Who's Judging Whom: The Challenge From Chiropractors

By William Boissonnault, Academy Practice Committee Chair

Although not as frequent as 6 to 8 years ago, Physical Therapy (PT) Association State Chapters continue to face legislative challenges from chiropractic organizations. A consistent chiropractic strategy has been to challenge physical therapists' educational backgrounds related to thrust joint manipulation and diagnostic abilities. Recently in one state the Chiropractic Association requested that written evidence to support the inclusion of joint manipulation, airway clearance techniques and wound care be submitted including: scholastic catalogues of ALL nationally certified PT school programs showing the number of classroom and clinical training hours PT students receive in:

  • Differential diagnosis
  • Pathology
  • Radiology
  • Neurology
  • Chemistry
  • Anatomy
  • Physiology
  • Microbiology
  • Psychology
  • Obstetric/gynecology
  • Orthopedics
  • Wound care
  • Spinal manipulation
  • Extraspinal manipulation
  • Airway clearance techniques

In addition, they requested documentation describing the educational levels of PT students from five, ten, and twenty years ago! The above was requested in the name of patient safety, a very credible concern, but ....

On what basis will chiropractic organizations make their judgment on our level of training? What will their standard or reference point be? Of course they will find discrepancies in curricula when comparing PT versus chiropractic education programs. We are two very different professions when it comes to patient care approaches and the underlying rationales that guide our educational training and clinical decision-making. For example, in the state of Wisconsin the key phrases of the Definition of Chiropractic Practice Act are spinal subluxations and associated nerve energy expression, and spinal column adjustment. A completely different approach than what you'll find described in the Guide To Physical Therapist Practice where the disablement model and evidence-based practice are the central themes to our scope of practice. The assumption would be that with approaches so different, the educational training and general perspective would also be very different. In my opinion, the analogy of comparing apples and oranges doesn't do justice to the differences in training and approaches. In fact, in many aspects I would argue the two approaches may be incompatible.

Chiropractors and their associations are not qualified to make judgments on our educational standards and training, unless of course we were presenting ourselves as practicing chiropractic. This is not what is being brought forth legislatively by PT Associations. Stating we utilize thrust joint manipulation is not synonymous with practicing chiropractic. No single profession owns this intervention that has been utilized for centuries (long before Chiropractic was "invented"). Its in what context the technique is being used and for what reason, is what differentiates the various professions who use manipulation. So, in Wisconsin if I state I am using spinal adjustments to correct a spinal subluxation to restore nerve energy, then it would be legitimate for a chiropractic association or examining board to approach the Wisconsin PT Examining Board questioning my actions and level of training. Of course I would not claim this, in part because I don't adhere to the vertebral subluxation and nerve energy theory that drives their profession.

All health care professional associations have the right and responsibility to advocate for public safety. It is a legitimate question to ask; will patients be at risk if this legislative language goes into effect? It is reasonable to be held accountable by other patient advocate groups (e.g. other health professions). So how do we as a profession respond to such questions? We simply describe our education and our practice, as well as to whom are we accountable to in order to insure quality and safety. The Guide to Physical Therapist Practice, a consensus-based document, clearly describes our scope of practice. How do we know if graduates from PT programs are competent practitioners? The educational training provided by all PT schools is clearly described in The Normative Model of Physical Therapist Professional Education, another consensus-based document. Another legitimate question is; how do we know if our PT Programs are meeting the appropriate standards?

From 1936 until 1977 the American Medical Association oversaw the accreditation of PT programs. Since then, the Commission on Accreditation of Physical Therapy Education (CAPTE) has "served the public by establishing and applying standards that assure quality and continuous improvement in the entry-level preparation of physical therapists and physical therapist assistants, and that reflect the evolving nature of education, research, and practice." Who is CAPTE? CAPTE is the ONLY agency in the United States recognized to accredit educational programs for the preparation of physical therapists. It is the only agency with the expertise and credentials to pass judgment regarding the scope and quality of physical therapists' training.

So, how do we respond to requests from groups like the above-mentioned Chiropractic Association? We state that we appreciate their concern for public safety.   We follow with; "We share your concern about patient safety. As a profession we have very high standards related to patient safety in our Standards of Practice, Code of Ethics and Guide to Professional Conduct; equal to any health professions like-documents. We also have State Examination Boards, like other health professions, charged by legislators to address concerns brought forth by the public related to physical therapist practice." We can describe in general our educational training and standards, noting that   our educational programs are held accountable by an agency "appointed" by the United States Department of Education, as with other health professions. We can in general terms compare and contrast education and approaches to patient care with other professions, but discussing how many hours or minutes is spent on a technique is not relevant and borders on the absurd.  Constructive dialogue and negotiations requires two parties willing to listen and who potentially will change their positions. I fully understand this 2-way street of communication involving chiropractic organizations often does not exist. Their objective is simply to restrict our practice. 

We should spend as much time, if not more, educating legislators regarding our training and practice as we do trying to convince other professions that we are qualified. Regardless of who we are negotiating with we have nothing to apologize for in terms of our training and practice of thrust joint manipulation. It has been a part of our practice for decades and physical therapists continue to be at the forefront of research investigating appropriate use of this intervention. The above is the message the Academy and APTA are giving to the PT state associations when they are confronted by these legislative challenges. I hope this is the message you will give to all relevant audiences.

From the AAOMPT official newsletter: Articulations (2005) 

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