X-ray of cervical spine (neck) in flexion (bending forward).
X-ray of cervical spine (neck) in flexion (bending forward). Image courtesy Stillwaterrising, Wikimedia creative commons.

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In the latest health care battle brewing at the N.C. General Assembly, chiropractors and physical therapists are facing off over patients’ backs.

By Rose Hoban

When Megan Standish’s convoy was struck by a rocket-propelled grenade in Iraq, metal pieces of the Humvee she was driving flew at her going 70 miles an hour. She suffered massive facial trauma, with injuries to her face, neck and back.

Megan Standish (l) with her physical therapist, Mary Kay Hannah. Both are retired military. While in the Army, Hannah said, she was able to perform spinal manipulation on her patients. Photo credit: Rose Hoban

A year of treatment at Walter Reed Army Medical Center and dozens of reconstructive surgeries later, the former Army captain now lives in North Carolina, where she continues to need treatment to reduce her pain. Standish has been looking for physical therapy to relieve muscle tension in her neck and back.

“I had some spinal manipulation done before from PTs in the military, and it just makes me feel …” Standish sighed and relaxed her shoulders by way of explanation. “Before, the pain is like a seven out of 10, and after, it’s like a two.”

But now, retired and living in North Carolina, Standish has learned that getting a physical therapist to manipulate her spine isn’t so easy.

“I went to a civilian physical therapist and, unfortunately, they can’t do anything for me until I can get a physician referral, which is going to take me another four to six months before I can get a physician referral from the VA,” she told lawmakers at the House Health Committee meeting last week.

Standish was there to ask legislators to approve House Bill 135, which would allow physical therapists to prescribe and perform spinal manipulation on patients without getting approval from a doctor.

Other states, the District of Columbia and the military allow PTs to do these spinal treatments without a doctor’s order. At the hearing, bill sponsor Rep. Nelson Dollar (R-Cary) read a testimonial letter from an orthopedist and told his fellow committee members the North Carolina Medical Society has taken a neutral position on the bill.

But there is opposition to the physical therapists’ bill, from chiropractors, who also make a living from manipulating their patients’ spines.

What’s the scope?

The face-off between chiropractors and physical therapists is a classic example of the battle over what’s called “scope of practice.”

X-ray of cervical spine (neck) in flexion (bending forward). Image courtesy Stillwaterrising, Wikimedia creative commons.

Most states have “practice acts” that loosely set out, in law, what procedures health care professionals can perform.

Complicating things is the fact that practitioners take national board-certifying exams, but they’re governed by laws that vary from state to state.

That’s why scope of practice issues pop up in state legislatures. From January 2011 until December 2012, the National Conference of State Legislatures tracked bills that affected the scope of practice from nursing to chiropractors to radiation therapists and found that 1,795 bills relating to scope of practice were introduced in all the states, the District of Columbia and U.S. territories.

Only 349 of them became law.

Conflicts come in, because sometimes the scope of practice for different practitioners overlap.

Who’s safer?

No chiropractors came forward at last week’s hearing, but Joe Siragusa, head of the N.C. Chiropractic Association, said in a phone interview he worries about physical therapists’ ability to manipulate a spine.

Siragusa said he believes it’s a “patient-safety issue.”

“We feel it inappropriate to accept the patient and manipulate their spine without being able to fully diagnose and, when appropriate, to X-ray,” he said.

Siragusa said he doesn’t have anything against physical therapists; he believes they are highly trained. But he pointed out that chiropractors get a four-year doctoral degree with “more X-ray training than most doctors and way more technique in spinal manipulation, including when and where to adjust.”

In the past, physical therapists could get their certification with an undergraduate degree. But in an effort to professionalize their credentials over the last decade, physical therapists are now required to earn a three-year doctoral degree.

And therapists, old and new, contend spinal manipulation is a practice they’ve been taught well, especially with the additional training.

“We’ve bren doing this for years and years and years,” said Mike Landry, head of the Doctor of Physical Therapy program at Duke. He said that adding spinal manipulation to the scope of practice only brings physical therapists in North Carolina up to international standards.

Siragusa contended that spinal manipulation is something that’s only recently been added to the physical therapists’ curriculum.

He claimed some physical therapists get their spinal manipulation training during weekend-long seminars: “$595 and you can take a course in a weekend, learn how to do spinal manipulation, and it qualifies for continuing-education credits for PTs.

“My point is, why would we license another profession to do what we do?”

Landry retorted that if under-qualified physical therapists were using only teaching from a weekend course to manipulate spines, there would be more malpractice lawsuits and more harm, something that isn’t happening.

“It’s not a zero-sum game. Having patients have access to physical therapists for spinal manipulation doesn’t take anything away from chiropractors,” he said. “There’s plenty of patients, plenty of health needs to go around.”

But Landry made the point that with the ever-changing reimbursement landscape, and with health care professionals leaving school deeper and deeper in debt, professional organizations feel they have to more aggressively protect their turf.

Inhospitable environment

Siragusa is also fighting another turf battle at the legislature.

During the busy crossover week, a bill that would lower co-pays for chiropractors from the higher specialist’s rate to the same level as primary care physicians made it through a House committee and then through a successful vote on the House floor.

“We’re not trying to expand our scope or usurp the role of primary care,” he said, “but we are already licensed to perform primary conservative spine care.”

Chiropractors are fighting for the right to be considered primary care providers in other states too, according to a study in the Journal of Manipulative and Physiological Therapeutics. The article notes that in dozens of states, chiropractors can do school and pre-employment physicals, draw blood and order X-rays.

Some states even allow chiropractors to do obstetrics and perform Pap smears, something that bolsters Siragusa’s argument for co-pay parity with primary care physicians.

But the co-pay initiative is opposed by both Blue Cross and Blue Shield of North Carolina and the State Employee’s Health Plan, which argued that lowering the co-pay for chiropractors would cost state government $3.6 million during the upcoming biennium.

Even though the co-pay bill and the physical therapist bill both passed the House, insurance initiatives, whether coverage mandates or not, have had a tougher time getting through the Senate.

Siragusa acknowledged the difficulty ahead of him in the Senate, even as he expressed confidence senators could be educated about his issue.

He argued that it’s a patient-choice issue.

“We do something that no other profession does, in the sense that patients can choose to walk in and receive a diagnosis, X-rays and/or appropriate referral,” he said. “That is primary care for the narrow scope of chiropractors’ treatment.”

Correction: The article originally stated 47 other states allow physical therapists to perform spinal manipulation. Ten states prohibit PTs from manipulating spines, three allow it by law, five states allow it with restrictions and the rest do not address the practice in their states’ practice acts, which, de facto, means the practice can be done by physical therapists.

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