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.)