Can the Chiropractic Profession Find a Road Map to Cultural Authority From Physical Therapists?

Chiropractic continues to suffer from an overemphasis on philosophical and hypothetical beliefs while reliable, evidence-based approaches are ignored. Clinical practice and future research should be informed by both experience and evidence. Is our profession striking the right balance between forming hypotheses (retrospective experience) and testing those hypotheses (prospective evidence)? Cultural authority requires that chiropractic shed the image of the charlatan engaged in premature advocacy and overclaim of unreliable, unproven health care beliefs. A road map for this strategy has been refined, to a high degree, by a related health care field - physical therapy.

An editorial in the October 2005 Journal of Orthopedic and Sports Physical Therapy (JOSPT) quotes the American Physical Therapy Association's (APTA)'Vision 2020:^1,2

"By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health. To achieve this goal, APTA's Board of Directors suggests that we should focus our efforts on five key areas: professionalism, direct access, the doctor of physical therapy, evidence-based practice and practitioner of choice. Because a majority of first professional degree programs have now transitioned to the professional doctoral degree and physical therapists can provide direct access care in 39 states, it is clear that we are quickly moving toward the Vision 2020. However, it would be helpful to reflect on where we are as a profession and what it is, exactly, that we want in our journey toward the goals set forth by our national organization."

A related article in Physiotherapy Canada gives a historical overview of the evolution of the PT profession, summarized as follows:⁴

• The Canadian Physical Therapy Association motto is Exercito manugue medica, or "exercise and the healing hand."
• By the early 1980s, multidisciplinary PhD programs had been instituted in various universities. "The promotion of rehabilitation services was essential to ensure adequate teaching resources and to meet governmental and societal demands for viewing rehabilitation as a continuum from impairments to social integration. Physiotherapy was one of the disciplines contributing to this area of research."
• In the mid-1980s, the PT profession helped articulate the World Health Organization (WHO) model for rehabilitation and the need to see rehabilitation as a continuum from physical impairment to social integration.
• Indicators that physical therapy is an evolving clinical science include the profession's theoretical framework; MSc and PhD programs; peer-reviewed publications and professional journals; expanding knowledge base; researchers of international reputation; evidence-based practice; and knowledge translation. The theoretical framework for physical therapy is "pathokinesiology as the science defining physiotherapy." The scientific discipline of physical therapy is "the evaluation and treatment of movement disorders."
• In 1998, in the Mary McMillan Lecture, Shirley Sahrmann said, "We must solidify our identity as a profession by developing the concept of movement as a physiological system and by accepting the role of practitioners responsible for a system of human organism. I believe we must be defined by our ability to apply scientific principles for the purpose of diagnosing, treating and preventing the movement-related dysfunctions."
• PT is building on its scientific base of knowledge: doctoral degrees, publication in peer-review journals, textbooks authored. It is promoting evidence-based practice. Sharon Wood-Dauphinee, in her 1997 Enid Graham Lecture, said, "Leadership is involved in defining what the future should look like, in establishing direction, aligning people, motivating and inspiring them to work collectively to produce change which is often dramatic."
• A summary of the past 40 years of PT's evolution includes the following: PT is an evolving clinical science specializing in movement disorders; PT is but one rehabilitation science; to promote further development, the profession must work together with members of other disciplines to enhance interdisciplinary research in rehab; and mentorship, leadership and personal involvement are important if PT is to continue to develop as a profession and clinical science.

Some Questions for Chiropractors to Ponder

1. Is this a model for chiropractic?
2. Is this a challenge to us?
3. Is this a warning to us?
4. Who are we?
5. Where are our leaders?
6. What is our vision?
7. Can we as a profession work collectively toward our goals?

Physical therapists should be commended for their explicit work to improve their ability to care for patients. In summary, they have embraced evidence-based health care; movement disorders; the WHO framework for disabilities and impairments;^5-6 peer-reviewed research; interdisciplinary dialogue; and MSc and PhD programs for their best and brightest.

These are all areas in which the chiropractic profession can similarly derive benefit. Chiropractic is a leader in the conservative management of NMS conditions. We have always emphasized restoration of function, rather than mere treatment of symptoms. Chiropractic research has evolved by leaps and bounds over the past few decades. However, there are a number of shortcomings which render us vulnerable to such a broad-based, progressive approach as enumerated by physical therapists. Our academic isolation is a major hurdle for us to overcome, as is our undying support for practice management models that do not emphasize evidence-based care and may even be unethical. Another issue is prioritizing our political goals to protectionist actions against PT's scope of practice, rather than quality improvement of our own clinical approach to care.

For chiropractic to remain competitive in the health care marketplace, we must benchmark ourselves as evidence-based, patient-centered NMS health care providers.³ Otherwise, we risk seeing even less than the 7 percent of population we currently see. To accomplish this, we should become experts not only at getting people out of pain, but also in showing them how to take care of themselves. Then, we can truly say we are offering patient-centered care.

References

1. American Physical Therapy Association House of Delegates. Vision 2020. HOD 06-00-24-35. 2000. Alexandria, VA: American Physical Therapy Association; 2000.
2. Childs JD, Whitman JM. Advancing physical therapy practice: the accountable practitioner. JOSPT 2005;35:624-627.
3. Liebenson C. Benchmarking - chiropractic care and quality assurance in the 21^st century. Dynamic Chiropractic, Sept. 12, 1995. www.chiroweb.com/archives/13/19/08.html.
4. Richards CL. 2005 Enid Graham Memorial Lecture: Physiotherapy and the rehabilitation sciences. Physio Can 2005;57:34-47.
5. Victorian WorkCover Authority. Clinical Framework for Chiropractors. www.workcover.vic.gov.au/dir090/vwa/home.nsf/pages/chiropractors.
6. World Health Organization. International Classification of Human Functioning, Disability and Health: ICF. Geneva: WHO 2001.