will need to have:
- A minimum of a baccalaureate degree in physical therapy with a B standing in the final two years;
- A minimum of two years of clinical experience in orthopaedics;
- Completed the Level II Upper and Lower courses in the CPA Orthopaedic Division - Advanced Orthopaedic Manual and Manipulative Physiotherapy
- 30 hours of documented mentoring.
http://www.uwo.ca/fhs/pt/MClSci/manipulativetherapy.html
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 3:29:00 PM
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Marc Bronson
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Ginger, ON
Aha! You fell into my trap ;) Actually it does raise an interesting question:
1) What is chiropractic? (and you can't say its about correcting subluxations since not all chiropractic programs teach subluxation theory)
2) what is physiotherapy?
3) How do they differ and how are they the same?
Perhaps the PT's can present a consensus statement and I can present the the DC position. I'm aware of various state/provincial differences in terms of scope of practice, but you know, the basics. Also, I would suggest they we stick to official policies/statements as opposed to personal interpretations of some things.
For the record, this is to see more or less what is really separating manipulative/orthopaedic PT's and DC's.
Note: I have edited my comment to Rob to change "incorporating chiropractic" into the curriculum into "incorporating manipulation" into the curriculum. The terms are not synonymous. If chiropractic does not equal manipulation, what does it mean, then? The profession was founded upon SMT. It was only after manipulation that the founder DD Palmer, tried to explain the effects of SMT and proposed the subluxation theory. This fact is lost amongst many professions, including many chiropractors who still cling to DD's teachings.
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BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 4:20:00 PM
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ginger
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there used to be common phrases summarising chiro, going something like "they treat bones", and another for physios " they treat muscles", which were spoken here . I haven't heard this for a few years , but I think the themes are still percieved as correct by the untrained.
Nothing of course could be further from the truth. Both groups seek to solve musculoskeletal ( and for physios, many other ) problems. They do so with a range of skills and understandings that are similar . Clearly no skill defines physios any more thsan chiros.we all are able to learn each others approaches, each others skills. The big question is why don't they/we.
I believe I have an answer to this , interested in yours though Marc , if you would.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 4:23:00 PM
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Jon Newman
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Hi Marc,
I'm interested in you defining chiropractic and I think the task will make an interesting thread. That said, I think ON and Ginger are representative of most posters' knowledge about the difference between SMT and Chiropractic which is why they were wondering what you were talking about.
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 4:27:00 PM
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proud
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I thought this little letter would spark some debate and discussion:
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.)
Just a note from the Canadian perspective. PT's in Canada do have direct access already. The piece above seems to suggest that in the US, the DPT program will eventually establish direct access.
US PT's care to comment on direct access?
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 4:27:00 PM
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Jon Newman
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Here's the American Chiropractic Association's take
[URL=http://www.amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117]Link[/URL]
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 4:49:00 PM
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Jon Newman
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Here's the [URL=http://en.wikipedia.org/wiki/Chiropractic]Wiki entry for Chiro[/URL]
and here it is for [URL=http://en.wikipedia.org/wiki/Physical_therapy]Physical Therapy[/URL]
Here's the [URL=http://www.apta.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=33205]APTA version[/URL]
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 6:35:00 PM
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savela
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I am a Canadian PT, work with a US trained chiro, and have friends in both fields.
My goal this year is to take post grad courses to manipulate the Lsp. EBM shows it will help some of my pts......and I feel my job is to help my pts. get better.
I have chiro friends who have "fellowships" in rehab, which cover Mulligan, MacKenzie....etc. Their goals are to get their pts. better.
I guess my point is.......why this PT vs. Chiro competition? I work in downtown Toronto, there are many PT's..Chiro's...osteopaths..RMT's...AT's....
As out patient therapists we are all trying to market to similar pts. and get them better!
I see my main business "competition" are therapists who work hard to keep up with science, and have an open mind to new idea's and techniques that will benefit pts. and more importantly cause no harm or fraud.
This competition helps me become a better therapist.
In Canada, I think most PT's and recent Chiro grads are on the same page and respect each other's education.
What both profession's should be concerned with is..... the non EBM and the growing practice of the post grad Osteopathic Canadian courses.
In the US and Europe, Ostopaths are MD's.
Not in Canada. Standard's into the program are low.
In Canada, any RMT, AT, PT or Chiro ,can take "weekend post grad courses" for 5 years and practice as an Osteopath.?
I am currently working with a RMT who has spent 10 days in this program, and is convinced that she can change bony structures, manipulate the fascia around organs etc.
Taking this into account... the old chiro "subluxation" treatment seems harmless. Science represents that one manipulation may help acute back pain.
I am more concerned about the patients who go to Can. trained Osteopaths for shoulder pain, and are told that the origin is in their pelvis?
Let's stop this PT vs Chiro and try together to educate the public about EBM and most importantly on techniques to help the injured to help themselves.
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 9:18:00 PM
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ginger
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Bravo
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Re: A novel approach to the DC/(D)PT relationship - March 29, 2007 9:58:00 PM
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nari
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Ditto.
Savela, Canada's PT/Chiro education sounds similar to Australia.
The public's view on the two professions not so long ago, was: chiros fix spines and physios 'do' muscles and chests. That is changing, fairly rapidly.
I was a bit amused by the Wiki entry on Australian physiotherapy which said "basic anatomy" is covered. Excuse me...our basic anatomy training was equivalent to the doctors', way back in the 60s. Oh well...
Nari
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Re: A novel approach to the DC/(D)PT relationship - March 30, 2007 2:56:00 AM
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Jon Newman
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[QUOTE]I guess my point is.......why this PT vs. Chiro competition?[/QUOTE]Perceived scarce resources, perceived tenuous job security and dislike of being wrong are all likely motivators.
[QUOTE]As out patient therapists we are all trying to market to similar pts. and get them better![/QUOTE]I disagree. Most marketing is to create business opportunities. Marketing to get people better is what public health does.
[QUOTE]I see my main business "competition" are therapists who work hard to keep up with science, and have an open mind to new idea's and techniques that will benefit pts. and more importantly cause no harm or fraud.
This competition helps me become a better therapist.[/QUOTE]I have seen facilities offer or do some things that are definitely not evidenced based but rather because the competition is doing it. Anyone feel pressure to start using something because their competition started doing or using something whether or not it made sense?
Here's an interesting marketing opportunity. Most inpatient treatment facilities are going "smoke free." Some have smoke free campuses. Others only have smoke free facilities, allowing smokers to go out of the building to smoke. Where do you think the smokers prefer to go for their health care? I could argue either way on which one is better which is why I find it interesting.
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Re: A novel approach to the DC/(D)PT relationship - March 30, 2007 5:04:00 AM
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Marc Bronson
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Savela,
Great post. It's going to be interesting to see how the government responds to this convergence between DC and PT. All I know, is that both professions have a common goal: have better access to and better coverage from the public sector so we can best provide NMSK care to our patients.
This wil mean breaking the current paradigm where MD is primary care for anything and everything under the sun, including NMSK. Studies have shown that they are extremely deficient in this field. Why not let DC's and (D)PT's handle those cases? At least there is increasing inter-disciplinary collaboration as witnessed by the St-Johns Rehab Hospital and the the St-Mikes Hospital with DC's participating part of the health care team. I hope to part of something like that, sooner rather than later...
On a lighter note, my fiancee's( Year 4 in chiro school) good friend is currently in year 4 of medical school. Our soon-to-be MD was recently doing a lot of studying for board exams and was having classic lower c/t junction, parascapular pain and was asked my fiancee to treat her.
My fiancee began treating our soon-to-be-MD and was told her that there was a lot of tension in the upper trapezius, levator scapulae area. The MD goes "don't you mean levator ani?"
"No, that's a different levator altogether..."
"Are you sure?"
"Yes".
I thought Nari and others here would appreciate this little story; PT's and DC's hardly know "basic" anatomy; it's what we work with for a living!
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Integrative Manual Medicine
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