Physical Therapists VS Chiropractors: Who is Better???

The short answer is neither. The long answer is also probably neither….but let’s humor ourselves and talk some details shall we.

Good vs Evil; Alpha vs Omega; Superman vs Batman; The age old question since the dawn of time…well maybe since early on in the history of musculoskeletal medicine and rehab. It doesn’t take long being in the physical therapy profession to see that with quite a few folks there is some animosity towards chiropractors. Conversely, I have sat by silently in discussions between chiropractors that didn’t know I was a PT who went on and on about how PTs were a huge threat to their businesses and they needed to do whatever they could to restrict their access to patients and/or limit their usage of certain manual therapies.

According to the American Physical Therapy Association (APTA):

“Physical therapists (PTs) are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility - in many cases without expensive surgery and often reducing the need for long-term use of prescription medications and their side effects.

Physical therapists can teach patients how to prevent or manage their condition so that they will achieve long-term health benefits. PTs examine each individual and develop a plan, using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness- and wellness-oriented programs for healthier and more active lifestyles.”

 

According to the American Chiropractic Association (ACA):

“Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health.  Chiropractic care is used most often to treat neuromusculoskeletal complaints, including but not limited to back pain, neck pain, pain in the joints of the arms or legs, and headaches.

Doctors of Chiropractic – often referred to as chiropractors or chiropractic physicians – practice a drug-free, hands-on approach to health care that includes patient examination, diagnosis and treatment. Chiropractors have broad diagnostic skills and are also trained to recommend therapeutic and rehabilitative exercises, as well as to provide nutritional, dietary and lifestyle counseling.”

Hmmmmm….these actually sound somewhat similar don’t they??

 

 

I was personally indirectly taught to have a bias against chiropractors when I was in PT school, but a huge amount of this stemmed from the idea that ALL chiropractors ascribed to the subluxation model. I was taught they ALL tried to see every one of their patients twice monthly for a maintenance program to prevent disease, ward off allergies, and all sorts of other wacky non evidence based hokum. Now we know today based on a plethora of fairly high quality studies that the subluxation model, at least its traditional rationale, is totally bogus. Spinal alignment has very little to nothing to do with people’s health. (Don’t  bother lecturing me about extreme cases of scoliosis…this is irrelevant in this conversation and manipulation can’t make an impact on scoliosis anyway.)

 

For those who are unfamiliar with the subluxation model it is a theory that at least traditionally states that altered spinal alignment impedes neural energy flow by pressing on nerves and subsequently leads to dysfunction in various systems of the body. For a much more in depth education on the topic I strongly encourage you to read this article on science based medicine by Dr. Sam Homola, DC. This definition has evolved over the years, but many chiropractors do in fact still practice under this ideology today. There is a division in the profession, and there is a certain percentage that still ascribes to this model and refer to themselves as straights. Those that have to varying degrees moved on from this school of thought refer to themselves as mixers. The category of mixers however is quite diverse and they all fall along the spectrum. Many of these mixers practice using exercise, education, EVIDENCE BASED nutrition, and manual techniques other than “adjustments”. Based on my conversations with various individuals, market research, and examining the curriculum of the local chiropractic school near where I live and practice the chart below gives a good breakdown of the composition of different types of chiropractors in my area. This could be very different for you based on where you live and which school is close by, as each of the chiropractic schools seem to vary quite a bit in the mission statements and focus of their curriculum.

 

Now I know the physical therapists reading this are sitting there on their pedestals thinking “damn right, those chiros are crazy with their thinking spines get out of alignment and messing with my patient’s heads.” However, I’m going to politely ask you to slow your roll. In the words of Ice Cube “you betta check yo self before you wreck yo self”. I’ve got a little PT calling out to do as well. We like to think we are the best out there because we are more integrated into the medical model, we work in hospitals, we work in nursing homes, we work in people’s homes, we have no problem getting insurance reimbursement, most patients get sent to us after surgeries for rehab, etc. HOWEVER, just because we have positioned ourselves as “evidence based providers” in the medical model does that mean we actually are? Show of hands; who still tries to “strengthen the core” of everyone with low back pain??

 

 

 

Make sure you preferentially activated your TA when you shot your hand into the air there…wouldn’t want you to develop a 50ms lag and start having back pain. Who still uses the supine to sit test to check innominate rotations? Or worse, you use palpatory diagnosis….and then uses their good ole METs to correct the pelvic obliquities? I certainly know they are still asking that question on the boards 3 different ways per my recent students. Hmmm, doesn’t a pelvic obliquity sound a heck of a lot like a spinal subluxation? Who is still telling every single patient with low arches they need orthotics because they are at increased risk of a million injuries due to the P word (pronation)? How many of you are still positive that “poor posture” will lead to pain? Who still thinks you can stretch out your IT band? How many of you think that your shoulder special tests are telling you exactly what is wrong, and that you can decisively determine what pathology someone has when they present with shoulder pain based on these special tests? Who still thinks pain is an output and the ALS tract carries PAIN AND TEMPERATURE information up to the brain? I sure know that was drilled into my head for several tests in school and on the boards. Who is still diagnostically palpating trigger points and whoever knows what when Travell and Simmons couldn’t even reliably palpatethe little buggers they basically came up with? (P.S. please follow the link in the last sentence and read some of the info that Paul Ingraham has compiled in that link as well as his article palpation pareidolia) Pretty much everything I just listed is still meat and potatoes curriculum in all of the PT schools I know of, required to know on the boards, and sadly far behind the best current evidence. The list goes on, but I think I’ve made my point.

 

Physical therapists, in my opinion, like to think they are the knights in shining armor, the evidence based gurus, the saints of the medical world. Yet, as we can see there are many ways that I listed, and many more ways that I don’t have the time to go into that the majority of us may not be nearly as evidence based as we like to think we are. We like to point the finger at other professions and put them down, only to try to make ourselves feel better. When what we should all (PTs, Chiros, MTs, personal trainers, etc) should be doing is working like hell to make ourselves smarter and better to better serve our patients.

 

I have had the pleasure of interacting with several very evidence based and extremely smart chiropractors via online discussion boards as well as in person during con- ed classes. I have no problem admitting that some of these guys and gals have easily rivaled and in some cases far surpassed my own personal rehab and pain understanding. This didn’t intimidate me at all. In fact it made me feel really excited to know that there are other professions and professionals out there scouring the evidence like I do myself in order to become a better clinician to better serve those we treat.

 

So as you can see both professions certainly have their downfalls and very own species of dinosaurs holding them back and slowing the evolutionary process. Chiropractors have the subluxation and straight mentality to break free from. While their schools still teach this and their associations choose to not completely turn their backs on it, they will continue to struggle to move forward at the rate they could. The same goes for PTs. While our boards and associations still require that our students be tested on certain less than evidence based topics, and the schools continue to teach students they can palpate hair through paper and the like; we will have trouble moving forward as fast as we could.  

 

It’s inevitable that during the course of almost every student rotation as a CI, the student will ask my stance on chiropractors and if “we are better”. What I feel now is that a good physical therapist and a good chiropractor should be almost, if not totally, indistinguishable if they are practicing in an evidence based manner. A physical therapist may be more skilled in applying therapeutic exercises or managing post op conditions; but not always. A chiropractor will probably be more skilled with manipulation and certain manual techniques, and maybe some nutritional education; but certainly not always. In a direct access environment in which both practitioners are focusing on evidence the differences are negligible because the evidence is out there for all of us to use. Evidence is evidence and what works best works best regardless of who applies the principles.

 

We are two very similar professions that practice almost the same scope and are trying to help the same patients. It seems to me that we should both be trying to be as evidence based as possible, and dare I say collaborating to better serve? Maybe we could move forward with improved patient care if we weren’t pointing fingers at each other and we both got rid of our dinosaurs? What do you think?

 

As always thanks for taking the time to read.

 

Jarod Hall, PT, DPT, CSCS

 

 

 

 

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