Jon Tan BSc(Chiro), BChiro, ICSSD*
Introduction
Sports Medicine is a constantly evolving profession.1 The past 20 years has seen an explosion in the sophistication of sports medicine and sports science within Australia. 2 Traditionally in Australian Rules football, a medical team would consist of a group of ‘sports trainers’ to assist players with injury management and prevention. Typical duties of a sports trainer would involve basic first aid, immediate injury management, ‘rub downs’ (massage), and strapping of various body regions. The title of ‘sports trainer’ is a loose term, but recognised by the completion of basic courses offered by Sports Medicine Australia (SMA). SMA is “Australia’s peak national umbrella body for sports medicine and sports science, and is widely acknowledged overseas as the world’s leading multi-disciplinary sports medicine body”.3 Football clubs which have greater resources have been able to employ people with more formal qualifications such as massage therapists, physiotherapists, or even a medical doctor.
The entry of chiropractic into sports medical teams has been more contentious.4 Chiropractic was founded in the late 19th century in the United States as an alternative to medicine that focused on “correcting spinal malfunction in order to allow the natural healing power of the body to take effect”.4 From its establishment, chiropractic vehemently opposed by the medical profession in both Canada and the United States on grounds that it lacked legitimacy in both theory and practice.4 Today, it still appears that a considerable communication gap exists between the chiropractic and medical professions.5
Developments in 2009
As part of a public education and public awareness policy, the Western Australian branch of the Chiropractors’ Association of Australia (CAA WA) set itself the task at the end of 2008 of integrating chiropractors into every WAFL club. The objective was to provide WAFL players with direct access to chiropractic care within the club rooms. Chiropractic integration within the WAFL could then form a platform to develop chiropractic through other high level sporting teams in Western Australia. This plan always emphasised chiropractic operating within a team environment, and chiropractors respecting the existing medical team structure.
At this time, several clubs already utilised chiropractic within the structure of their medical teams: Claremont, Subiaco, Swan Districts, and to a lesser extent, South Fremantle.
This initiative required first contact with the respective club’s football manager, however, utilising known people within the club’s hierarchy appeared to be a much more effective approach. Over months of negotiations and meetings, the CAA WA was strategically able to secure chiropractic involvement across most WAFL clubs. The East Perth Football Club and the Peel Thunder Football Club are currently the only two WAFL clubs who do not have a chiropractor involved in some capacity.
Barriers to chiropractors in the WAFL
Chiropractors are registered primary contact health care providers, that is, are qualified to be the first point of call for various disorders especially those of the musculoskeletal system. One could argue they should play an important role in diagnosis and management of injuries. In the absence of a doctor or physiotherapist, it may be appropriate for a chiropractor to carry out the diagnosis and management of certain conditions. Perhaps within the structure of a multidisciplinary sports medical team however, a more sensible role for chiropractors would be assessing and correcting articular (joint) dysfunction as a maintenance and preventive form of health care. Evidence does support chiropractic as a preventive form of care in the sports setting (for example in the prevention of hamstring injuries6), however chiropractic is typically utilised in a wide variety of musculoskeletal considerations, with the profession made up of an assortment of different technique and philosophical groups.4
The barriers faced by chiropractors within the WAFL are typical of those barriers faced by chiropractors in sport nationally and internationally. The integration of chiropractors into the ‘traditional’, high level Australian Rules football medical team raises several issues. Perhaps the first of these is the role that a chiropractor plays in a team of health professionals already equipped to diagnose and treat sporting related conditions. Despite university training of five years duration, it appears that some medical staff in the WAFL feel that chiropractors have “little to offer” the sports medical team. This perception about chiropractic in sports medicine is not new. Indeed the Australian Sports Medicine Federation (SMA’s progenitor) released a news-letter in May 1992, stating this very idea, that “Chiropractors have little new to offer sports medicine in Australia”.7
Another major barrier that chiropractors have faced in the WAFL is the perception that a chiropractor would ‘disrupt’ the existing medical team’s procedures. This idea could be based upon differences and overlaps in treatment approaches. Indeed the entry of chiropractic into a system of sport medicine professions introduces another profession whose scope of practice overlaps with other therapeutic professions, most notably physiotherapy, but also, adds another dimension with expertise in a range of therapies and other approaches to patient care.4 This was evident at a meeting on the 9th of October 2008, where two chiropractors were invited to speak at a meeting of all WAFL Football Managers along with the WAFL Football Operations Manager regarding the issue of chiropractic integration within WAFL clubs. As one football manager put it, he did not want to “upset the apple cart” by introducing a chiropractor onto the medical team. This reinforces the importance of chiropractors building good relationships with other medical staff in the early stages of integration. This has been a factor previously documented in determining the success of chiropractic integration into multidisciplinary health care teams.8
During the process of chiropractic integration within the WAFL, it became evident that decisions involving medical or healthcare are often left to the present medical team personnel. After all, these people have more knowledge about sports medicine than a head coach or football manager. Typically, the first approach regarding the integration of a chiropractor at each WAFL club would go through the ‘Football Manager’. The Football Manager would then seek advice from the existing medical staff, essentially allowing the medical staff to restrict certain people or certain professions from the respective medical team. Instances where a physiotherapist is a sponsor of a club presents a significant barrier to the introduction of a chiropractor, as this would be seen as a financial threat to the physiotherapist. This was exactly the case at the Peel Thunder Football Club. In season 2009, a chiropractor began voluntary work as a chiropractor at the club. In April 2009 however, the chiropractor was asked to cease their services because the physiotherapist who sponsored the club, threatened to withdraw their sponsorship if the club continued to utilise chiropractic.
Chiropractic integration in the WAFL also faces an ‘internal’ problem – finding individual chiropractors who are not only willing to ‘restrict their normal scope of practice’, but also work for little or no remuneration. In multidisciplinary medical teams in the WAFL, it has become evident that the successful integration of chiropractors requires the chiropractor to restrict his or her normal scope of care. The best example of this would be the chiropractor surrendering virtually all acute injury management, and leaving this in the hands of the sports trainers, physiotherapists, and/or medical doctors. Careful consideration would also be needed by the chiropractor when providing soft tissue treatment, or prescribing individual exercise and stretching programs, as again this would be the typical domain of the team’s physiotherapist.
Restricting chiropractic entry into WAFL medical teams by existing medical staff (for example physiotherapists) appeared to be based on several alleged ‘reasons’:
Physiotherapists/doctors carried out some spinal manipulation and hence a chiropractor would form an unnecessary duplication of resources (i.e. had ‘little to offer’).
A chiropractor would conflict with sponsorship arrangements that a physiotherapist may have with the club.
Existing medical staff were simply not interested in working with a chiropractor.
Having said this, several WAFL club physiotherapists, were open to the idea of working with a chiropractor. This raises another issue regarding the perception and understanding of various sports medicine disciplines, and that it appears people are often lacking in knowledge of other professions’ fundamental education and what they truly to have to offer a sports medicine team.1 It is also worth noting here that the proposal of introducing chiropractic at each club was purely on a voluntary basis, i.e. no remuneration was expected or sought.
Past and current utilisation of chiropractic in the WAFL
The utilisation of chiropractic has increased significantly in the WAFL over the past 5 years. The following tables show the utilisation of chiropractic at each club from 2005–2009.
Claremont Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | Yes |
| 2008 | Yes |
| 2007 | No |
| 2006 | No |
| 2005 | No |
East Fremantle Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | Yes |
| 2008 | No |
| 2007 | No |
| 2006 | No |
| 2005 | No |
East Perth Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | No |
| 2008 | No |
| 2007 | Yes |
| 2006 | No |
| 2005 | No |
Peel Thunder Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | Yes |
| 2008 | No |
| 2007 | No |
| 2006 | No |
| 2005 | No |
Perth Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | Yes |
| 2008 | Yes |
| 2007 | No |
| 2006 | No |
| 2005 | No |
South Fremantle Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | Yes |
| 2008 | Yes |
| 2007 | Yes |
| 2006 | Yes |
| 2005 | Yes |
Subiaco Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | Yes |
| 2008 | Yes |
| 2007 | Yes |
| 2006 | No |
| 2005 | No |
Swan Districts Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | Yes |
| 2008 | Yes |
| 2007 | Yes |
| 2006 | Yes |
| 2005 | Yes |
West Perth Football Club
| Year | Chiropractic Utilisation |
|---|---|
| 2009 | Yes |
| 2008 | No |
| 2007 | No |
| 2006 | No |
| 2005 | No |
Current perception and utilisation of chiropractic in the WAFL
It appears that once chiropractic is offered to players within the WAFL, it is well regarded and well utilised. A good example of this would be at the Subiaco Football Club. During the 2008 season, the club purchased a new chiropractic table, based on the need for better equipment to facilitate the provision of chiropractic care. During the 2008 season, 675 individual chiropractic treatments were carried out and recorded. Divided by the 23 week season, that averaged out to just over 29 chiropractic treatments per week. Chiropractic was provided to players in conjunction with various other forms of healthcare for example physiotherapy, medicine, massage, and podiatry. At the commencement of the 2009 season, the Subiaco Football club agreed to remunerate their club chiropractor as a result of the high value placed on chiropractic at the club. It is also worth noting that at the Swan Districts Football Club, the ‘Medical Coordinator’ is a chiropractor. This contrasts to the situation in the National Football League (NFL) in the United States, where one hundred percent of medical teams are headed by a medical doctor.9
The current status
Currently, seven out of the nine WAFL clubs have a chiropractor involved in some capacity. Five WAFL clubs have a chiropractor working directly within the structure of the medical team as follows:
Claremont
South Fremantle
Subiaco
Swan Districts
West Perth
Whilst two clubs were happy to “refer out” to a designated chiropractor as necessary:
East Fremantle
Perth
The East Perth Football Club declined the services of a chiropractor for the 2009 season, despite utilising chiropractic during the 2007 season. It was reported that the club physiotherapist was disinclined to work with a chiropractor.
As outlined earlier, the Peel Thunder Football Club initially integrated a chiropractor within the medical team in 2009, only to reverse its decision due to a conflict with sponsorship provided by a physiotherapist. It is worth noting here, that all nine WAFL clubs have utilised chiropractic at some point in time.
Summary
The purpose of this paper is to document the evolution of chiropractic integration within a high level, state football competition. Indeed, most WAFL clubs currently utilise the services of a chiropractor in some capacity. All WAFL clubs have utilised chiropractic at some stage in the past, but never before has the WAFL seen chiropractic involved at the level it is today. It is evident that the ‘initial’ integration of chiropractors is determined largely by known people or ‘contacts’ at each WAFL club. The ‘successful’ integration of chiropractic relies on the chiropractor initially restricting their normal scope of practice, good communication among medical staff, and a willingness of all medical staff to accept other treatment methods and protocols. It does appear that chiropractors in the WAFL have worked with these principles in mind, and this has likely contributed to a relatively successful integration of chiropractic within multidisciplinary sports medical teams.
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