BC College of Chiropractors Scope of Practice Hearing,
June 7, 1999
Oral Presentation
I am a member of the BC College of Chiropractors. I am also the Executive Director of the BC Chiropractic Association. I attend today to speak on behalf of both the College and the Association. With me today is Dr. John Triano. Dr. Triano has had significant involvement in the United States with the growing trend to clarify the extent to which physiotherapists may perform the chiropractic adjustment which is described by reserved act 2(c).He will speak briefly to this issue within our allotted time.
Introduction
We are attending today to address the preliminary report of the Health
Profession Council (the "HPC") in so far as it recommends that reserved
acts 2(c) and (d) be granted to physical therapists. Since, in the context
of the physical therapy scope review, both 2(c) and (d) concern the movement
of the spine using high velocity, low amplitude thrust we will simply
refer to both as reserved act 2(c). There are two fundamental points that
we make in relation to the preliminary report:
1. Since the submissions received from physical therapy concede that reserved
act 2(c) is not a part of the basic education, training, and practice
of physical therapists, the HPC errs when it recommends that reserved
act 2(c) be granted to all physical therapists without any restrictions;
and
2. The submissions received from physical therapy are not sufficient to
establish that the education, training, and practice experience of the
few physical therapists who complete the CPA orthopaedic division program
qualify them to perform reserved act 2(c). The new regulatory model
Before elaborating on these points, we want to emphasize that the profession
seeking the right to perform a reserved act has the onus to demonstrate
that the profession is qualified to perform the reserved act. Although
the HPC has a mandate to increase overlapping scopes, the HPC must recognize
that, within the new model for professional regulation, to protect public
safety, it may be necessary to narrow what some professions can do. Indeed,
it may be necessary to make some reserved acts exclusive. It is not inconsistent
to broaden overlapping scopes while at the same time narrowing access
to reserved acts.
Currently, the existing scopes of practice of physical therapy, medicine,
and naturopathy give those professions latitude to perform the dangerous
reserved act 2(c) even though it is not part of the core competence of
these professions. On the new model for professional regulation, it is
essential that the dangerous reserved acts only be granted to professions
who can prove that they are truly qualified to perform them. Within this
context, it is not clear to us what criteria are being applied by the
HPC to determine the threshold for establishing qualification to perform
a reserved act.
Furthermore, it is not clear to us how the HPC will satisfy the public
interest in knowing that a profession's core competence allows that profession
to perform the reserved act safely. Reserved act 2(c) is not within the
core competence of physical therapy From the HPC preliminary report, it
is clear that for physical therapists reserved act 2(c) is, at its very
best, an "advanced skill" acquired by participation in a " rigorous post
graduate education program followed by competency based examinations."
That is, it is only acquired by voluntary participation at a post graduate
level.
There is no evidence that reserved act 2(c) is taught in physiotherapy
schools as a form of basic physical therapy training. The College of Physical
Therapists (the "CPTBC") should be challenged by the HPC to produce proof
that it is taught before making any recommendation that the profession
can do it. Rather, the material submitted refers to specific techniques
of facilitation, manipulation, or mobilization without specifying the
technique of moving the joints of the spine using a high velocity, low
amplitude thrust. This is the Achilles heel of the physical therapy submissions.
In summary, the CPTBC submission concedes that reserved act 2(c) is not
part of the core competence of physical therapists. Given this concession,
there is no basis for recommending that reserved act 2(c) be granted to
physical therapists. The CPA post graduate program is not sufficient to
justify reserved act 2(c) We have submitted extensive materials on the
relative education, training, and experience of chiropractors and physical
therapists when it comes to reserved act 2(c). We are not going to repeat
these previous submissions at this time. However, the extensive submissions
on the critical point of qualifications to perform a dangerous act are
not substantively addressed.
The fundamental point for the HPC to grasp in relation to the CPA orthopaedic
program is that it lacks depth with respect to the acquisition of competency
in the movement of the spine using a high velocity, low amplitude thrust
as a form of spinal manipulation. We have reviewed this program in detail.
Only 2 of 21 course topics pertain to the manipulation of the spine, joints,
and musculature. Most, if not all, of the techniques discussed do not
involve the high velocity, low amplitude thrust of the spine. In fact,
the CPTBC did not provide any specific information on the proportion of
the education, training, and practice devoted to the movement of the spine
using a high velocity, low amplitude thrust.
This is the essence of the dangerous act which is reserved, yet the CPTBC
submissions mask the shortcomings in its core competence by combining
all discussion of facilitation, manipulation and mobilization. Respecting
core competence in order to protect the public interest in safety In order
to focus the public interest in safety, we raise, and we ask, the HPC
to address the following pertinent issues in its final report:
1. Is it within the HPC mandate to assist a profession to achieve recognition
in a practice area such as the performance of reserved act 2(c) when the
profession itself is in doubt about its relevant competence to carry out
the function and where the profession, by its own account, has yet to
make any significant contribution? Interest in manipulative therapy within
the practice of physical therapy is relatively recent. In Canada, it really
dates from the 1980's. The CPTBC did not provide evidence to support its
assertion that physical therapists have been "performing this technique
since ... 1946" as a part of its common practice of the treatment of the
spine.
The use of the word "manipulation" in connection with physical therapy
should not be interpreted to mean that physical therapists have been performing
reserved act 2(c) since 1946. As we have stated on other occasions, "manipulation"
clearly refers to procedures and techniques which are in the public domain.
The documents submitted to the HPC by the CPA orthopaedic division state
that "manual therapy in Canada became recognized and was taught in the
late 60's and early 70's by a relatively small group of individuals...
the curriculum of the [CPA orthopaedic division] was first approved ...
in June 1985 and amended in 1986." For many years, physiotherapy has been
a profession dependent on the judgments, diagnoses, and the prescription
of treatment made by medical practitioners.
Like medicine, physical therapy did not approve of the unique form of
chiropractic treatment of the spine which is represented by reserved act
2(c). Although a few physical therapists have developed a personal interest
in varieties of mobilization techniques such an interest is not part of
or reflected in the core competency of physical therapy. The physical
therapy submissions show that in 1994 only 136 of 2,016 physiotherapists
(or 7%) had participated in a voluntary post graduate training to perform
"orthopaedic manipulative therapy". Simply claiming that a treatment procedure
is within a scope of practice does not equate to developing that competence
through education and training in the treatment procedure. This is a very
important distinction in the context of a new professional regulatory
model which requires proof of qualifications to perform a dangerous act.
In the absence of proof of qualifications to an appropriate level, there
is no basis for "grandfathering" any existing practitioners.
It is clear from much of what physical therapy has submitted to the HPC
that there is a debate within physical therapy about the manipulative
therapy curriculum and there is disagreement about whether it is worthy
of specialty status. The submissions of physical therapists supporting
specialty status within the profession concede that physical therapists
have not made any significant contribution to health care in this "vital
area".
2. Is it within the public interest mandate of the HPC to establish a
variable threshold for the qualifications required to move the joints
of the spine using the high velocity, low amplitude thrust? Does the public
interest in safety and fully informed consumer choice not demand that
the HPC qualify its recommendation by pointing out that there are limitations
in the physical therapy education and training in the movement of the
joints of the spine using the high velocity, low amplitude thrust? There
are reported cases in the literature of serious harm resulting from the
performance of reserved act 2(c) by physiotherapists. The serious risk
of harm includes death and stroke. As well, there is in the literature
evidence which shows that physical therapists experience a greater percentage
of severe complications following spinal manipulation compared to chiropractors.
We have supplied this literature to the HPC and we urge you to consider
it as you prepare your final report. The HPC notes in its preliminary
report that, in Ontario, physical therapists were granted the reserved
act. The HPC must be very careful in what it reads into this fact. It
is our understanding that the Ontario review proceeded without any significant
analysis of exclusivity. In particular, chiropractors were specifically
directed away from making any submissions on exclusivity in relation to
reserved act 2(c).
There are a number of jurisdictions in North America which now prohibit
physical therapists and other health practitioners from performing the
chiropractic adjustment which is characterized by reserved act 2(c). We
have supplied this information to the HPC and Dr. Triano will be updating
that information for you today. In preparing its final report, the HPC
should consider this information and decide whether British Columbia should
follow this trend or not.
3. Is it in the public interest for the HPC to assume that a College will
protect the public when the dangerous act is not part of the profession's
core competence? In a context where we know that the development and evolution
of physiotherapy has been strongly influenced by medicine and where we
know only a small fraction of physical therapists have any interest in
reserved act 2(c), the HPC is justified in challenging the CPTBC to demonstrate
that it properly understands reserved act 2(c) and the danger inherent
in its performance. If reserved act 2(c) really is a part of the core
competence and practice of physical therapists, where is the evidence
of standard setting by the CPTBC or by the CPA? Where is the literature
from the CPTBC or CPA which advises physical therapists on the need to
obtain informed consent from the patient before performing reserved act
2(c) in the context of the treatment of the neck. The apparent absence
of such discussion within physical therapy should preclude the HPC from
assuming that the CPTBC will set and enforce standards to protect the
public interest in relation to the performance of the reserved act 2(c).
Conclusion
In conclusion, we submit that the HPC should revise its preliminary report
to make it clear that the CPTBC has not established that physical therapists
are qualified to perform reserved acts 2(c) or (d).