As more practices adopt the multidisciplinary model, the inquisitive doctor of chiropractic will want to learn more about alternative therapies.
While some chiropractic practices have expanded to offer multidisciplinary services so that patients can get the care they need at a one-stop shop, others have begun teaming up with alternative therapy (AT) practitioners, but keeping their own independent business.
Why is this trend happening? Because patients want to feel better and then stay healthy. Although chiropractic can provide tremendous healing and preventative care, there may be times when you should refer a patient to another practitioner. And your patients will likely be receptive to another practitioner of complementary and alternative medicine.
Before you begin referring patients, it’s crucial to know what alternative therapy offers, how it can work synergistically with chiropractic, and how it can mutually benefit you and the other practitioner.
What they are and what they do
For this story, we examined the following alternative therapies: yoga, massage, acupuncture, naturopathy, and Traditional Chinese Medicine (TCM).
Yoga: According to Jasper Sidhu, DC, from Toronto, Ontario, yoga is “a practice of posture exercises and breathing techniques that may or may not involve mental and spiritual components in addition to the physical exercises. In some Western forms of yoga, the focus may only be on the physical part.”
Sidhu stresses that although yoga does have breathing and meditative components, when discussing yoga in reference with chiropractic, it’s considered more a kind of exercise. “Yoga can help increase core strength, increase flexibility and help reduce tension through breathing techniques,” Sidhu explains.
Massage: There are several massage concepts and approaches—just like there are in chiropractic, according to Michael Koplen, DC, MT, a self-employed chiropractor in the group clinic Capitola Health Center. “A primary intention of massage therapy is stimulating the nervous system to help reduce muscle tension, stress and pain.”
Acupuncture: Like massage, there are a number of different techniques and approaches, says John A. Amaro, DC, LAc, president of the International Academy of Medical Acupuncture. Surprisingly, there isn’t one specific procedure that universally defines acupuncture.
“Acupuncture is known for its stimulation of specific skin points, which have been described differently by a host of various techniques. The most well-known is the stimulation of a specific point or points on the body through use of slender needles. However, a variety of non-invasive techniques—including simple finger pressure—have been used for acupuncture for thousands of years with predictable response and international respect,” Amaro explains. “These procedures—although quite different from one another—are used worldwide for the common goal of balancing body energies, removing stagnation of energy and to create a normal flow of energy (chi) in the body.”
Naturopathy: Jaclyn Chasse, ND, says naturopathy is a branch of medicine emphasizing optimal wellness through healthy living. “Naturopathic doctors are trained in primary care medicine and can perform all routine preventive and treatment-based care that you might receive from a conventional medical provider, but treatments tend to focus on addressing the root cause of illness through lifestyle changes and natural medicines like vitamins and herbal medicines. Pharmaceutical medicines may be used as necessary,” Chasse says.
Traditional Chinese Medicine (TCM): According to Leng Tang-Ritchie, DAOM, LAc, TCM is a complex system encompassing a number of modalities such as acupuncture, Chinese herbology, cupping therapy, moxibustion, diet and massage, with acupuncture being the prime physical modality. “By stimulating the range of systems of the body, acupuncture can reduce inflammation, decrease pain, improve digestions and organ functions, and promote a general sense of well-being,” Tang-Ritchie says.
Working with AT practitioners
Alternative therapies can work well with chiropractic to enhance patient outcomes. But as the practitioners we consulted explain it, you need to know how the ATs work best, what to look for in a practitioner, and what the ATs can’t do.
For example, Sidhu says that chiropractors have a number of choices when it comes to recommending exercise to patients. So when he refers patients to yoga, he makes sure that they fit with the program.
“I rarely send someone to yoga as the first line of exercise,” Sidhu says. He will refer patients to yoga practitioners once he knows that they can perform exercises without pain or limits in motion, if they are motivated to make lifestyle changes by continuing with a form of community exercise, and if they have a lot of anxiety or stress—because the meditative and breathing components can improve overall health.
“Don’t look just at the physical benefits for your patient. There are also mental and psychological benefits,” he says. “Be aware that not all yoga is the same. Educate yourself in what type does; maybe even take a class. This small bit of homework will pay off big when it comes to knowing exactly what your patients will be getting.”
If your patients have any medical red flags, Tang-Ritchie says, don’t refer them to alternative therapy practitioners—send them to their primary care physician or the ER.
Amaro cites a case in which a patient had been treated for a post-traumatic hiatal hernia, which produced severe back and chest pain upon the simplest exertion. Although the patient received some relief with chiropractic, the debilitating pain would return the same day.
After being treated with both chiropractic and acupuncture for a year, with no permanent resolution, the patient was referred for a cardiac work up. To everyone’s amazement, the tests revealed that the patient had severe coronary blockages. After quadruple bypass surgery, the pain disappeared. Not referring the patient to the proper medical professional “would have ultimately been a death sentence,” Amaro says.
Finding the right AT
If you want to work with an AT practitioner, know that some require licensures. For example, Tang-Ritchie says that acupuncture licensure is regulated by each state. A licensed acupuncturist (LAc) will have passed state and/or national boards. National boards require more hours and more training.
As for a naturopathic doctor (ND), Chasse says they should maintain a current state license, but because not each state offers licensing, know that some may maintain an active license in another state if the one in which they’re practicing doesn’t offer one.
Look for an ND who has graduated from a school accredited by the Accreditation Council for Continuing Naturopathic Medical Education (ACCNME), which is the only accrediting body for NDs approved by the Department of Education.
While Koplen says that he recommends massage to nearly every patient because the effects are far-reaching—for example, massage therapists (MTs) sometimes have special expertise like pregnancy massage, certain myofascial release techniques, and neuromotor reprogramming, he stresses that it’s important for chiropractors “to know the type and quality of care that an MT provides.”
“Knowing which MT you can rely on is not so much an issue of their credentials or the techniques they apply; what you really need to know is that an MT understands the nature of chiropractic care, listens to your recommendations and provides supportive care that integrates with the care you provide for the referred patient,” Koplen explains. “There should never be a competition among DCs and MTs when treating patients—only a collaboration.”
Koplen says that not many DCs have formal massage training and, likewise, not many MTs fully understand chiropractic. Because of this glaring problem, he has created educational resources about chiropractic that provides essential protocols and communication strategies for MTs.1
To refer or hire
Say you’ve done your homework and now you’ve decided to work with AT practitioners. Do you refer patients to them? Do you hire them? Do you give them space and split the fees?
“There’s no set answer,” Koplen says. “Preferences depend on a clinic’s goals. Some clinics hire MTs as employees who are instructed to provide specific types of care. Others are extremely lax, and MTs rent space and practice however they wish. There are some massage centers that have DCs renting space to fill that need.”
“There are a few ways to affiliate,” Tang-Ritchie says. “One would be bringing in an acupuncturist as an employee under a medical corporation. Another option would be to have an independent contractor relationship. A third avenue would be to rent space to or from an acupuncturist and have them practice independently. It is important to check with state business and profession codes for the legalities, as they vary from state to state.” In California, for example, acupuncturists cannot split fees.
During his 44 years of clinical practice, Amaro has employed a variety of professionals—at one point, he had 12 clinical assistants as part of his office staff, each making a salary. “I have employed doctors of various disciplines all of whom were paid a predetermined salary. I have seen numerous DCs hire acupuncturists, MTs, and physical therapists for a specific salary and specific hours. Some have been rewarded with a commission when they are responsible for bringing new patients into the office,” he explains.
“In as much as all offices run on individualized protocols, hiring a professional to join the staff has to be discussed in detail with all parties, and all procedures must be agreed upon in advance of hiring.”
Chasse says there are many models out there, including NDs working independently in the same space and paying rent for space, staff, and materials; NDs working on a percentage basis, where they are paid a percentage of revenue they bring into the practice; or NDs working as staff.
Previously, Chasse worked in a practice that she co-owned with a chiropractor. She says that she and the co-owner would refer patients to each other.
For example, if she was seeing a patient who had pain or physical issues, she would refer that person to the chiropractor. If he was seeing patients who mentioned other concerns, he would refer them to her or one of the other NDs on their team.
“We also learned a lot from each other, and the chiropractor expanded his knowledge of nutrition and began to consult with patients around certain chronic illnesses from a nutritional perspective after several years. As practitioners, we had a consistent referral stream coming in, and patients loved the fact that we could coordinate and discuss their care—each bringing our own expertise,” Chasse says.
Finally, make sure to get all your legal ducks in a row. “Formalize exactly who the patient belongs to,” Sidhu says. “Make sure other professionals don’t leave and take your patients with them.”
Making the arrangement work
Our experts offer the following tips to make your collaboration with AT practitioners advantageous for both of you:
- Transparency is key. Owners take on a lot of overhead, and practitioners who aren’t the owners should recognize that their compensation is related to the value they bring to the practice.
- Know exactly what you want from this business relationship, and know exactly what you’re capable of doing and offering.
- Before making the leap, hold a seminar or two at your clinic about the AT you are thinking of adding. This helps you see if your current patients have interest.
- A new employee or contracted practitioner must share a similar philosophy and approach as the principal who hires them.
- Don’t assume anything, and put all contractual agreements in writing.
- Interview, interview, interview. Get to really know the practitioner and his or her objectives.
- Make sure the practitioner understands and is dedicated to the principles of chiropractic. You don’t want disagreements with your protocols.
- Be clear about your expectations and theirs, too. Put it in writing.
- Make sure that all legalities are in order. This is the most important aspect of any venture.
“Providing satisfying, integrative care among DCs and others is the ultimate formula for practicing successfully,” Koplen says.
Michele Wojciechowski is a national award-winning writer based in Baltimore, Maryland and author of the humor book Next Time I Move, They’ll Carry Me Out in a Box. She can be contacted at firstname.lastname@example.org or through wojoenterprisesllc.net.
1 Koplen M. “Q&A: Massage & Chiropractic Working Collaboratively.” Masters in Massage Institute.
https://mastersinmassage.com/blogs/news/q-a-massage-chiropractic-working-collaboratively. Published Oct. 2018. Accessed Oct. 2018.