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Tuesday, June 6, 2023

Scope Wars

Brent Brookbush

Brent Brookbush


New Panel Discussion: SCOPE WARS

What discussion was inspired by a post from a colleauge and friend Rob Fluegel, PT, OCS, COMT. He requested that I sign a petition to revoke legislation that would prevent physical therapists from being able to dry needle in the state of Maryland (see petition here - http://chn.ge/1Akp0Ai ). My thoughts:

Why do we fight over scope of practice? What do we have to gain, or lose from fighting over individual interventions? What should dictate scope? How should our scope be protected/policed? What should dictate the difference between a PT, ATC, DC, LMT, CPT, DO, OT etc….

Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

Dry Needling - Who should have the scope to use this technique? - http://www.spectrumrehab.net/wp/wp-content/uploads/2013/01/Trigger-Point-Dry-Needling.jpg

This discussion started on my Facebook page: https://www.facebook.com/brent.brookbush on February 28th, 2015 and continued on April 11th, 2015


Dr. Brent Brookbush DPT, PES, CES, CSCS  This panel discussion is off to a slow start.

I think that scope should do less to dictate intervention and more to dictate the populations we are permitted to work with.

Your thoughts?

Like  · Reply  · February 28 at 11:01am

Erik Korzen DC  Simplicity is key. If you are licensed as a physician you should be capable of diagnosis. If not, then your role is no less important in the collaborative care of patients/clients, as some PTs and ATCs are more capable at certain aspects of care compared to other healthcare professionals.

February 28 at 2:49pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  Oh my, the diagnosis question. Did you know that ATC's are allowed to make an "on-field diagnosis", but PT's and DC's are not? And if we can't diagnose why do special tests, are they not by nature diagnostic? Further, what do you call the result of a DC's or PT's assessment?

And why does insurance ask me for a "diagnosis code (ICD - 9)?"

February 28 at 3:44pm

Erik Korzen DC  I was not aware of the on field Dx stipulation. Does that differ between states? I agree with you that many of the tests/assessments are intended to be diagnostic and therefore PTs are obviously contributing to Dx or helping change current Dx. I do think that the situation changes outside of the physical medicine realm though. For example, providing a Dx for patients with internal disorders such as cardiac arrhythmias, DVT, carotid bruits, appendicitis, pancost tumors, etc….

February 28 at 3:58pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  So it sounds like your headed toward my thinking - scope should dictate population more than intervention… thoughts?

February 28 at 4:12pm

Erik Korzen DC  That is an interesting way of wording it-but yes. If I'm following you on this- your scope should determine the group of people you can serve? Example, a cardiologist works with heart conditions and orthopedist works with MSK issues, correct?

February 28 at 4:34pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  Correct. We could also take this one step further and say that Physical Therapists and Chiropractors have the same access to treatment options, although a Chiropractor may not be willing or able to address neurological pathology (Stroke, parkinsons, MS, TBI, Etc.).

February 28 at 6:43pm

Erik Korzen DC  Very true, assuming a DC is into physical medicine. I know quite a few DCs that are into internal medicine. My opinion is that, as I was trained, I can function as a primary care physician for appropriate eval of a number of conditions (including neuropathology as well as considering imaging/labs) and then determine if treatment options I offer as a doc that specializes in physical med/pain management are appropriate or if referral is best.

February 28 at 9:28pm

Rodger Fleming  Just wanted to clarify the wording… Athletic Trainers are not allowed to diagnose anything. We are only allowed to make assessments.

March 2 at 3:48pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  Really Rodger Fleming ,

I thought there was a limited ability to code and bill insurance for an on-field diagnosis?

If not than it sounds like your "diagnositic capacity" is the same as a PT's - we make an assessment.

Like  · March 2 at 3:57pm

Rodger Fleming  I have no prior knowledge of having any capacity to bill insurance for an on-field "diagnosis"/'assessment". My interpretation/understanding of licensure and state regulations where I practice Athletic Training, When its 'on the field', ATC's are an extension of physicians,EMT's. we assume the role of First Responders who make referrals. and return to play decisions as written and allowed per physician standing order. We operate under a physician's standing order. I am not sure how this may or may not differ from state to state.

March 2 at 7:52pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  That's really interesting info… obviously I am on the side of all human movement professionals and think the dicing of terms is a little excessive… what's the difference between and assessment of shoulder impingement based on special tests and a diagnosis of should impingement syndrome made by a physician is beyond me.

I would guess that the limits in autonomy for an ATC have to do with the minimum standard of education for an ATC not including differential diagnosis… Your thoughts?

March 2 at 7:19pm

Erik Korzen DC  That is interesting about ATCs Rodger Fleming. Dr. Brent Brookbush DPT, PES, CES, CSCS  I think you are correct with regards to ATC education. Shoulder impingement is a good example of a Dx because many times it is an MSK issue. However, neoplasms/internal organ referrals/neuro conditions/etc… must be R/O, which is where a "physician" comes into play. Someone that can put together a Hx, Physical, Labs/Imaging into some form of DDx.

March 2 at 7:31pm

Rodger Fleming  There is definitely a correlation to the limits of autonomy. Unfortunately, too many look at the credentials and make assumptions to the level of intelligence that a professional may or may not possess. I have known many ATs, PTs, DCs that influence the MDs progress thru DDxs. On the same note, same credentials, have known people that makes me wonder how they were accepted into college.

March 2 at 8:11pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  LOL… I here you.

I am a DPT, and some have used that credential to imply superiority over other human movement professionals (ATC's, DC's, LMT's)… I am not one of those people. Some of my closest colleagues are ATC's, DC's and LMT's and I would recommend their work over many others who hold the title of Clinical Doctor.

The point of this post, for me anyway, is to shed some light on how sad and misguided the "SCOPE WARS" really are, and how we should be trying to come together.

I would actually like to see a unified degree, something along the lines of Integrated Orthopedic Manual Therapist - that unites our professions… and create separate tracks or degrees from this model based on population. For example, the degree above may limit your scope to orthopedics and another degree is created for Integrated Nuerologic Therapists… Just my thoughts.

March 2 at 8:16pm

Rodger Fleming  Absolutely!

March 2 at 8:18pm

Rodger Fleming  "SCOPE WARS" is sad and misguided. There is a DPT in the area where I'm employed, stated "AT's are not qualified to work with neck & spine patients based on level of education". Really???

March 2 at 8:24pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  I guess chiropractors should stay away from knee's?

March 2 at 9:30pm

Tim Henriques  I think an interesting question is what is the exact scope of practice for a personal trainer? The various certs/organizations each put forth their own definition. Of course I am biased but I like NPTI's definition the best as I feel it is the clearest and would make the most sense legally. We say the scope of practice for a personal trainer is to enhance the components of fitness for the general, healthy population. The general healthy population would be defined as a low risk client based on the ACSM model of risk stratification. The components of fitness include your 5 classic components (strength, muscle endurance, cardio, flexibility, body composition) but are not just limited to those so power, speed, agility, quickness, balance, etc can also be included. I think an important component of this is including body composition which means nutrition and nutritional advice is definitely included in a well trained personal trainer's scope - some argue that nutrition advice is outside our scope - I personally disagree with that notion. What our scope is and isn't is more fully fleshed out in our text which you can read under the "look inside" feature on amazon here if one wishes to do:http://www.amazon.com/NPTIs…/dp/1450423817/ref=asap_bc…

[NPTI's Fundamentals of Fitness and Personal Training](http://l.facebook.com/l.php?u=http%3A%2F%2Fwww.amazon.com%2FNPTIs-Fundamentals-Fitness-Personal- Training%2Fdp%2F1450423817%2Fref%3Dasap_bc%3Fie%3DUTF8&h=WAQGcApzF&s=1)

NPTI’s Fundamentals of Fitness and Personal…


February 28 at 1:31pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  That is a fair definition, but it does not limit scope, only address what the focus or intent of the personal training profession is. For example, if putting you hands on someone is used to assess a component of fitness like strength (and as in the use of MMT's) is that with in a personal trainer's scope? What about manual release and soft tissue work for flexibility? What about writing out diet plans as part of general nutrition advice?

February 28 at 3:41pm

Tim Henriques  There will be always be some grey no matter how clearly we try to define things. Posture is one of those areas. Putting your hands on someone would be fine, just like you would need to do so to spot someone. Manipulating a joint or physically re-aligning something (what chiros do) would not. Partner stretching and PNF work would fall within the scope, but ART or deep tissue would not (assuming normal personal trainer certification); writing out diet plans is fine (or should be anyway, although laws on that vary by state to state) assuming the client is in the original scope (doesn't have diabetes, etc) and assuming the trainer's education includes reasonable nutritional information (which all PT programs should but most aren't comprehensive enough).

Like  · February 28 at 4:17pm

Dr. Brent Brookbush DPT, PES, CES, CSCS  I generally stay away from nutrition, but in terms of human movement I have often remarked that a personal trainers scope stops where pain and manual therapy begin. Self-administered techniques used to address inefficiencies in the human movement system (postural dysfunction) are within a trainers scope.

February 28 at 6:46pm


Rob Fluegel  Just to clarify:

HB 979 was withdrawn due to overwhelming response from PTs and patients in signing various petitions and several PTs presenting their argument in Annapolis prior to the proposed vote.

April 11 at 12:06pm

Brent Brookbush  That's awesome Rob Fluegel , glad the petition and attention garnered for the subject over-turned the ruling; however, I am sure this i not the last battle of scope we will hear about.

April 11 at 12:21pm

Rob Fluegel  Unfortunately that is likely true Brent . It doesn't help matters that some PT state boards allowed certain verbiage into their practice acts that limits manipulations to only be able to be performed by chiros.

It should also be noted as you and I both practice in NY State, that Dry Needling is NOT in our practice act but I hope one day that it is.

April 11 at 12:28pm

Brent Brookbush  Dry needling certainly has me curious, and for more reasons than wanting to stick you with needles Rob Fluegel

I would love to see some statistics on the financial impact this actually has on a professions. For example, in states where Physical Therapists are unable to do manipulations, has revenue for chiropractors actually increased (or was a precipitous drop in revenue abated)? In states where PT's are not allowed to dry needle, do acupuncturists actually do better?

April 11 at 12:31pm

Steve Middleton  The turf wars between healthcare providers are financially motivated, plain and simple.

April 11 at 12:46pm

Brent Brookbush  But are they financially effective Steve Middleton ?

Does anyone really have stats to show that acupuncturists benefit from denying PT's the right to Dry Needle?

April 11 at 12:47pm

Steve Middleton  Unfortunately, statistics don't matter, Brent ; ensuring the financial opportunities of your members does. One of my friends did a study showing the cost effectiveness of an AT in an outpatient setting but it went nowhere in as far as obtaining 3rd party reimbursement for us.

April 11 at 12:54pm

Brent Brookbush  Okay.. so showing the benefit of a practice is one thing, the question then becomes, is this the most beneficial solution when compared to other solutions?

But, showing something is not effective may be easier. For example, if after legislation passes prohibiting dry-needling there is no change in revenue amassed by all acupuncturists than the legislation itself is of no consequence. In fact, the shear cost of creating legislation would seem to be a deterrent. Unlike, your example where proving a positive, may also imply proving the benefit over other solutions, proving a negative does not result in further questions.

My guess, would be that legislation prohibiting dry-needling does nothing for acupuncturists as individuals do not look for someone to stick a needle in them, but rather someone to resolve their issue. If someone was going to see a PT, they were going to see that PT regardless of what intervention was used.

April 11 at 1:03pm

Andrew CrushFitness  It's good to know legislation has been halted temporarily. It's not a resolution. MDs, DOs etc., have a lock on diagnosis based on private interest not public interest. Businesses suffer from over regulation while clients should benefit in the larger health care scheme they don't. When referrals and diagnosis have to go through a primary care doctor who has to research the problem or take a shot in the dark, it becomes a waste of time for the patient. Patients get lost being transferred from specialty to specialty, it's frustrating. So a technique such asas dry needling does require additional training but other simple techniques shouldn't be over regulated. It should benefit the patient but doesn't if the higher education cost is transferred to the patient. In short, when alphabet gangs protect private interest middle America suffers.

April 11 at 1:30pm

Brent Brookbush  So Andrew CrushFitness , what should dictate scope?

April 11 at 1:31pm

Andrew CrushFitness  Education, experience and this may sound revolutionary but population need and provider care accessibility.

April 11 at 1:33pm

Melinda Reiner  If it were possible, make it individual. Some folks have the ability to do certain procedures, and some don't--regardless of the letters after your name. I could write a book on this.

April 11 at 1:35pm

Andrew CrushFitness  I'm exhibit A: I paid for several chiropractor visits to catch a condition I knew I had. Doctor couldn't tell from his knowledge base. Orthopedic surgeon i was referred to seemed overworked and inept. Chiropractor took X-rays and showed me the obvious. Further treatment required further diagnosis. Which costs more money. I went to another doctor nd chiropractor for a second opinion but couldn't get any tests and results transferred. And the latter doctors wouldn't move forward without new duplicate tests and costs. These DCs may have been allowed to scan xrays, diagnose and treat but not required to share results with my primary care. I guess HIPPA laws didn't apply? It's a discombobulated and disconnected network, I'm sure with many loopholes but who's benefiting and who's profiting?

April 11 at 1:39pm

Melinda Reiner  Andrew, great points. However, let's also tie in intent--if a practioner doesn't care, they won't do what you need or properly examine you, or even provide info/call another practitioner to, actually, provide continuity of care. That's the key…continuity in the medical system rarely exists these days.

April 11 at 1:42pm

Brent Brookbush  To add to Andrew CrushFitness 's argument… I think it is the responsibility of every practitioner to develop a network they trust. It sounds like some of what you went through could have been avoided with the "right" referrals from the get-go.

April 11 at 1:54pm

Melinda Reiner  Good point, Brent. However, you don't know if you can trust someone until you meet them, and this is what one goes through to figure that out.

April 11 at 1:55pm

Melinda Reiner  And, not all geographic areas have great folks in all areas of medicine.

April 11 at 1:56pm

Brent Brookbush  The later is certainly an unfortunate truth Melinda Reiner

April 11 at 1:58pm

Melinda Reiner  Exactly. I feel that here in Syracuse.

April 11 at 1:58pm

Andrew CrushFitness  We could use statistics and and geography (Google earth) to determine what providers are available and what that population needs in this new robust computerized health care system. It doesn't need to be so robotic. Additional CEUs make sense, however, AMA, and other alphabet gangs guard their interest so well it's so hard to see their influence. We've heard, "You should go see a doctor" forever, for everything. The family doctor who did not study nutrition but recommends an apple a day. The same doctor who knows little of kinesiology, biomechanics and corrective exercise and hasn't shifted to the bio psychosocial model of pain?

On the other side:

Why can't a PT diagnose my back pain? Because they can't order tests and pain isn't as mechanical as we once thought.

April 11 at 2:08pm

Andrew CrushFitness  Thanks you guys just transitioned into my next point. With the new robust computerized health care network it wouldn't be a tall task to integrate geography. Study the population need based on density and statistical reporting. Measure current practices and effectiveness then assess opportunity for future business or better standards. Think Google Earth for healthcare where teams of students and seasoned vets alike are sent in based on statistical reporting and of course independent analysis. Similar to the seriousness of epidemiology and epidemics with the sincerity of each intimate practice. This is what the future of healthcare should be. I'm a premed student who hasn't fit too well into one particular mold, so it's hard to swallow the blue pill. I can't give away all of my practical ideas until I'm able to implement.

April 11 at 2:20pm

Brent Brookbush  Although it is a little off topic Andrew CrushFitness  I think switching to a BioPsychoSocial model of Pain is a bit premature as there are issues with this model regarding the practical applications it implies. As evidence-based practitioners we must consider the effectiveness of interventions, as well as theories that encompass several facets of care. If we were to switch to a BPS model, realize we would need the scope to assess the contribution of each piece of this model, and as a PT/CPT my scope does not include psychological or social interactions in a diagnosis of pain… and I am not entirely sure it should. I can guess that one's outlook, support system, or perception of "threat" contribute to pain and tailor my speech and patient education accordingly, but at the end of the day if I have evidence to support the use of soft tissue, arthrokinematic and exercise intervention to treat pain than I can apply those interventions with confidence.

Regarding my ability to diagnose as a PT… well, this is really little more than a matter of word play. I may not be able to diagnose a herniation and nerve root impingement, but I may assess and determine this is the most likely culprit and treat accordingly.

Now, back to the discussion at hand:

If I determine that someone has chronic low back pain with poor social support, and the perception that they will never get better… Why shouldn't I be able to do manipulations, dry needle, or use other physical means that have been shown to be effective?

April 11 at 2:22pm

Andrew CrushFitness  You should be allowed to "help" Brent. But legally, if help actually hurts the patient there are risks involved. Moreover, when these techniques are used as profitable interventions and cuts into another specialty's profit there exists a conflict of interest. You must ask; based in my education and toolset am I picking the right tool for the job. Why should you stop manipulation if it is effective? It just causes another referral and health care fragment. Good discussion. Let's continue another day.

April 11 at 2:34pm

Jason Erickson  Brent Brookbush  stated, " I think switching to a BioPsychoSocial model of Pain is a bit premature as there are issues with this model regarding the practical applications it implies. As evidence-based practitioners we must consider the effectiveness of interventions, as well as theories that encompass several facets of care. If we were to switch to a BPS model, realize we would need the scope to assess the contribution of each piece of this model, and as a PT/CPT my scope does not include psychological or social interactions in a diagnosis of pain… and I am not entirely sure it should."

If we are not going to subscribe to a BPS model of pain, what is the alternative? The biomechanical/structural/postural model is, at best, a flawed and incomplete model to work from. This was apparent even to Rene Descartes, who wrote about phantom limb pain as a construct of the mind in addition to his better-known writings on possible biological explanations of pain.

At the San Diego Pain Summit , which was all about applying pain science research and knowledge in practice, the scope of practice issue was addressed multiple times in many different ways. Not one of the mental health professionals in attendance indicated concern about infringement upon their SOP(s).

There are many studies of the practical applications of BPS pain science education for both health care providers and for patients/clients. For starters, a basic understanding of pain science can contribute to better provider "soft skills" (AKA "people skills"), leading to more positive and productive client-therapist interactions. This is within SOP for all health/fitness professionals, as there is no way to eliminate psychosocial factors from any interaction, even by way of advertising.

April 11 at 3:11pm

Brent Brookbush  Hey Jason Erickson ,

I believe "flawed" is the wrong word. "Incomplete" is fair. As with all models, the postural/movement impairment model is a work in progress. I could argue that the BPS model is far more incomplete, being only about 25 years old (with only 25 years of research) compared to the work on postural dysfunction which is better than 60 years old (with research originating from Janda's work), and a bio-mechanical model, from evidence-based stand-point (see Cyriax), going back much further. I have posted nearly 50 research reviews supporting the model used at the Brookbush Institute with 25 more in progress (we will post 1 a week for the next several years). Not to give myself undo credit, but this is a much larger attempt at maintaining an evidence-based model than I have seen from many other educators, BPS or otherwise.

It is not that I do not believe the BPS model has it's place, but from my perspective most orthopedic pain starts from an incidence of tissue injury that can be explained mechanically. Now, how we respond to that pain may be answered by the BPS model, but that does not discount any effort to understand the "Bio" portion of this model.

I agree that all practitioners, could learn from the BPS in term's of interaction (bed-side manner) and patient education, but this is still not treatment. We have discussed this at length before. Using my own practice as an example, I base my interventions on a movement impairment model (using BPS concepts for communication) and from what I can tell I get better than average outcomes. Most patients are discharged in 3 - 5 sessions, and many of these patients have seen many other practitioners. My students also report an increase in outcomes based on this model.

As I mentioned above, it may be necessary to compartmentalize the three facets of the BPS and remain respectful of each practitioners skill at one or more of those compartments.

There are other models out there, and I am an integrationist through and though. It is not that I do not like the BPS model, I actually think the work is quite brilliant. But, I detest the idea of adopting any model to the exclusion of others.

Now, back to scope. If the BPS model continues to gain in popularity and scope what you do if physicians and mental health professionals tried to establish legislation that restricted your use of BPS assessment tools, pain scales, and outcome measures?

To everyone reading this post you can see a more detailed discussion of Pain Science with some very enlightening posts by Jason Erickson  here -https://brentbrookbush.com/online-courses/online-courses/where-does-pain-science-fit…/

Where does pain science fit, and how does it affect practice? | Brent Brookbush

Where does pain science fit, and how does it affect…


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