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Episode 8: The Ultimate Debate: Chiropractic Care vs. Physical Therapy


Nate Reynolds 0:05

Welcome to this week's episode, I'm talking with Sarah kara macco. She is a chiropractor and she owns her own chiropractic clinic called Pinnacle Hill, and I will let her introduce herself.

Sarah Tiramacco 0:42

Hello, everyone. Thank you very much to Nate for having me on the podcast today. As he said, my name is Dr. Sarah Tiramacco and I am a chiropractor, my husband and I Mike Penkin own Pinnacle Hill Chiropractic in Rochester, New York. We are both New York Chiropractic College graduates and are very excited to be part of this podcast today.

Nate Reynolds 1:04

Yeah, thank you for joining me, I think one of the reasons why I wanted to have this conversation is because I think a lot of times physical therapists and chiropractors get compared to each other. And the more I think about it, the more I think before I met Sarah, I didn't really know what a chiropractor really did. I think you hear more about the bad ones than the good ones. And vice versa with physical therapists, you only hear that you only hear from the patients that either went to physical therapy and then like I didn't work so they went to chiropractor or or they went the chiropractic route. And somehow that didn't work. And then they went and saw you. And so I really think you kind of see only one side of the story. So I think the point of this episode is to really kind of look at both of our backgrounds kind of see what they learned in chiropractic college, what what I learned in physical therapy school, and kind of see where why you should go to see a physical therapist and when you should see a chiropractor. And so I think the first thing that I want to talk about, you said you went to New York chiropractic college, what was the curriculum like there? What was your focus?

Sarah Tiramacco 2:20

So chiropractic college in general is a program that is three years and four months following your undergraduate degrees. You don't necessarily need to come in with a full four year degree by any means. But you need to have at least 90 credits that are going to encompass all of the prerequisites that you need. So you're going to need your anatomy and physiology, biology, chemistry, organic chemistry, and physics are the big ones that you're going to need coming out of undergrad. From there, going into your chiropractic program, three years and four months, which is on a trimester system. So we have three semesters a year, 10 trimesters in total, at least at New York chiropractic college. From there, the very first year is all basic sciences, a full year cadaver dissection, anatomy, two semesters of neuroscience that includes brain dissection. In addition to that you're doing biochemistry, microbiology, histology, cell and tissue biology, as well as getting into the basics of nutrition. But in your first year, you're also going to slowly start to get into technique courses, you're going to start with a palpation course. So just pretty much like bony landmarks. So the spine, basic outline of muscles, which are main muscle groups, like the gluteus maximus, the trapezius muscle, like very, very basic stuff, just starting with your palpation as well as the psychomotor skills class, the psychomotor skills classes, literally learning the muscle memory and all of the motions to put together your true manual manipulation skills as you go through the program. Once you get into your second trimester, the fifth week of your second semester is actually when you deliver your very first spinal manipulation. You start with a thoracic adjustment, super simple, like straight up to a deep breath in deep breath out. Straight adjustment nice and easy. From there, you're just going to continue to build on your skills as you go through the program. As you get to the end of your first year, beginning of your second year is where you're going to start to learn a lot of Orthopedic tests. So you're going to start with a lower extremity class, where you're going to start to kind of go through a bunch of orthos. For the lower extremity, you're going to go through a bunch of different manipulations for the lower extremity and then as you start your second year, it'll be all upper extremity. As you get into your second semester, or sorry, your second year, it's all diagnostic sciences, learning how to read a radiograph that has abnormal findings on it, learning how to read MRIs that have abnormal findings on them, as well as all of your orthopedic exams, neuro exams, visceral exam, and then slowly be able to bring that into clinical practice. And then as you get into your third year, into your last four months of the program, you're really going to start incorporating how all of those diagnostic sciences are going to pertain to your clinical practice. So how to incorporate that into practice on a daily basis? What types of skills do you need in order to treat a patient successfully? When do they need to be sent for imaging? When do they need to be sent to a different provider, and then all of a sudden, your doctor, and it's been three and a half years, and you're kind of just tossed into the real world?

Nate Reynolds 5:42

So would you say that like your focus is more like orthopedics? Or do you think that like there's any other populations that you learn about? Because I know in physical therapy, you know, we come out as generalist. And so you can be like an acute care physical therapist, you can become neuro, pediatrics, oncology, you have your your sports PTs, your orthos. So I think what you're talking about is it seems like you're mostly ortho, is that kind of correct?

Sarah Tiramacco 6:14

Yeah, so pretty much coming out of chiropractic college, you, you pretty much are coming out as an orthopedic basic chiropractor. To be honest. From there, you really have the ability to kind of branch out however you see fit. It's tough. Depending on what chiropractic college you go to, to really be able to specialize as much as I think a lot of people would like to specialize, you can come out of chiropractic college and say, I want to be a sports chiropractor, or I want to be a pediatric chiropractor, I want to be a pregnancy based chiropractor, or you want to do anything else. But our education doesn't really give us the tools to really specialize before leaving the program. So as a pregnancy and postpartum based chiropractor, pretty much everything I learned about those two populations, I got following my education at New York chiropractic college. The same with my husband. So my key got the majority of his education on complex spine cases, outside of chiropractic college, we've really learned the basics and the base knowledge that is necessary to be an efficient and a good doctor. But there's so much more than that. And I'm sure you guys see it in the PT profession all the time as well, that what you learn in school is literally the bare minimum. And it's our job as professionals to be able to continue our education and take incredible continuing education courses to just learn and be up to date on the most evidence based research and read the literature and know what all of these things are really telling us in order to be the best providers that we can possibly be. So yeah, like coming out of school, we're pretty much like an orthopedic based chiropractor is really what we are. And then it's how you mold yourself after that really brings you into your specialty.

Nate Reynolds 8:18

Yeah, I think that's why in physical therapy, like we've actually started to mirror the medical model, and that you can do a residency after PT school in a niche. So like, I've had friends that, you know, went to Boston University and did a neuro residency and then became neuro specialist. I have friends that did orthopedics or sports, and they just did the residency. And it kind of sped up that learning curve in like one year. And so they actually got to see that population a lot. Because if you don't do a residency, you had to have 2000 hours with treating certain population, before you can sit for the specialty exam. So like, I'm a board certified orthopedic, clinical specialist. And I and I've seen 2000 hours worth of that. I sat for a seven and a half hours exam and passed it, and probably would have been much better off if I did a residency because I think some of those tests like you just study for, but it doesn't always translate to clinical skills. You know, the hands on aspect of it. So I think that's, that's something that like, I feel like I kind of missed out on but also, at my point in my life, I already made a commitment. So I don't work at the hospital for three years. And then I wasn't gonna do residency four years out. This didn't make sense financially. But I think when I look at the PT school curriculum, you know, like our first year, you know, we did gross anatomy as well. And then we did kinesiology body movement. We looked at modalities, which is kind of outdated. I don't use really much modalities in the last three and a half years. Pharmacology, exercise and movement, spraying, we started looking at inpatient, pretty much trying to learn how not to kill a patient in the hospital, make sure they don't end up on the floor

Sarah Tiramacco 10:16

Fair strategy, fair strategy.

Nate Reynolds 10:18

Yeah. And then, you know, the second year, I really think I would say that the first year is you're really kind of learning what normal is. And then the second year you're learning like what is abnormal, and then diagnose it. And then your third year, you're developing your clinical skills by actually having your clinical rotations, and really learning how to apply interventions. And so there's a lot of different variety. But like you said, you know, we come out as generalists, and you're not very good at any of them. So really, you can only get good based on one I think, who you surround yourself with, so you got to find good mentors. And, two, it's just experience like things take time to get good at, and you can't speed that up.

Sarah Tiramacco 11:00

Really, when I was in chiropractic college, I treated one pregnant patient, my entire education, and I came out of school, and I said, I want to treat Pregnant Patients. And then I had my first pregnant patient in private practice, and I was like, we're gonna do this, it's gonna be great, we can do it, it'll be fine. But then it was just slowly building my name as a prenatal chiropractor, and being able to pay for continuing education and just continue to learn, so that I could really establish myself as a prenatal expert in my field. And it takes time, but I knew I wasn't going to learn what I needed to learn in chiropractic college. However, having some type of a residency program in chiropractic college, I think would be wonderful, it would be beneficial for us to be put in front of the population we wanted to work with, whether that was sports, or concussions, or just general orthopedic, prenatal postpartum pediatrics, to be able to be in that atmosphere, I think, would be extremely beneficial for us. But it's just not something that our institution necessarily offers, we do have the option to do a number of rotations. But the rotations weren't. In the field that I was interested in, we did rotations at VA hospitals, where we saw a lot of chronic pain, a lot of comorbid comorbidities, where there really wasn't the realm that I wanted to be in some rotations at some, like free clinics, we did rotations at institutions. So like the University of Buffalo had a rotation that we go to, and treat students as well as St. John Fisher here in Rochester. So those were some additional options that we could do. But it still wasn't necessarily putting me in front of the patient population that I really wanted to work with. So I think the fact that the PT, education gives you the opportunity to do those residency programs is great.

Nate Reynolds 12:57

Yeah, I think one thing that is definitely beneficial about that is that you're having an experience set of eyes looking at you. And then you can learn and pick their brain. And it's probably very stressful when someone's actually observing you're treating, but I think it speeds your learning curve up. And then it also teaches you how to focus on a patient with intent. You know, I think when my last clinical rotation, you know, a lot of the feedback I got was Nate treat with intent. Don't just give them an exercise and be like, Oh, that's why I'm just gonna have him do it. Like you have to have intent with everything that you do. And that way, if they ask you, you can rattle off an answer just like that. One thing I want to talk about because you talked about a being a chiropractor treating postpartum and prenatal compared to like a woman's health physical therapist, what do you think the differences are?

Sarah Tiramacco 13:48

Honestly, when you have a traditional women's health physical therapist, especially a therapist that does an internal exam, so a pelvic floor physical therapist, there's a big difference. The big difference is the fact that I don't do an internal exam and women's health pelvic floor physical therapist is going to do an internal national exam, or rectal exam, like those are huge differences. But when it comes to anything that is external rehab based, I really should have the same knowledge as a women's health PT that is going to be doing a non internal exam or any type of non internal treatment. My education taught me none of that. I came out of my education, knowing nothing about postpartum care. And what I did know about prenatal care, at this point in my in my education and in my career, are not evidence base. And it's extremely frustrating that everything that our profession when it comes to prenatal and postpartum care, is teaching other chiropractors is not evidence based. The more that I've dove deep into physical therapy and physical therapy, continuing education, the more that I am pretty much getting slapped in the face with literature, that is contradicting everything I learned as a chiropractic student, or as a early women's health care records, which is one frustrating and too empowering, because I'm actually able to grow as a provider and intently, be able to treat these patients and get them from point A to point B and get them to achieve their goals. The way that I treat I would say, is probably similar to the way a traditional women's health physical therapist would treat, I do a thorough past medical history history of their chief complaint, extensive physical exam, neurological exam, so whether that includes, you know, ruling out the lumbar spine is a component to pelvic girdle pain, we'll do a diastasis CEF, we do some external pelvic floor palpation, anything that I can possibly do to get as much information as I need to, which is in my scope of practice, I will do and then from there, it's developing that treatment plan. So as a chiropractor, my treatment plan doesn't always include spinal manipulation. And a lot of times it shouldn't include spinal manipulation. And I think that that's something that our profession in general has a hard time with is knowing when to manipulate and when not to manipulate and manipulating a patient, two to three times a week, for weeks, months or years. I don't care what your injury is, and what you came in with, that's inappropriate. But and if you look at the literature, that's just not the case, it's a component. You can't just continue to adjust somebody and think that you're getting to the root cause of the problem, because you are 100% not doing that. Especially when it comes to postpartum or pregnant women, we need to stop telling women that they are hyper mobile, and that they are unstable, and that their pelvis is out of alignment and all of these things because that just isn't true. Their body lacks motor control, their body is lacking the muscle activation and the control in order to stabilize appropriately through their activities of daily living, they aren't able to coordinate their movements well enough, which is giving them pain or some type of dysfunction and physical therapists and chiropractors need to work together. And we need to understand what the literature is telling us because it's not telling us that we need to manipulate, manipulate, manipulate. And it's not telling us that we need to rehab rehab rehab, there is a time and a place for each of them. But there is also a time and a place for them to overlap and overlap efficiently. So that we can get patients better whether that's a postcard a mom, whether that's a pregnant mom, whether that a 55 year old male with chronic low back pain, or a 35 year old male with particular disc injury, like with a particular disc injury, you know, like, there's a time and a place for everything. And I think it's really important for providers, whether they're Cairo or PT to know, like, when is the appropriate time to deliver what appropriate therapy,

Nate Reynolds 18:36

I think was a podcast by Jeff Moore, who's the CEO of the Institute of Clinical Excellence. And he said, it was kind of using the CrossFit idea of the hopper, where the hopper is kind of a tool that I think they use it in bingo where, you know, they throw all the numbers and letters in, and then whatever pops out is that number. So it's like, whatever patient comes to your clinic, like you need to be able to treat them. So if you're a physical therapist, like you, they're with acute pain and a manipulation is what's going to make them get out of pain, then you need to have that skill set. Or if it's someone that there's someone that that has instability and they need, you know, those stabilization exercises, you need to be able to give that, you know, like you shouldn't have a weakness, like whoever comes in, you need to be able to treat and if you have a weakness, you need to address it and not just avoid it. Because is the patient failing physical therapy? Or are you failing them as a physical therapist, and I think more times than not, we probably failed them because we don't use an intervention that they need because we're not comfortable or confident. And so I think, just like you're talking about with chiropractors, physical therapists, like we need to address our weaknesses. And sometimes it's kind of remarkable that you were able to find your weaknesses by going to see physical They're going to physical therapy courses. Because I am sure that if there was a physical therapist that went to a chiropractic course, we would realize how bad our hands are, and manipulating, and how, you know, we really don't get that in school. And so I think it's pretty courageous for you and Mike and your crew to try go to physical therapy course. Be like, yeah, we are chiropractors. And, you know, we were taught this one thing. And we're gonna figure out if, if it's right or not, or if PT is a bunch of whack, but at least we have both sides of the story.

Sarah Tiramacco 20:40

So when we're in school, and our second year, we take one active care course, this active care course is like, here's how you do wall Angel. Here's how you do a pelvic tilt. Here's how you do like some external and internal rotation for the shoulder like, it's pretty basic. And what I now give my patients as true rehabilitation is nothing like I learned in school. And the same with what Mike gives his patients, it's nothing like we learned in school. But taking the leap to go to a physical therapy seminar was the best thing I could have done for my patients. And for my practice, I think that the physical therapy seminar that I met you at was the best seminar I've ever taken in my entire career. And I've taken a lot of continuing education. And it was by far the best course I've ever taken. And I have told people that I have pulled, people who teach for that seminar that I have told my staff that and I like that seminar so much that all five of our chiropractors are going to the next one, like it is so important to learn what we learned in that seminar. And it's important to be able to put ourselves as chiropractors in front of physical therapists and say, like, this is what we do. And I want to educate you on what I do so that you can educate me on what you do. Because I went into that seminar that I was going to be the best manipulator, because I'm a chiropractor. But I knew that I wasn't going to be the best rehab specialist, I wasn't going to be the best diagnose er, and I wasn't going to be the best assessor. But I knew that manipulation was probably going to be fine, I was probably going to be okay. And my husband even said, like, I'm hoping that you're one of the best if not the best at doing that. And I was like, that's fine, I can handle it. But the other stuff I knew I was going to learn and I learned a ton. I learned a ton from you, I learned a ton from the other PTs there and I had a blast. Knowing that we were able to have this, like collaborative experience in this collaborative atmosphere where it could work. And I think it's so important for providers to learn, because I recently did a workshop for all of our providers. And I sat in front of them. And I said, over the last six years, I have become lazy, and I become complacent. And I took this seminar in November where I met Nate Reynolds. And I have become a hell of a lot better of a provider, because I knew I was being lazy, and that I could do better. And since that seminar, we've extended our new patient exams an extra 20 minutes, because what we need to incorporate we need that time we were feeling rushed. And it's it's not what we want, we want to be able to give everybody the appropriate amount of time and come up with the appropriate diagnosis and not just say like, well, this works for every pregnant patient. So I'm just gonna keep doing it. Because I know it works every single time. Because everybody is different, and everybody deserves a different treatment plan. And I think that the best providers are the ones that are putting together a patient specific treatment plan that is going to be completely tailored to them. And I know I shadowed you, I know that every treatment plan that you give every patient is different, doesn't matter. If they all have low back pain, or if they all have ankle pain, it's going to be slightly different because everybody has a slightly different issue going on. And I think that, in general, like chiro's and pts, we can't become complacent, we can't become lazy. Because being in practice for six years, it's easy to become lazy. manipulating people automatically makes people feel better. We know that it's a neuro physiological response, and it automatically happens. And that's why patients have such high satisfaction with going to the chiropractor, because they leave feeling better because most of the patients going into a chiropractor's office are getting manipulated, and it's immediately decreasing their pain. And we know that because of the science. But that doesn't mean that we're getting people better if you just keep manipulating, manipulating and manipulating people. You're creating hypermobility There's so much more to it than that. And I think that if you put a really good PT and a really good kairo next to each other, you shouldn't be able to tell who's who the PT should be manipulating, and the Cairo should be doing enough rehab, that they can hold the room next to the physical therapist. And if you can't do that, we're missing something I missed like, that means that the Cairo is missing something, and they have a gap in their practice. And that means that the PT is missing something. And if there's a gap in their breakfast, and we need to fill it, we 100% need to fill it. Or if you don't want to do it, you need to find somebody that you trust to do it.

Nate Reynolds 25:37

So I've taken probably three or four ice courses now, what I've realized is that you want to surround yourself with people that are motivated, and are willing to do what you did and go into a different discipline and kind of learn from them. Because I think that makes you more well rounded. Like the next course that I'm taking is, it's a strength and conditioning course. It's just something that I realized that is often overlooked in the physical therapy realm is that we don't know how to load patients up well, I think we're notorious for under loading our patients. And that's why they probably don't get as good results as they should. And, you know, you talk about your patients always feeling better with manipulations. You know, I think, sometimes as physical therapists, we don't explain well enough that it's good, that they're sore, it's okay that you don't feel that you feel sore, and it took a few days to get to feel better. But you're, it's not gonna be a linear progression, not going to keep going. Feeling better and better. Because if you feel good right after, then I underloaded you, and I did not stress your tissue enough to create adaptive change. And so if I have a patient say, that comes back to me like, yeah, last time, it's fine, like, Well, I'm not gonna tell you to your face, but I failed you.

Sarah Tiramacco 26:58

And we're gonna be less fine this time. You just wait.

Nate Reynolds 27:01

We're gonna push you a little bit. And so sometimes I like it when a patient says like, "Oh, Nate, you're an asshole." Oh, my God. Yeah. All right, good. Well, we'll be friends after.

Sarah Tiramacco 27:12

It's stressful, though, like, going into a physical therapy. dominant, continuing education course, definitely had me nervous, you know, out of how many people do you think were there? 25?

Nate Reynolds 27:28

Yeah, I'd say probably 20,

Sarah Tiramacco 27:29

You know, 20, I was the only person that wasn't a physical therapist, which meant that my education was way different than everybody else's. You know, we have relatively the same background. And I knew that I wasn't going to be completely off base taking that course. But I knew I was going to learn a ton. And I definitely did. And that was from, you know, the presenters, as well as from the people in the course. And I've continued to learn from people in the course, including you, you know, I, I shadowed you a week and a half ago, and it was awesome. I thought things that I don't always see, in my practice, I saw you treat things way differently than I would normally treat in my practice. And it's exciting to be able to see how people can approach the same complaint in so many different ways. Because you had, you know, evals came in, and I was like, Well, I would do this, and I would do this, and I would do this and you did something I never would even the thought of which is awesome. Because it opens up your eyes as a provider to really how many ways you can treat the same thing. There's not it's not one size fits all, and it never should be. But we look at it that way. And we'll take a look at chronic low back pain and wellness, manipulate it all day long. But if you're not loading that patient, and you're not re educating their body, and you're not teaching them how to adapt, nothing's going to change. You know, like, it's just, it's not going to change. And that's the same as pregnant women, like if you were continuing to adjust them and adjust them, and adjust them and you're not changing anything, or creating more motor control in their bodies, nothing is going to get better. And you were just prolonging the inevitable by giving them that quick fix that they want.

Nate Reynolds 29:33

Yeah, and I think one thing that if you're a provider that gets someone from a chiropractor or if you're a chiropractor to get someone from a physical therapist, the best thing you could do is ask them what their previous treatment looked like. Because if you you're already getting a piece of the puzzle, you know what didn't work. And so if you're not paying attention, and you're not like, Oh, well manipulation didn't work, and then you try to crack them or you try to do A lot of mobilization. I mean, maybe they do need some mobilization. You know, I would say that the difference between manipulation mobilization is that manipulation is pain relief. mobilization is trying to improve range of motion. But you're, you have an opportunity for that patient to have like that reset. Because we know that the mental aspect of recovery is just as important as the physical aspect, if you have this opportunity to change their beliefs in change. Okay, that failed, but I'm gonna do this, then you can get that buy in, and then maybe you can actually get them on the path of recovery.

Sarah Tiramacco 30:34

Absolutely. When we have a patient that comes in from a physical therapist, let's just say, hypothetically, they, quote unquote, failed physical therapy, and were their last resort. The first thing I asked is, what is your physical therapist Have you doing? Well, you know, I have chronic low back pain. I was doing like, some dead bugs, some bird dog, I was on the bike for a while. Great. Did you ever pick up a weight? Nope. Cool. Okay, so we're going to talk about that. And we're going to talk about how to load you. And if that means that I'm not the best person for the job, I'm going to refer you to refer you to a physical therapist, that's going to do what I know you need, you know, that means I'm going to refer you to Nate and he's going to probably put a kettlebell in your hand, and you're going to make you do some work. And he's going to make you move. Because what do you want, like, we're gonna move, you have to move, we'll find a way. We'll find a way we're going to make you move, you know, and that's, that's what's frustrating about patience is like, if people aren't willing to put in the work, you're not going to get better. My husband, Mike. So he's done a ton of training with Stuart McGill, who's like, pretty much the gold standard of fine care, at least in our profession. Everybody who's a chiropractor knows who's doing the villas. And he has this mentality that if you aren't willing to work, you deserve your pain. And we've definitely gotten to the point with some patients like, Hey, listen, I'm giving you the recommendations, you're not willing to put in the work. So either you live with the pain, or we're gonna have to, we're gonna have to compromise. And you're gonna have to do something, because eventually, we have to work through this. So you can sit on the couch all day long, and you can eat like hell, and you can drink five liters of Mountain Dew a week. But eventually, we're going to hit a wall, and we've hit that wall, and we need you to move and you need to move in, you need to decrease the amount of Mountain Dew you're drinking. You know? And at that point, like, how honest are you? how honest Are you willing to be with the patient? Because I don't want to waste your time. We don't want you to waste my time, and I don't want to waste your money. So if you're not going to put in the effort, then I don't know what to tell you. ow.

Nate Reynolds 32:58

Stuart McGill, would you consider he's on like the Canadian Mount Rushmore of rehab? research?

Sarah Tiramacco 33:06

I guess, because he is Canadian. So he actually has a PhD out of the University of Waterloo, which is an institution in Ontario. And he everything that he teaches, is 100%. Evidence based. It's interesting, though, because he's not a Chiro, he's not a PT, he's not an acupuncturist, you know, like, he doesn't have the same background that we do. But that research that he does, is so pivotal to what we do as professionals. But it's interesting, Mike took this four day seminar with him. And every question that he was asked, you be like, Well, it depends. It depends. It's going to depend on a million different things. And that's our job is to be a intelligent and efficient clinician to be able to say, we guess you're right, it does depend. And this is what it depends on. And this is how we get an answer. You know, like, that's, that's what we do as providers, and that's our responsibility to our patients is to understand that, yes, it depends. And it depends on your lifestyle, and how much you sleep and how much water you drink and how much soda you drink and how much alcohol you drink and how much you exercise, what you do for exercise, and how much you sit on your butt all day while you're at work because you're working at home because we're in the middle of a worldwide pandemic. And like all that stuff, you know, and everything is patient centered, it has to be patient centered care, and it's going to depend it's gonna depend on a million different things. But I think what he teaches is very important for what we do as spine providers, especially as chiropractors, and what Mike's learned from Stu McGill is worlds beyond what I know about counting spine pain world beyond. And I would rather him treat a disc injury, like a lumbar spine disc injuries any day before me. I would much rather him do it than me. He's a way better at it.

Nate Reynolds 35:16

So I think talking about like disc injuries. So one thing I want to touch on is that as chiros you guys can order imaging, we cannot. Why do you think that's the case?

Sarah Tiramacco 35:29

So in school, we learn that we are like portal of entry providers. So you can come see a chiropractor right off the street, you don't need a referral, you pretty much never need a referral. So based on what I know, is you can come off the street to see a physical therapist. But after six weeks, if you want your insurance to cover it, you need the referral from the medical doctor. Correct?

Nate Reynolds 35:55

So it depends on the state. So in New York State, we can treat someone for 30 days or up to 10 visits. And okay, yeah, so most, I mean, most patients, you never meet the 10 visits, because, you know, you see them twice a week, and that's in four weeks, that's a visit so you never meet the 10. So it's always like 30 days. And that's becoming more popular, I think, a port of entry is huge, in physical therapy realm. Because plenty of times when someone thinks of back pain, they go to the chiro more times than not, they go to their primary care. And the only ammunition that a primary care has is medicine, medications. And that's not addressing their mechanical, low back pain, you know, you're just treating the symptoms, and then you're just prolonging it, and then their symptoms come back in three to four weeks. And so then, you know, the more acute you see someone, the quicker you can make changes. So there's like this vicious cycle where you go to ego, the primary care, which is like $100, then you go like, Okay, well, we get an X ray, because for some reason Everyone needs an X ray. Even if there's no like, dangerous mechanism, you're like, Alright, well, that's another chart for the dollars. And so by the time they come to see you, they spent $350. And they're like, oh, that physical therapy co-pay is a lot of money. And you're like, but I'm the only one that's actually going to treat you for what you have. You spent $400 without batting an eye. But as soon as you see one copay, you're like, Oh, that's deep, and you're like, you've wasted your time. That's a steep price. But I'm sorry that, you know, you don't see the value just yet what I do. But that's a different topic. I mean, that's something I could go on and on about.

Sarah Tiramacco 37:38

I know that this is a podcast, and you can't see me, but I'm nodding and say yes, yes, yes. Because that's exactly what we see, you know, people have back pain in the first place they go as their primary care doctor. And I 100% think that there is a time and a place for worse Western medicine. But when it comes to spine pain, it is not the medical doctor, unless you are seeing somebody who is progressive, and who is willing to refer to chiro or to a physical therapist, or even to an acupuncturist. It is not the place to go. As chiropractors, only 8% of the entire population actively seeks chiropractic care. People really don't know what we do. And I think a lot of times people really don't know what physical therapists do, either. We, we see it as medical doctors will refer to PT quicker than the chiro, which is fine, but it should your medical deficit and be your first step for musculoskeletal pain. I don't care what anybody says PTs & Chiros for fighting the same battle, we want to make sure that conservative care options are at the forefront of what musculoskeletal pain should be treated as. Unfortunately, that's not the case. And I think that something that we have to do as conservative healthcare providers is really educate the medical providers on what we do and how we can help people and how we can prevent unnecessary medication, how we can prevent unnecessary surgeries, because that's a huge issue, too, is just seeing how many people end up with unnecessary spinal surgeries that lead into more fundamental surgeries and more degeneration and more spinal surgeries and more spinal fusions and fusion. So fusion fusion, and if people still have chronic pain, we're developing way more issue than if we just sought out conservative healthcare right from the beginning.

Nate Reynolds 39:39

When we talk to patients, you know, there's really only two options. It's either conservative care, PT or chiro or it's surgery. And more times than not, people don't want surgery. And so then when I tell them, I was like, well, then you don't need an MRI. I'm gonna save you $2500 they're like, really? I'm like, yeah, that's how much the Average MRI costs.

Sarah Tiramacco 40:02

But back to like why you think that we can order imaging and whatnot. That was your question and I've got up in a tangent. But I think because we're portal of entry providers, we have the option to order imaging. And it makes it a little bit easier because we're not bound by a medical referral. However, we can send for a radiograph. Whenever we want, patient comes in, they have history of trauma, or it's been, you know, a course of conservative care, they haven't been getting better. We haven't seen any improvement. Great center for an X ray. Everything's digital these days, we get a report within 24 hours, it's awesome. However, when it when it comes to MRI, it's not as easy. If we want to send a patient for an MRI as a chiropractor, and they want to pay out of pocket. Super easy. They just pay out of pocket and call it a day. However, if we want their insurance to cover it, we need to have proof of six weeks of conservative care that is failed, before the insurance company will cover it. It's especially in Rochester with BlueCross BlueShield, they want to see that there was six weeks of conservative care that failed before they will prove the MRI. And that has to be proven by patient notes that are submitted to the insurance company as part of the approval process before they'll say yes, let's schedule it.

Nate Reynolds 41:22

Okay. So then my follow up question is, so when you order this x ray, does it really change your course of care all that much? Or are you using it more just to rule out any red flags?

Sarah Tiramacco 41:35

It does not change our course of care. I bet you in the time that all five of our chiropractors have been in practice collectively. We've maybe said so Mike's been in practice, like eight years I've been in practice six. Caitlin's been in practice almost two, James has been almost a year, Rachel's been six months, you take all of that together, we've maybe sent for like 50x rays in that entire collective, because it's not going to change our course of care. If a patient comes in and they're like, Hey, I fell down the stairs. And I'm having excruciating pelvic pain, okay, we'll send you for an X ray, we'll make sure nothing crazy going on. I send the patient I think the last patient is in for an X. She was having this like anterior hip pain while she was pregnant. And then following her pregnancy, the pain persisted. And we just like couldn't get to the bottom of it right away while she was pregnant, at least. So she's a physical therapist, actually. And she was like, doing this make sure nothing crazy is going on? Sure, why not? So I signed up for the X ray X ray came back by you know, like FA joint looks great. And then we were able to at least rule out that there was no bony pathology because this has been going on for like a year, you know, like you're pregnant for 10 months. And I can't get deep into her. So as I can't get deep into her abdomen while she's pregnant, there's baby there. She was like, Can we just make sure. Yep, totally. So we're just going to send you to make sure. Also, a lot of insurance companies won't let us in for an MRI until we have an X ray. Anyways, my rule is pretty much that I want to see 50% improvement in two weeks. And if I don't see 50% improvement in two weeks, that means I either miss something, or we have to change up the treatment plan. And I'll change up the treatment plan once if I think it's appropriate. And if after I change up the treatment plan, and we do two more weeks of conservative care and nothing improves up to that 50% Mark, then I either refer out or we refer for imaging or like I missed something. So I really like to use that I find that it's pretty, like straightforward. Normally we'll see 50% improvement in two weeks unless it's something like crazy. We don't we don't refer for MRI at the time either. Because it's so subjective. A patient can come in with excruciating radicular pain, and you can send them for an MRI and there they have like the baby a little disc herniation known to man, or you can have no pain at all. And then you see this massive disc herniation on an MRI and people catastrophize it out and blow it out of proportion. Which is the worst because then they go back to their primary care doctor and the primary care doctor says oh, well, you have this massive disc sequesteration or whatnot. Let's send you to a neurosurgeon, the neurosurgeons gonna say this and it just gets blown out of proportion and it's a pain in the butt. And it unfortunately affects the way that the patient is going to improve and it affects their healing process. Because it's a bio psychosocial model like catastrophizing and giving people this information of having this giant disc herniation when their symptoms don't actually pertain to that. It really hinders somebody's healing process.

Nate Reynolds 44:58

So one thing that I've started doing especially Like with radicular symptoms is that I kind of explained that like ridiculopathy is like twofold, like it's either radiculitis, where there's like inflammation of the nerve root, or it's true mechanical compression. And more times than not, you know, the nerve root is very resilient. And so you can handle a lot of compression, but it's chemically sensitive. And so if it's bathed in the inflammatory soup, then you're going to have those symptoms that radiate down the arm. And that are, what we need to do is we need to either pump fluid into the area and dilute that inflammation. So either do that with offloading techniques, like taping up the shoulder to basically that stretching the, you know, the brachial plexus and stretching the nerve root, you can do some traction, create some of that small pump. Or you can use the big ticker, and use cardio and really get the heart pumping, get blood flowing through the body, and really try to use the body to heal itself. And more times than not, that works. And that helps treat these radicular symptoms. You know, I always use the analogy of and I don't know if they had this in Canada, but growing up we had like the sugary mixes of like Gatorade or like the old time like lemonade mixes

Yeah, yeah. And so yeah, if you didn't put the right mix, it was super saturated and tastes awful. And saris as like an example is like now we just need to get fluid in there and just a dilute it. And then that can make things feel better. like Oh, that makes sense. Okay, it gives them a visual of like what we're trying to do. And so from what it sounds like, it sounds like when I if I was going to summarize this, the difference between Kairos and PTs and orthopedics. I think we both agree if you're an orthopedic setting, a good Cairo is doing a lot of rehab. And a good physical therapist has a good skill set with manipulation, and that there really shouldn't be a difference between the 200%. And that the schooling is that you come out as a generalist for both. And that if you really want to develop your own niche, like you really have to find either good mentorship, you have to find someone highly qualified and someone that you trust that they're doing evidence based practice, or you're finding a group of courses like ice, that is one, they're great teachers to they're highly motivated. So it makes you excited. And I think that you just have to find a system that works for you. And whether that's ice or whether it's something else, you want something that has consistent messaging. And then the last thing is that we're both fighting the battle, the good battle against the scalpel, it's either there or it's surgery. And we got to find a way to get people to come to see us directly as a Chiro or PT. And so that we can really make a difference early on and stop this kind of vicious cycle of going to all these different stops just to get medication that isn't gonna actually fix the problem.

Sarah Tiramacco 48:26

Absolutely, I'm so grateful to have the relationship that I have with so many PTs in town, because I know that we are fighting the same battle. And there is a time and a place for that scalpel. And in our practice careers. If you take all five of our Chiros and add them all together again, we have referred for neurosurgery three times. All three of those times have had either bowel and bladder dysfunction, or progressive neurological weakness three times in a collective of 10 plus years of practice, practice years. And we are very, very lucky to be able to collaborate with providers like Nate, and like the providers that I use and like the providers that have got by physical therapy, who are willing to take the same time and really spend the time to assess and diagnose these patients and help us get to the bottom of what's really going on and get answers for our patients and really be able to help people because that's what people are coming to see us why they're coming to see us. I remember the course that we took with Jeff he's like people want to be heard, but they really want to be heard. Well you know, and if we can take the time to listen to people and to give them the time of day that they may not have ever gotten from another provider. That's what makes us different. And I think that as a physical therapist, and as a chiropractor, if you're listening to this, you should be collaborating with the other profession. 100% if you are a physical therapist, and you're not 100% confident in your manipulation skills, you need to find a chiropractor that you trust. And if as a chiropractor, you are very comfortable with your manipulation skills, but you know, that you lack in the rehabilitation realm and that you aren't comfortable loading patients, you need to find a physical therapist that is comfortable with those things. Because your patients are not getting the benefit of therapy and of recovery if you are not giving them those things. And in the end, it's no one's fault, but our own if we're not doing everything we possibly can for these patients.

Nate Reynolds 51:12

Yeah, I think that's a good point to end on, is that, you know, you need to check your ego at the door, and you need to do what's right for the patient. And more times than not, if you refer them, they're gonna appreciate that and then you're going to referral down the line.

Sarah Tiramacco 51:26


Nate Reynolds 51:28

So, Sarah, thank you for joining me today. It was a pleasure having you.

Sarah Tiramacco 51:32

Absolutely. Thank you for having me. I appreciate it.

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