January 31, 2010 at 1:51pm
Good information! I have a question for Dr. Kestner, please. What should one expect to get from a chiropractor that one would not get from doctor ordered, lumbar modality specific physical therapy? Thanks!
February 01, 2010 at 10:05am
Good question. This is an area of confusion for many, including many doctors.
Although the question is straightforward enough, it is difficult to answer it simply. There are wide variations in the practices of chiropractic and physical therapy, so the short answer would be “It depends on where you go for physical therapy and where you might go for chiropractic.” Every professional in these two fields has their own background and level of training and their own preferred method of addressing specific conditions.
Nothing in this response should be interpreted to indicate that universally either profession is better than the other. There are many similarities between the two, but there are some striking differences as well.
There is often a significant difference in the treatments offered by chiropractors from that of physical therapists. There are quite a few technical differences between the training and practice concepts of the two approaches. I have been asked on numerous occasions to testify before Tennessee Legislative committees to help determine what laws and rules should apply to both Doctors of Chiropractic and Physical Therapists. Besides training variances, state laws determine scope of practice issues that affect treatment as well.
Physical Therapy sessions often begin with a physical examination of the area of complaint and the formation of a treatment plan. The actual treatment sessions often consist of application of modalities such as heat, ultrasound, electrical stimulation and massage to the injured area. In some cases this may be accompanied by teaching the patient to do some strengthening or stretching exercises. These treatments are typically beneficial to most patients. Usually a series of treatments over several weeks is ordered.
Some physical therapists have advanced training and may provide some form of mobilization of the body. Physical Therapists (PT) with advanced training in manual therapy often have Master of Manual Therapy (MOMT) degrees. In recent years, many physical therapy schools have begun offering Doctor of Physical Therapy (DPT) degrees.
Currently, although physical therapists can do an initial evaluation of a patient in many states, a licensed physician (which may be a licensed Chiropractic, Medical or Osteopathic Physician) must write an order for the therapy in Tennessee.
Doctors of Chiropractic (DC’s) are licensed as primary care providers. That means their license allows them to see patients without a referral. In fact, DC’s may write referrals to physical therapy and I sometimes do for certain conditions to see certain therapists that offer particular treatments that are not available at my office. Only Medical Doctors (MD’s), Chiropractic Doctors (DC’s) and Osteopathic Doctors (DO’s) are licensed as primary care providers. This is due in part to the training in what is known as differential diagnosis.
A Doctor of Chiropractic will begin their assessment with a history, order any appropriate tests or imaging, perform a physical examination, and determine a diagnosis. (Physical Therapists are not licensed to order or interpret lab testing, x-rays or other imaging) They then will create a treatment plan and provide most if not all of the treatment in house. Usually several weeks of treatment are required.
Chiropractic treatment is centered upon a very important procedure called spinal manipulation or spinal adjustment. Spinal manipulation involves the use of the doctor’s hands or sometimes an instrument applying very specific thrust force to specific points to achieve an improvement in the spinal function. This procedure requires longer training to learn to apply correctly and safely. This is the procedure that some people refer to as “having their backs popped”, because it often creates a harmless popping sound caused by little gas bubbles within the joint fluid. It is very safe when performed by a licensed, experienced chiropractor. There are literally dozens of methods to provide spinal manipulation and each method requires expensive and time-consuming training. .
Because Doctors of Chiropractic focus on spinal treatment they often have expensive equipment called adjusting tables designed exclusively for spinal care. For example, in my office, I have two rooms set up with treatment tables that cost several thousand dollars each that were designed solely to provide exceptional results for lumbar disc problems. These tables, called flexion-distraction tables, allow me to perform specific treatments on lumbar discs while the patient lies in a comfortable prone position.
Some Chiropractors limit their treatment to spinal manipulation, but most also offer the same modalities available to Physical Therapists such as ultrasound and electrical stimulation. In our office, we also provide training in rehab exercises, application of physical therapeutic modalities such as electrical stimulation and traction. Some chiropractors do not include modalities or rehabilitation training in their treatment regimen, so the visit might consist of spinal manipulation only.
Note that some physical therapists may provide a form of manual therapy called mobilization. Technically, manipulation and mobilization are different things in that mobilization generally is a slower, more generalized manual procedure that does not create the popping sound. In Tennessee, a law called the Spinal Manipulation Safety Act prevents any health care professional except Chiropractic, Medical and Osteopathic Doctors from performing spinal manipulation. Therefore, Physical Therapists may legally provide spinal mobilization but not spinal manipulation.
Spinal manipulation has been shown in government studies to be more beneficial to low back pain patients than most other treatments, including ultrasound, electrical stimulation, massage, medications, and exercise. However, after twenty-one years of experience I have found that a combination of manipulation along with therapeutic modalities such as electrical stimulation and rehab exercises helps the patient get better faster and stay better longer than any other approach.
Because each professional of either group chooses to develop their own preferred treatment methodology, there is very wide range of possible treatments that might be offered at one clinic or another. Of course, within each profession there are wide variances in the training, skills, and expertise of individuals. Just as there are differences in the abilities of musicians, quarterbacks, and plumbers, there are exceptionally gifted and talented professionals in both fields that achieve better results than average. Both professions usually provide quality care, although some patients might respond more favorably to one approach versus the other.
Thanks for the question, and next time I’ll try to create a shorter answer!
February 02, 2010 at 9:13pm
While your opinion is certainly a good one, your information is a bit dated. Per Tennesse law, Physical Therapists were granted to ability to see patients without a physician's referral a couple of years ago. Many are now Doctor's of Physical Therapy that are trained at land grant universities, unlike most Chiropractors who still don't have a traditional land grant univeristy in which to study. So you will see most Chiropractors trained at private colleges that were originally started by Chiropractors, where Doctor's of Physical Therapy are trained at institutions such as the University of Tennessee or the University of Kentucky.
Chiropractic has it's place, but certainly not as primary care. And legally Chiropractors cannot perform Physical Therapy.
So in a perfect world, we would all work together.
February 03, 2010 at 2:25pm
Thank you for your contribution to the discussion. You brought up a good point that I left out due to space constraints. Although Tennessee law still requires a doctor’s referral for physical therapy, there are exceptions that may apply to certain circumstances whereby physical therapy may be provided for up to 30 days without a referral.
To avoid confusion I will quote the Tennessee Department of Health website.
The State of Tennessee Law pertaining to the scope of Physical Therapy states:
“(a) The practice of physical therapy shall be under the written or oral referral of a licensed doctor of medicine, chiropractic, dentistry, podiatry or osteopathy, except for the following:
(1) A licensed physical therapist may conduct an initial evaluation of a patient without referral;
(2) A licensed physical therapist may provide physical assessments or instructions, including a recommendation of exercise to an asymptomatic person, without the referral of a referring practitioner…”
A recently enacted provision for Physical Therapists in the State of Tennessee allows a licensed Physical Therapist to provide “emergency” care without a referral and in certain circumstances to provide up to 30 days of non-emergency care without an order from a licensed doctor of medicine, chiropractic, dentistry, podiatry or osteopathy. According to current Tennessee law, the PT may treat the patient without a referral as long as all of the following conditions are met:
*The Physical Therapist meets certain requirements such as holding a Master’s or Doctorate degree in Physical Therapy along with at least one year’s experience or the Physical Therapist has completed a clinical residency or fellowship or has three years experience as a licensed Physical Therapist and has taken a minimum fifteen-hour course approved by the State “designed to enable the physical therapist to identify signs and symptoms of systemic disease, particularly those that can mimic cardiological, neurological, oncological, or musculoskeletal disorders, and to recognize conditions that require timely referral to a physician, dentist, osteopath, podiatrist or chiropractor”
*The Physical Therapist documents patient progress within fifteen days or six visits, whichever comes first.
*The treatment is not to continue beyond 30 days without a consultation between the Physical Therapist and one of the mentioned licensed Doctors of Medicine, Chiropractic, Dentistry, Podiatry or Osteopathy.
The updated language is set forth in the Tennessee State Laws as noted at this State webpage:
As to your point about whether a college is a Land-Grant university, that has no relevance. Land Grant universities are simply universities that benefited from the federal Morrill Acts of 1862 and 1890 that created mandated programs focused on agriculture and mechanical education. Each state was given large tracts of land to sell to produce funds to create college agricultural and mechanical education programs. This was an effort to provide opportunities for more practical education as opposed to what was then known as classical studies.
The only two universities that qualify as Land Grant universities in Tennessee are UT and TSU. There is no reason to suggest a college that offers federally mandated programs in agriculture would be a better choice for physical therapy or any other healthcare education than one that does not.
Private colleges are certainly not Land Grant colleges. Locally, Belmont University has an excellent Physical Therapy degree program and is not a Land-Grant university. Vanderbilt is not a Land Grant university yet manages to turn out some pretty respectable graduates including medical researchers and physicians. MTSU is not a Land Grant university yet offers an exceptional nursing educational program including master’s degrees.
Chiropractic colleges are private graduate-level colleges and are federally accredited to provide the appropriate education to prepare a Doctor of Chiropractic. They obviously do not have agriculture departments as Land Grant colleges are obliged to do, so they will never be considered Land Grant institutions. Having an agricultural or mechanical engineering department would not benefit chiropractic or any other health care education. I do not expect to ever see a chiropractic educational program offered at a Land Grant university, as there is no need for that.
I did mention that some physical therapy programs are now offering Doctor of Physical Therapy degrees and I applaud the raising of the educational requirements to qualify for this degree. All Physical Therapists have put forth considerable effort to obtain their education and license and this should be recognized. This benefits the profession and consumers.
Just as pharmacy colleges began offering doctorate (Pharm. D.) degrees several years ago, this move will not only raise the bar for educational standards but also help the consumer understand the amount of work involved with obtaining such a degree.
Also, as I mentioned, I do refer to physical therapists occasionally and appreciate their work to help my patients return to health. I refer to many types of medical providers and accept referrals from many medical doctors and occasionally physical therapists as well, so in my view, everyone is working together.
Thanks again for your comments.