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Advisory Council Member thoughts on the PT vs Chiro conversation...
PT or Chiro? Chiro or PT? This is a question that I get asked almost on a daily basis by 3rd and 4th year university students who are interested in getting into a healthcare profession. I can still remember the day when I decided to apply for Chiropractic school, and the feelings I had about the profession before starting my first day of class 3 years ago. A lot has certainly changed since then, such as my opinion on both professions, and I felt it was necessary to communicate my own thoughts on the matter so that prospective students could have a better understanding of what they just might be getting themselves into. With that being said, I don't think I could give an honest, unbiased, comparison of both professions as - well - let's face it I'm a Chiro student after all who is giving you an opinion on PT school. So in the interest of removing as much bias as possible I have asked my good friend, and DPT candidate, Kyle Balzer to help me out. Kyle is one of the brightest minds that I have had the pleasure of meeting and I firmly believe that he is more knowledgeable than most PT's who have been out in practice for years. Now just before I continue I want to warn everyone that this article isn't going to be what you think it is. We are going to give you an honest audit of our educational experience and how we view our profession. This is going to cover many "touchy" subjects which I'm sure we will take some flak for. We are ok with this as we believe that every student has the right to know what happens behind the closed doors of institutionalized education. Likewise, for the practising clinicians reading this - I hope you gain some insight into what the future of the profession will look like. Finally, for those of you who are currently students in either of these professions, we hope to open your eyes to a new movement which we firmly believe will be the new standard of care; this is the performance therapy renaissance, and it is sweeping the nation as we speak.
A Brief History
It seems like Chiropractors have been at war with almost every health care profession at some point or another and this battle is being fought over cultural authority. We were able to fight off extinction with a victory over the AMA many years back, but as of late it seems like we have turned our attention to the world of rehab. It's not uncommon for our patients to ask what separates us from a PT, and there certainly is a plethora of small group conversations in school regarding what diversifies us from the PT profession. Unfortunately, I find many students will resort to the standard "we are more qualified because we are in school longer" answer which ultimately fails to recognize many important factors that would otherwise dismiss this nescient statement. Now throw in the fact that many PT's are utilizing adjusting, or manipulations for those of you south of the boarder, in their practices and you now have a reason for Chiropractors to get all up in arms. I mean let's face it, adjusting is what has defined this profession for so many years and the fact that some other profession is utilizing it scares the crap out of us. This is/was supposed to be "our" thing, and for many members of the profession, sadly nonetheless, perhaps the only tool in their tool box. So now what? Do we go stick our heads in the sand and quit? Now please don't get me wrong here but this next part is important; I'm not saying that adjusting isn't an effective tool, but I am saying that's its only ONE tool in what I believe every practitioner should have - a tool shed. Furthermore, the sheer fact that another profession has chosen to incorporate this into their patient management protocols actually adds validity to what this profession has done for the last 100 years or so. If anything we should be greeting this with enthusiasms instead of being so pessimistic.
Adjusting As A Standalone Method
This will be the part of the article where I will inevitability get a lot of heat for, but in my opinion I am not convinced that solely relying on adjusting painful segments will alleviate dysfunction. If we have an understanding of the joint by joint approach, as well as the concept of regional interdependence, then what I have stated above becomes very logical. Rarely is the site of pain the actual origin of dysfunction (excluding acute trauma). Unfortunately these pillars are not integrated into our theoretical knowledge at school, which is one of the major issues embodied by the institutionalized education programs we all must go through. Now unfortunately there will be those of us that choose to operate under a strict policy of only ever administering adjustments as a course of action. These individuals really are selectively removing themselves from a multidisciplinary approach to healthcare and are segregating themselves from the rest of the profession. Invariably, these are also the same individuals who other healthcare providers tend to see as the majority in our profession, and this in itself has led to a lot of interprofessional issues. There is no better example of this than when you tell someone-else that you are a Chiropractor for the first time. How many of us have followed this up by saying, in your own defense nonetheless, "but I'm not one of THOSE Chiropractors." So where did it all go wrong for us? And, as a student what can you do to set yourself apart from everyone else? This is where we turn to the rehab renaissance and where I believe we need to catalyze interdependence amongst healthcare practitioners.
Because there is no plan B
A Movement Based Solution
As many of you already know, I was strength and conditioning coach before being accepted to Chiropractic school. Working with athletes was something that I had a passion for and this stemmed from my own experience as collegiate athlete and pro fighter. I did, however, understand that there were caveats to working as strength coach, especially when it came to athletic care. This fact inevitability led me to seek the path I am currently on. Originally I was slated to go to Medical school but this would have severely limited the constant interaction with athletes, which I wanted; thus I decided to come to Chiropractic school instead. I strongly believe it was my experience as a strength coach that really solidified my view on how we need to deal with dysfunction. Those earlier years were spent with countless hours of reading the works of giants like Boyle, Cook, Sahrmann, Liebenson and anything else that had to deal with the now proverbial term, movement. As such, I expected that once I came to school I would really get to dive deeper into this world and have a better understanding of how dysfunction arises and how to treat it. I thought we would be taught the classical works of Janda and Lewit while integrating the newest research from McGill, Cook, Khan, Powers, Schleip and others. To my dismay, literally none of those things happened and truthfully it seemed like many of the instructors were still just doing the same thing they themselves were taught oh some 20 years ago. So here I was in this institution learning about various subjects that really should have been connected together, yet they were being taught without even considering the importance of their unified integration. Without this vital piece I think even our basic knowledge of terms like mobility and stability are skewed.
Understanding both of these terms is paramount in a profession that generally deals with joint pain and dysfunction. Mobility is a prerequisite to stability and when we speak of stability we do not mean rigidity. One of the biggest issues I see students facing is being able to discern when there is a stability problem or a mobility problem. Now we only ever need stability in the presence of change but please don't fail to realize that sometimes we already have the requisite mobility, and as such we really may have an underlying stability/motor control issue.
Is this squat limited by Mobility, or is it in fact a Stability issue?
I think most students are taught to believe that everything comes down to a mobility problem and the only real tool we are given in school is a mobility hammer, aka the adjustment. As you can see from the picture above, throwing mobility at a stability problem doesn't exactly qualify you to be on the "A -Team". Now if you had an appreciation and an understanding of movement, you may have been at a better vantage point for assessing the dysfunction. It's important to understand that assessing movement is a skill, and perhaps is something that we have lost over the years. We have become much more reliant on orthopedic tests which look to isolate structures, and passive care has become a huge component of our treatment plans. As I had stated earlier, it seems like the joint by joint approach has slipped through the cracks. With all this being said, I think the biggest turning point in my education came half way through first year, and it was at this point I realized that things needed to change.
The Tipping Point
I was attending a presentation at school, along with my colleague Ricky Singh, where a group of 4th year students were discussing how to manage post-op ACL rehab. I was hoping this would be the point in my education where I had my "ah ha" moment, and where all my concerns about the quality of our education would be put to rest so I could finally see that there would be light at the end of the tunnel. Instead I got to witness clinic interns preach about how important the VMO was, and how mandatory it was to prescribe adductor ball squats amongst other foolish exercises. I don't need to tell you how I feel about this, instead I will refer you to read the following article (Adductor Squat) which was written by one of my mentors, Charlie Weingroff, in response to what was recommended at that seminar. That whole experience made me realize that there was a dire need for the student body to be brought up to speed with what the best clinicians in our field were doing to manage rehab, amongst other things, as we were never going to be taught this stuff at school. This lead us to create a Strength and Conditioning club at our school which then blossomed in to what is now known as the Rehab 2 Performance (R2P) club thanks to the tremendous insight and help of Dr. Craig Liebenson, and other great clinicians such as Dr. Jason Brown.
Enter the Rehab, or Performance Therapy, Renaissance
As I have alluded to earlier in this article, I feel that most of the students who graduate from this program are not equipped with all the tools that could make them successful. I understand that everyone has a niche, and that many of you may not agree with what was said above, but the one thing we can all agree on is that every treatment plan should have some type of active care component to it. The question then becomes, do you think you are proficient enough to prescribe the correct rehab protocols or better yet can you teach someone how to perform them? This is one of the reasons why R2P was created, to give students the hands on skills they need to be better at what they do. The only real way to deal with dysfunction is by having a skill set that first allows you to identify it (meaningful assessment principals), the tool shed which houses the optimal method to deal with altered motor-control (secondary to pain), and a knowledge of progressive exercise selections which will allow specific physiological adaptation to occur in order to "reset" the central operating software. So if all this is true, what then separates us from PT's? Aren't they the experts of exercise solution for dysfunction? Regardless of titles, it all comes down to individual skill sets and appreciating the fact we need to move from a state of independence towards one of interdependence. If we stay in an independent state of mind and choose to only communicate with other DC's I think the profession as a whole will suffer. There is an incredible amount of opportunity awaiting us if we decide to work in an interdependent state; as a multidisciplinary team. Not only will we gain a lot of clinical insight but patients will be better off for it. A paradigm shift like this - which not only includes DC's and PT's but also ATC's and Strength Coaches - is what my ultimate goal is with the R2P movement, and teaming up with the International Society of Clinical Rehab Specialist (ISCRS) will only help this goal. We are bridging the gap for many health professions and this will be the future of our profession. It really is time to leave your ego at the door an embrace these changes as in the future, titles will mean nothing. So you have heard what a future DC thinks, but what about those on the other side of the fence? Let's hear what Kyle had to say and keep in mind when you hear things being repeated, it's probably a good idea to write them down.
A Doctor of Physical Therapy Perspective
I guess I'll start with my big eye opener, which occurred in the spring semester of my first year in graduate school. My brother was going to a gym in Albany, NY and saw a poster on the wall about something called the, "Functional Movement Screen," and he thought to himself that this is something I might be interested in, going to physical therapy school. Let me tell you, I have no idea where I would be with my thought process right now if he hadn't thought of me when looking at that poster. So, on my own time, I started researching it, bought up Gray's Movement and Athletic Body in Balance books and started delving away. The timing of this couldn't have been more perfect, as we had just started taking our first Clinical Application course for neuromuscular impairments, called Motor Control...and for people who haven't read Movement, Motor Control might be the most important term to understand before or after reading it. So, as we're learning about Proprioceptive Neuromuscular Facilitation (PNF) and Neurodevelopmental Theory (NDT) to integrate into treatments with patients who have suffered strokes, traumatic brain injuries, etc., I was reading about how important these principles are for treating orthopedic populations. I could go on for a while about how integral reading Gray's book has been in my development as a physical therapist, but I'll stop there (maybe) as it gets me to my first problem with MY experiences with "Institutionalized" education.
Being In School Feels A Lot Like Being In Prison
Learning About the Body's Systems Separately & Their Implications For Treatment In Separate Populations
What I mean with this, is that throughout the three years of graduate school, there is a progression of learning within each system, or population of patients. We learn our gross anatomy, neuroanatomy, pathophysiology, biomechanics, exercise physiology, etc., right out of the gate, which is extremely important. But, from there, we get into Motor Control/Adult Neuromuscular, Musculoskeletal, Cardiopulmonary, and Pediatric Neuromuscular courses. And these are all great things, but shouldn't we discuss/consider the importance of the brain and neuroplasticity in post-ACL Reconstruction patients? Or, breathing and response to exercise in stroke patients? Or, the neurodevelopmental sequence in ANY population of patients? I'm sure you'd agree with me in my saying that "tummy time" is important for both infants, as well as adults, to develop/improve posture. How you implement them will probably be different for each population, but the principles behind neurodevelopment would probably support the fact that prone on elbows is a great way to develop scapular stability, thoracic extension, a packed neck, etc. Yet, we learn that we improve scapular stability by doing ITY exercises, rotator cuff isolation exercises. Supine chin tucks, which we learn help train the deep neck flexors are not good because of EMG research, but because that's how the baby learns to first control its head. But better than just having someone lie supine and tell them to, "Make a double chin," we should put them in the 3.5-4.5 month old position, assess breathing, centrate EVERYTHING, and then re-train neck flexion in conjunction with breathing and intra-abdominal pressure, and then work from there to pack the neck during deadlifting or half kneel chops and lifts. This kind of segues me into my next problem with institutionalized education.
Evidence-Based Practice Should Not Solely Be Based On Research, Especially Research That Was Published Years Ago.
This one's sort of two-fold in that, 1) research doesn't tell the whole story, and 2) having 60 year old professors teach you what they've been using for the past 25 years is not going to move our profession forward. For the first one, I'll give two quick examples. During Musculoskeletal II, I started reading Stu McGill's book about low-back disorders because I knew we'd be learning about the lumbar spine in this class. Anyway, our teacher presented us with several research articles (that I believe were from her alma mater, and this is why she chose them) on EMG activity and % of MVIC of the "core" musculature during various "core" exercises. What do you know, on the next test I got a question wrong that compared the bird-dog to prone back extension. (Disclaimer: I do not remember the exact wording of the question, but that shouldn't stop me from making my point.) Now the question MAY have asked, which exercise has the greatest activity of the Erector Spinae, but I'm about 90% sure it asked something about which exercise was better. It's true that the Erector Spinae have a greater contraction with prone extension, but I think McGill's research showed that the compressive loads it produces on the lumbar spine make it a ridiculous exercise to train with. And this doesn't mean the bird-dog is right for everyone, but that I believe it's more right than the prone extension exercise. The second example is the entire three hour lab that was spent discussing the importance of the Transverse Abdominus in low back pain patients and core stability...great, right? Wrong, the entire lab was to learn a progression of leg movements that became increasingly more difficult to perform while holding the draw-in! I chose to practice them while holding a brace because this is what McGill discusses in his book, and even now after having learned some of the DNS principles, I believe there might even be a better way to perform these exercises by incorporating breathing and intra-abdominal pressure.
Forget Hogwarts, This Is How You Become A Wizard
The second statement I made about moving our profession forward is why Rehab2Performance clubs are so important and are starting to pop up all over the continent in PT and DC programs. The way the system is set up, most of our professors are from older schools of traditional rehab methods and they are mostly stuck in their ways. So, we have professors who graduated roughly in the 70's and 80's teaching us what they've practiced for however many years that they expect us to practice over the NEXT however many years? That doesn't look like a formula for staying ahead of the curve or progressing our professions. After starting to read Gray's Movement book (I knew I'd go back to it), I brought it to my orthopedic professors, who fall into that "old school" approach. They quickly dismissed it as important, but finally read it later on when we approached them with a research project using the FMS. Unfortunately, I don't think it was enough to show them the "Paradigm Shift" that Gray discusses. They don't know who Gray Cook, Craig Liebenson, and Charlie Weingroff are; nor do they care at this point in their careers. Why should they? Maybe if it were earlier in their careers they'd be much more open to newer perspectives. Or, maybe our only goal in PT school is to graduate and pass the Board exam, and none of the stuff these guys teach is on the Board exam. It's one of those vicious cycle things I think and the system doesn't allow for learning the way we need it to.
If someone were to look at the titles of the three people I just listed, they would wonder how all three fit into the same conversation which leads me to the big topic of discussion... PT vs. DC. Gray is a PT, OCS, CSCS; Craig is a DC, McKenzie Board of Directors, among other things (his list of achievements goes on for a while); and Charlie Weingroff is a DPT, ATC, CSCS. How are PTs and DCs mentioned in the same breath? Well, they are all rehab professionals who are experts in movement, that's how. These are three people I've been following for some time now, reading their articles, meeting them at seminars, listening to their podcasts, and watching their videos because I believe the way they treat patients is the way patients deserve to be treated. However, they are not good representatives of the majority of the professionals of their respective professions and this, I think, is why PTs and DCs have become "rivals". From what I've seen and discussed with people, PTs and some lay people (and probably some intelligent DCs) seem to view DCs as "back crackers" who will manipulate until the end of time without appropriately assessing the patient and giving them the right activities to get them moving again. At the same time, I know there are DCs and lay people (and definitely some intelligent PTs) who believe that PTs are going to stretch their patients for five minutes and then give them a laundry list of mundane band exercises to perform 3 sets of 12 of until the band breaks without appropriately assessing the patient. I could probably be more critical of PTs than DCs at this point because of what I've learned, but I know there are intelligent PTs out there saying that as much as 85-90% of PTs are not doing it the right way. I think the majority of people don't want to think for themselves, want to get a diagnosis from an MD, take out their glossary/cookbook of treatments for said diagnosis, and then get to billing and paperwork so they can go home and do it all again tomorrow. Me, I'm a problem solver. The SFMA is the greatest thing I've ever come across because it gives me a systematic approach to help me understand WHY a patient is having the problems they are. If you're not a good problem solver I don't think either of these professions is good for you... And, the way I've explained it to a lot of people, especially PTs who think DCs are doing the wrong things, is by saying that every profession has a bell curve. It is our job as advocates of our profession to push that curve as far to the right as we can.
I think guys like Gray, Craig, and Charlie are doing an awesome job of this, but I think it's our responsibility as students to help make these changes at the most fundamental level. I know you would agree with the fact that the title(s) of said clinicians is not important. Below is a diagram that I feel represents what I have observed in the field of rehabilitation in regard to clinician title(s). I know it will likely change over time, but I think it's a decent representation of our professions.
I made this as a slide to put in a future presentation that I will end up giving at some point down the line, with the sub-note saying, "The best are more alike than different." And I'm sure the stuff inside the triangle will probably evolve over time, but I think those four concepts are very important to helping build our professions. I think the more we can work together to bring systems such as DNS, FMS, and SFMA to the surface (and many others, but those are just the few I've been exposed to), the sooner we can appreciate each other and further both of our professions at the same time. Because currently, and I agree with you 100%, it's a pissing match. I wish you or any other DC representative could have been there for my in-service on Vojta therapy at the conclusion of my final PT clinical rotation. The reactions and discussion that my presentation created was EXACTLY what I either expected, or was hoping to elicit. The content took maybe 20-25 minutes to present, but the presentation went on for about an hour because of the discussion it created amongst myself and the 7 PTs in the room. I'll leave it at the fact that some PTs were more receptive than others, and that some thought that the fact that the Vojta course we attended was taught by a DC means that there is "NO" reason for them to learn it, or believe in it. It was immediately written off because it was coming from a DC. I think one of the best ways to learn is by learning from those outside the profession, which is why it's important to build these networks of PTs, DCs, ATCs, LMTs, Strength Coaches, MDs, etc. That way we have open lines of communication along the movement continuum to give each patient the best care possible. Isn't that what it should be all about?
The follow up movement lecture is available here PT VS DC
Written and originally published by Dr. Jas Randhawa
June 5, 2016
December 6, 2015
June 11, 2015
May 21, 2015
April 6, 2015