Physical Therapists are the safest providers of manipulation!

Thanks to Dr. Rob Landel and the California Orthopaedic Manual Physical Therapy Special Interest Group for the following post.

 In my last post, I made it clear that physical therapists are more than adequately prepared, through their education and clinical experiences, to perform thrust joint manipulation (TJM). In this post, I like to address the issue of safety, more specifically, the claim that allowing physical therapists to perform spinal manipulation will prove harmful to the public.
 The two issues are closely interrelated.
The safe application of any technique requires the use of clinical judgment, specifically, determining not only who is appropriate for the technique, but also for whom the technique is contraindicated. This must occur prior to the procedure being performed. Adequate clinical judgment is based on knowledge of anatomy, pathoanatomy, biomechanics, pathomechanics, pathology, and a differential diagnostic process. Even the most skillfully applied technique can be harmful if done in the wrong circumstances. Also, the decision of whether or not to perform a manipulation must be evidence-based, i.e. taken into account the best available evidence, the clinician’s experience, and the patient’s needs and goals.
As I noted in my last post, all of these aspects are basic components of any Doctor of Physical Therapy program. Furthermore, this knowledge and clinical judgment is tested extensively through written, oral, and practical examinations, as well as put into practice during as much as one year of supervised clinical experiences. Finally, in order to become licensed in the state of California, every physical therapist must pass their licensure exam, which includes testing their knowledge and clinical judgment on manipulation, as required by the Federation of State Boards of Physical Therapy.
Thus it is clear that physical therapists are well prepared to safely perform manipulation techniques, and in fact are required to be safe in their application before being allowed to practice. But is that what actually happens?
Well, let’s look at the evidencewho poses a greater threat to harm a patient by performing manipulations, chiropractors or physical therapists?
Published reports show a very low probability that physical therapists who use TJM will cause harm; the vast majority of serious complications from manipulation are NOT caused by physical therapists.
Summary of scientific reports on TJM complications by profession:
  •            61% of complications due to chiropractic and only 5% (12/220) due to PT (1)
  •           87% of complications due to chiropractors and only 6% (6/98) due to PT (2)
  •           70% of complications due to chiropractors and only 2% & no deaths due to PT (3)

Published review of medical literature over a 77‐year period found only 10 reports of cauda equina syndrome (a medical emergency lower spinal cord injury) after lower back TJM; none of those injuries were caused by PTs (4)

These numbers speak poorly for the chiropractors on their own, but are even worse when you consider that practicing PT’s outnumber chiropractors 4 to 1. (5)
Further evidence of the safety of physical therapists practice can be seen in the cost of our malpractice and liability insurance. A basic tenet of liability insurance is that the riskier the practice, the higher the fees. My California malpractice insurance is $361/year; in 2008, the typical chiropractor paid nearly $2700/year. (6) According to HPSO (largest liability insurance carrier for PTs in the US) there are no higher claims losses related to PT use of TJM than other PT treatment techniques.
The evidence is clear: ensuring public safety is not a valid reason for SB 381. Physical therapists pose no greater threat to patient safety than do chiropractors; in actual fact, the opposite is true!
I propose the following solution: introduce a bill that, in the interests of public safety, chiropractors are no longer allowed to “adjust” the spine.
As always, comments are welcome and encouraged!
  1. Assendelft WJJ, Bouter L.M., Knipschild PG. Complications of spinal manipulation. A comprehensive review of the literature. The Journal of Family 
Practice 1996; 42(5):475‐480.
  2. Patijn J. Complications in manual medicine: a review of the literature. J Man Med 1991; 6:89‐92.
  3. DiFabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999;79(1):50‐65.
  4. Haldeman S, Rubinstein SM. Cauda Equina Syndrome in patients undergoing manipulation of the lumbar spine.Spine. 1992;17(12):1469‐1473.
  5. http://www.bls.gov/oco/ocos080.htm and http://www.bls.gov/oco/ocos071.htm accessed January 12, 2010.
  6. http://www.chiroeco.com/news/chiropractic-news.php?id=3553
Written by Rob Landel, PT, DPT, OCS, CSCS, FAPTA
Please go here for more information.  Support your CA colleagues on April 15!!

72 responses to “Physical Therapists are the safest providers of manipulation!

  1. Mike Scott says:

    Great post and love the background on clinical judgement.
    Not everyone is a candidate for every skill we have as professionals and like you said, even a “safe technique” can be dangerous in the right circumstances.

    http://mikescottdpt.com/2013/03/05/ca-sb-381/ holds my own opinions on the bill.

    Mike

  2. Great post and perfect timing. I’m heading off to the East coast (Newark, DE) to teach the LP weekend intensive (WI) for EIM. We will spend many hour perfecting the TJM so that patients are receiving the best possible care safely and effectively. I feel proud to be part of a great PT organization (AAOMPT) that has such high standards of OMT. We have a tough battle here in CA as this political debate continues. Our big challenge will be this Mon. 4-15-13. Come on out and support the PT’s in defeating SB 381.
    Cheers,
    John Seivert

  3. Great talk.Hope it will not just be on this website but the facts made available at the “court room” come Monday 15 May,2013.I have seen manipulation solve many vertebral problems,low back pains,scoliosis and other severe problems,even as an inchoate Pt. We have been trianed to do this job and must protect our integrity!!! This bill must not come into force and I urge all the PTs in California to stand against it!!!!
    I’m in Ghana,and I wish U all the best!!

    1. Anthony Wilson says:

      ignorance is bliss – you guys can’t hold a candle to chiropractors – get a clue

  4. Joe Brence says:

    I agree with your proposal. I have also proposed that we assume ownership over the term “neurophysiological manipulation”. The primary effects of manipulative techniques are likely related to an alteration in the nervous system vs. the joint, so let those guys mess with the bones all they want as long as they don’t elicit a neurophysiological effect (analgesic, motor control, etc). If the chiropractic association wants to play childish games, without sufficient literature to support their arguments, lets step it up as a profession and use our play book (our research) to our advantage.

  5. ChristieD says:

    As much as I am a supporter of PT’s being able to perform TJM, I think we have to take caution before proclaiming we are “safer” than chiropractors. None of the studies presented were designed to determine if a “chiropractic” manipulation was safer than a “physical therapist” manipulation, rather the purpose was to report on the relative risks and number/types of incidents that occur with TJM. In fact, the studies themselves overall state that TJM is a risky treatment and that AE’s are likely underreported.

    One of the reports does break it down by which profession had which number of incidents, but we have to keep in mind that, by FAR, chiropractors perform more TJMs than PTs. This inherently makes them more likely to experience an adverse event by sheer exposure alone. Making the statements that PTs are safer in performing manipulation is akin to proclaiming that ER physicians perform safer infant deliveries than an OB/GYN because OB/GYN’s have MORE incidents of AE’s.

    The age of these studies also has to be taken into consideration…they were written at a time before TJM became more common amongst practicing PTs. If we want to claim to be safer, we need to compare the rate of AE’s per manipulation per profession and in today’s current practicing standard.

    As I said, I’m in no way saying that PT’s shouldn’t perform TJM, just that stating we are safer (based on the studies above) is a bit of a stretch.

    1. Ethan says:

      Thank-you ChristieD for that well thought-out and unbiased analysis. I agree that chiropractors inherently perform more TJM and thus the increased risk. It would be interesting to see what would happen to PT malpractice insurance if they started performing TJM on a routine basis.

      1. Jon says:

        Exactly. Along this line of thought, one could say that therapeutic exercises are safer when instructed by a chiropractor than by a PT, because PTs by far instruct more patients in exercise!

    2. I have to concur with Christie D. Your conclusions don’t correlate directly with the evidence you are presenting. I’ve been a chiropractic physician for 15 years and I also am in support of DPT’s have access to joint manipulation, with adequate training. I even made the case for that to my state board when I was interviewed for the Industrial Insurance Chiropractic Advisory Committee I serve on, where we write best practice documents for Washington state. Four of which are now on the National Guidelines Clearinghouse. http://www.lni.wa.gov/ClaimsIns/Providers/ProjResearchComm/IICAC/Resources.asp .

      That being said, everything you mentioned in terms of training and appropriate use of manipulation prior to the evidence you cited has been part of the standard Doctor of Chiropractic curriculum since before DPT programs were in existence. We have extensive training in differential diagnosis throughout the approximately 5000 hours of our DC education.

      There is no doubt that the statistics you are mentioning would be vastly skewed if you look at the actual number of manipulations performed in each profession, side by side. They just can’t be compared with any intellectual honesty in reporting, in terms of actual saftey comparisons. The sample size just wouldn’t be accurate.

      In terms of safety, when you really look at the data, there isn’t a treatment for low back pain that is safer. Honestly. Crunch the numbers yourself. Even in terms of neck pain, look at Cassidy, 2009 for stroke risk. http://www.ncbi.nlm.nih.gov/pubmed/19251066 Ibuprofen is more dangerous.

      It’s also important to note that even after 15 years of practice, my malpractice insurance is under $3000/ year. That is because what we do is generally and comparatively extremely safe.

      I have many colleagues across the nation that work hand-in-hand with PT’s and provide phenomenal care to patients in need, which is how it should be. We all should be combining our knoweldge, for the betterment of patients and the care we provide. All this “we’re better than them” stuff really needs to stop. This is healthcare, not a football game. Let’s focus on what really matters. The patients we care for.

      1. Thanks for the honest assessment of skills and risk

      2. Thanks for the honest assessment of skills and risk. I started my career as a massage therapist. First working for DC’s then for PT’s. I chose to be a DC because of the independence factor. I want to do what is best for the Pt independent of what an MD demands. Not all DC’s base our practice on the subluxation. Many of us work in the realm of what is proper joint motion and how to improve that thru the adjustment and improving strength and flexibility. Improving postural and breath awareness is also part of what we do. The adjustment does have the most immediate affect for pain relief, mobility and at times unexpected improvements in seemingly unrelated health problems. The chiropractic understanding of the importance of treating the whole body from head to toes is what sets us apart and of course our level of diagnostic education and skill. Hopefully we will all be working together soon to provide the most effective and efficient remedy for the person in need of our services.

  6. Matt Weigel says:

    Thanks Christie for your reply. The honesty toward research is what I love about EIM. I think you hit the nail on the head. I will be appalled if CA loses the ability to manipulate. Lets beat this bill. But after, lets be-friend the clinicians who use sound clinical judgement, regardless of degree (DO, DC, DPT). Lets use the commonality that we all have – to improve the health of our communities, not our differences. Some of the chiro’s can be our assets as they aren’t all in favor of this bill. My understanding from our professions MT experts, is that it is not the degree that determines superior outcomes or safety, but rather the individual performing it. Please, lets not become the group we are trying to defeat. Lets take the high road.

  7. Shaun says:

    This is an interesting post but flawed. If you really want to make the claim that PT’s are safer than DC’s at manipulation then you need to show how many PT’s are performing manipulation and how many incidents occur from said manipulations. Then compare the percentages. I think all of the fighting between professions should stop and we should work together as a group for the benefit of the patient. I don’t know about the rest of you but that is why I entered health care, so I could help people get well again. Maybe you should ask yourself why you entered into health care, was it to help people or was it to minimize someone elses scope of practice? Lets focus on helping the patient instead of focusing on fighting with other associations, I think we will realize that the true winner will be the patient and a close second will be the Doctor.

    1. Juan Di Leo Razuk says:

      Shaun,

      With screening manipulation are a very safe procedure. I agree in stop fighting: so let’s both have access to manipulations.

      Juan

  8. I am glad that you are learning clinical judgement in determining the best candidates and circumstances to perform TJM as we do, too.
    What you fail to mention is that PT’s have not been a part of the manipulation community near as long as chiropractic physicians of doctors of osteopathy. Therefore, the studies shown reflect a disproportionate history of number of adjustments performed.
    Further, the incidence of injury is still so small as to be statistically insignificant.
    At the risk of singing Kumbiya, doesn’t chiropractic and PT bring patients unique skill sets that sometimes overlap? I have ordered PT numerous occasions for my patients when passive therapy is no longer affective or needed.

    1. Juan Di Leo Razuk says:

      Cheryl,

      PTs have not been utilizing manipulation as often as chiropractors and osteopaths, though we’ve used them. I have a question: what is the scientific evidence describing an “adjustment”? I have found nothing in the www.
      The incidence of injury in manipulation is miniscule, I agree. I believe that we treat the same patient population.

      Juan

    2. Bill Egan, PT, DPT says:

      From Cheryl DC, MEd: “I have ordered PT numerous occasions for my patients when passive therapy is no longer affective or needed.”

      PT’s are skilled in providing passive therapy (manipulation), identifying when its indicated, and also whens its no longer indicated. PT’s do not utilize manipulation as a stand alone treatment. PT’s provide manipulation as part of a multi-modal package including therapeutic exercise, and patient education. In my mind this makes PT’s the clinicians of choice to provide manipulation.

      Bill

      1. Stefan M. Herold, DC, DACNB says:

        The vast majority of DC’s I know always combine active therapy, lifestyle education and home exercises along with ‘passive’ therapy and joint adjustments as clinically indicated. Please do not make blanket statements about a whole profession as doing just one thing. Further, to claim that no PT’s utilize only manipulation or never overtreat is just plain naive. There are always a minority of bad apples in every profession.
        I refer to and work with PT’s who do joint manipulation along with functional strength training, muscle energy techniques, etc. and I have no problem with them doing something they are skilled at that is of great benefit to their patients. A good clinician is a good clinician and benefits their community. A bad or lazy clinician, no matter their license is a hazard to the public. Let’s not fight each other, but instead support the good work that each profession adds to the health care field, both in our commonalities and uniqueness.

        Stefan

  9. Timothy Broden says:

    This summary of scientific reports on TJM complications is flawed to say the least. As an outsider that has no background with PT or chiropractic, I would assume most manipulations are done by chiropractors. I most certainly could be wrong and if so I apologize. When I think of manipulation I think chiropractic. How many PTs actually even use a thrusting manipulation in their practice? I have been to a couple of different PT offices for treatment over the years and was unaware physical therapists used manipulation. My point is that seeing 61% (1) and 87% (2) of complications are due to chiropractic and only 5% (1) and 6% (2) are due to PT is certainly alarming looking from the outside. However, this study/article does a poor job or reporting how many chiropractors and PTs this study involved. Since I assume more chiropractors manipulate than PTs, this study certainly could have looked at 10,000 chiropractors to 100 PTs. If this were the case then PTs are more likely to cause complications. I understand that I am assuming a lot here but this article does such a poor job of giving all of the necessary information that anyone reading this report is forced to draw their own conclusions. This just happens to be mine.

    1. Juan Di Leo Razuk says:

      Timothy,

      Your point is fair. Your assumption is common yet incorrect: PT use manipulations on a daily basis, is just that we classify the patient prior to treatment. Take penicillin as an example: is it good or bad? Well, if you have an infection yes, if you’re having a heart attack no, if you have an infection and are allergic to penicillin definitely no. So is the case with manipulation, there are effective for the appropriate patient.
      The truth is that manipulations are generally very safe.
      Your opinions are logical.
      Sincerely,

      Juan

  10. Common’ now. Let’s be fair and rational here. The reason the injury rate to patients is higher for Chiro’s is because we do 95 % of all the manipulations on The Planet. The PT population to Chiro. may be 4:1 but the manipulation ratio PT:Chiro. is likely 1:100,000. or more. Like any other Medical procedure including Surgery it always turns out that the more the procedure is routinely performed by an individual, the more proficient they become thus the higher the likely hood of a successful outcome. Ex: If all you do are appendectomies all day long on people of all shapes, sizes and complications the better you are going to be at it than the next guy. That’s The Doc I want doing mine. Ron Grassi, DC.,MS.,FACFEI. Boca Raton & Jupiter, Fla.

    1. Juan Di Leo Razuk says:

      Ron,

      I don’t think that chiro do 95% of the manipulations on the planet but I do agree with you in that you do them very much. One question: I classify responders using clinical prediction rules and treatment based classifications, why is it that since we see similar populations the ratio of manipulations in chiros offices is so high when many patients are inappropriate for them?
      I agree with you in that as an individual becomes proficient with manipulations the results improve but only if the patient is appropriately classified for the treatment. Otherwise the results can be most negative. And the comparison with surgery is unfair since surgeons have a high risk profession and we have a very low risk one. Finally about your example on appendectomies: the results are best by an expert if you need an appendectomy, if you went in for cancer the appendectomy won’t help you one bit.
      Sincerely,

      Juan

  11. Jesse Resari, PT, DPT says:

    Agree with Matt and thanks Cheryl for your perspective. I hope we see more of you for the benefit of our patients. I must say however respectfully that PT’s have been part of the manipulation community. We just judiciously and selectively use it based on the unique history and clinical presentation of the individual patient. We don’t manipulate just to manipulate. I think the reason why we are “under the radar” from the manipulation community is (correct me if I’m wrong) because the chiropractic profession at large refuses to believe that PT’s are trained to perform manipulation. I think you and the DC community will understand why we get so worked up, angry, and truthfully dumbfounded when legislation like this keeps coming up despite the overwhelming evidence. It’s never a good public policy trying to restrain someone’s trade. Patients should decide where and what practitioner they think will benefit them. Your profession has been in this position before when the AMA was trying to curtail your practice way back when. Your profession fought for your rights and won. We want our rights too and we know we will win. Thank you.

  12. Christopher Bunn DC says:

    In reply to your comments Jesse, I think that the reason that PT’s aren’t “believed to be properly trained to perform manipulation” is two fold, first we have no knowledge of your training requirements to be able to perform manipulation. Typical chiropractic college curriculum calls for 2+ years of clinical and classroom training to be trained properly to diagnose joint dysfunction through orthopedic, neurologic and radiological analysis and then administer manipulation if indicated. I think most of us in the Chiropractic profession are unaware of your requirements.

    Secondly, to compare your plight to the plight of the Chiropractor in their struggles with the AMA is not a fair comparison. No one is throwing you in jail, calling you quacks, telling patients to avoid you like the plague… We have been ridiculed, boycotted and jailed for our rights to adjust patients, now in spite of all that struggle, the medical community says “oh it works? Then we want ownership of it… sorry we called you all those names” So you can understand our getting worked up when a PT says that not only can you perform manipulation, but that you can now magically do it “safer” than we can? It’s not an apples to apples comparison. Its like DC’s getting limited prescription rights, and then a DC writes an article saying “DC’s are the safest providers of prescription medications”. Just because we haven’t killed anyone…yet!
    I applaud your decision to try to help your patients, but instead of attacking DC’s perhaps you should give credit where credit is due? Don’t attack DC’s, educate us as to why you are qualified to perform manipulation…maybe even learn from us, since it is our area of expertise?

    1. Juan Di Leo Razuk says:

      Christopher,

      Your points are well intended. I have a few comments.
      1) Who does not believe that PTs are properly trained to perform manipulations?
      2) The PT programs are public and they do include training, research and classifications for patient who would respond to manipulations. (a)
      3) We are trained in orthopedic, neurological and radiological analysis, although I must say that bringing radiology to this discussion is out of place since manipulations have no correlation with radiologic findings.
      4) What is the scientific evidence and therapeutic prove of an “adjustment”? I have found nothing in the literature.
      5) Manipulations are a most safe intervention when the patient is properly screened.

      Sincerely,

      Juan

      a) http://www.apta.org

      1. Hythem Rahman says:

        Juan,
        1. “Who does not believe that PTs are properly trained to perform manipulations?”

        The chiropractic profession believes you are not. Bottom line is do you have as much training as a chiropractor in manipulation? No

        Is your entire focus of your practice manipulation?
        No

        Up until recent years you were not allowed to diagnose spinal lesions and still are not allowed to perform x-rays to determine safety and prognosis of manipulation.

        So tell me why a patient should choose a PT for manipulation?
        When someone needs rehab and exercise/therapy your profession is king, but don’t get into the delusion that your training or execution of manipulation is comparable to a D.C.’s . No disrespect, but that is all we do and I know we do it better than anyone else.
        H.R.

        1. Dan Rhon says:

          Hythem, thanks for your comments. I just want to point out one piece of faulty rationale.

          “Proper training to perform manipulation” and “as much training as a chiropractor in manipulation” are really 2 different arguments. Although I do not know the exact requirements for manipulation training for DCs, you cannot infer that manipulation training is not “proper” because it is not “as much”. Proficiency standards have been established by credentialing and governing bodies, and most physical therapists that include spinal manipulation as part of their treatment plan likely far exceed those standards. Caution needs to be taken to not compare apples to oranges.

          I attended an international conference on research in low back pain in primary care in Denmark last fall, and what stood out to me was what seemed to be a much stronger collaborative spirit between all the various disciplines that manage LBP (physicians, physiotherapists, and chiropractors). Of the research platforms presentations I observed, from an international multidisciplinary community, and to an audience of the same, there was never even a hint of spinal manipulation being inappropriate for physical therapists to perform. Several were presented from the physical therapy community on this topic. I think in a setting like this, that notion would seem foreign, and likely not even worth the argument.

          Respectfully,
          Dan Rhon
          A licensed physical therapist who is (and has for the last 10 years) allowed to diagnose spinal lesions and able to independently order radiographs and MRIs as needed, although never to “determine the safety or prognosis of manipulation”, because absolutely no medical literature exists to support the routine use of imaging for that purpose.

          1. patrick determan says:

            Here is a DPT program At the University of South Dakota It has 1 Credit hour for diagnostic Imaging. Wow and these DPT’s are capable of ordering radiographs and MRI’s when they have no clue how to read them or take them. 136 credit hours this is a PHD program. Doctor of Chiropractic Progams have 4500 contact hours equivalent to around 300 Credit hours. 16 hours depending on the program is Radiology
            Program requiremenTs
            Year One: Fall Semester: Total 23 credit hours Course Course Title Credit Hrs ANAT 711 Human Gross Anatomy (6 cr. required) 1 to 8 ANAT 712 Human Embryology 2 PHTH 780 Basic Research Design & Statistics (1 cr. required) 1 to 2 PHTH 781 Evidence-Based Practice 1 PHGY 730 Human Physiology 6 PHTH 701 Intro to Patient/Client Mgmt. 2 PHTH 706 Client & Community Health Educa- tion in Physical Therapy 2 PHTH 712 Professional Conduct & Ethics 3
            Year One: Spring Semester: Total 19 credit hours Course Course Title Credit Hrs NSCI 731 Medical Neuroscience 3 PHTH 702 Physical Agents & Electrotherapy 3 PHTH 720 Medical Pharmacology 2 PHTH 710 Movement Science 6 PHTH 718 Pathophysiology (4 cr. required) 3 to 4 PHTH 786 Research Proposal Course in Health Sciences 1
            Doctorate of Physical Therapy (D.P.T.) Degree Completion Plan:
            Year One: Summer Semester: Total 14 credit hours Course Course Title Credit Hrs PHAR 704 Physical Therapy Examiniation II 2 PHTH 714 Integumentary Physical Therapy I 1 PHTH 720 Differential Diagnosis (4 cr. required) 3 to 5 PHTH 722 Diagnostic Imaging 1 PHTH 724 Clinical Education I 6
            Year Two: Fall Semester: Total 21 credit hours Course Course Title Credit Hrs PHTH 730 Musculoskeletal Physical Therapy I 4 PHTH 732 Musculoskeletal Physical Therapy II 4 PHTH 734 Neuromuscular Physical Therapy I 5 PHTH 736 Cardiovascular/Pulmonary PT 5 PHTH 783 Qualitative and Quantitative Data Analysis 1 PHTH 787 Research Project in Health Sciences 1 PHTH 790 Physical Therapy Seminar I 1
            Year Two: Spring Semester: Total 19 credit hours Course Course Title Credit Hrs PHTH 740 Musculoskeletal PT III 4 PHTH 742 Geriatric Physical Therapy 3 PHTH 744 Neuromuscular Physical Therapy II 4 PHTH 746 Orthotics and Prosthetics 3 PHTH 748 Pediatric Physical Therapy 4 PHTH 787 Research Project in Health Sciences 1
            Year Two: Summer Semester: Total 6 credit hours Course Course Title Credit Hrs PHTH 738 Health Care Mgmt. and Systems in Physical Therapy 4 PHTH 752 Clinical Application of Diagnostic Imaging 1 PHTH 754 Integumentary Physical Therapy II 1
            Year Three: Fall Semester: Total 18 credit hours Course Course Title Credit Hrs PHTH 762 Clinical Education II (8 cr. required) 1 to 16 PHTH 764 Clinical Education III (8 cr. required) 1 to 16 PHTH 787 Research Project in Health Sciences 1 PHTH 790 Physical Therapy Seminar II 1
            Year Three: Spring Semester: Total 16 credit hours Course Course Title Credit Hrs PHTH 772 Clinical Education IV (8 cr. required) 1 to 16 PHTH 774 Clinical Education V (8 cr. required) 1 to 16

        2. Dustin says:

          H.R.
          I really appreciate your comments regarding this hot-button topic. Maybe you can clarify something in your comment that I found to be alarming. You, a D.C. stated that all your profession does it manipulation. Your words. So, why, may I ask, do chiropractors routinely advertise that they provide much more? Why do they advertise that they provide nutrition (a licensed profession), exercise (depending on qualifications, can be a licensed profession), and physical therapy (a licensed profession)? By advertising that you offer these services, without license to do so, is why other professions have started questioning the profession. These bad apples in the field of chiropractic medicine are diluting your product and pulling the profession from one of manipulations to a jack-of-all-trades approach. If you are truly the best at something, why would you try anything else?

          I assure you that physical therapists are more than capable of performing these techniques. I can also assure you that if a physical therapist only uses these techniques, they are not practicing for very long. Manipulations are taught in our basic education courses, with fellowships offered throughout the country to advance study and practice of manual therapy techniques for clinicians wishing to further their understanding and technique. I assure you that the Fellows of Manual Therapy can perform these techniques with similar ability as any DC. However, they still use these techniques only when necessary.

          I know that this makes it sound like we shouldn’t use manipulation because it is not our best card. However, I would argue that physical therapy is an evidence-based practice that uses the best practice on an individual basis to increase a patient’s gains and rehabilitation. While we may not be as good at manual therapy as your claim, we certainly use it when it is needed the most. I would argue that performing a procedure really well on someone who does not need it will produce no effects. Performing a technique well (not really) on someone who qualifies and needs it will produce real, measurable results.

          1. ?Anthony V. Fasano, DM(P), DC., Ph.D. says:

            Anthony Fasano, DM(P), DC, Ph.D.,

            I have been reading all of the posts regarding manipulation and who is more qualified. I am tired of listening to this.

            As you can see I have a Ph.D. and that is in Anatomy/Neuroanatomy. In that capacity I have taught medical, dental, chiropractors, nurses, and physical therapist anatomy , neuroanatomy, embrology, etc., and as such I can say without the slightest hesitation that I would trust a chiropractor to do my manipulation, although maybe not all, to adjust my spine or anything else the feel qualified to adjust, before I would subject myself to someone who wants to get onto the bandwagon, because it works.

            Chiropractic education can stand up against any other profession, and I can compare it because I was there in the trenches for many, many years.

            There are Physical Therapists, Medical Doctors, I would trust with my life. There are many I would not go near. You all know that there are those in your profession that would be better collecting trash. You do not weed them out, you say they are a small minority. Yet, one chiropractor, who does not belong does one thing that may be questionable and it is on every TV news cast, and becomes the thing to talk about on sites like these, saying that all Chiropractors should not be trusted and you are better qualified..
            All of a sudden you want to compare your anatomical knowledge to that of a chiro. NO WAY. I have been there and most of you have not, PERIOD. You are stating your opinion on what you think you know. Your anatomical knowledge is no where near what a Chiropractor gets and utilizes each and every day, based on there clinical experience, X-rays, MRI’s, just as you are all claiming you do. Why do the PT’s feel they are more qualified? All of the professions should be working together, if they really have the desire to help their fellow man, not stroking their EGO’s.

            Are you sure that is not what you are doing.

    2. Jesse Resari, PT, DPT says:

      Appreciate your points Christopher. Lets call it as it is, DC’ s curtailing PT’s from practicing manipulation thru legislation is an attempt to restrain trade. I’m not comparing I’m making a point Chris. I’m telling you what I feel when nonsense like this continue to distance the chance that our professions can actually work together and collaborate. I’m surprised that you mentioned that most of you are unaware of what we can do. If this is the case, why then does the chiropractic profession keeps on trying to legislate our profession? It doesn’t make sense. To your point of educating your profession, well we’ve been telling you for many years! We are educated in biological science, clinical sciences, pathology, radiology, pharmacology , differential diagnosis etc and yes we are trained to perform manipulation! We are all over the world. We are in universities for god sake. We enjoy close relationship with the medical community etc. We do a ton of research etc. We have specialties, residency and fellowship programs. Need I say more? So I will only say this, before your profession tries to push your thumbs on us and tell us what we can’t do, KNOW US FIRST! Thank you.

  13. Brett J. says:

    Joe, if you knew anything about chiropractic, you would understand that the primary reason we adjust the spine is to remove interference (the subluxation) from causing dys-communication in the nerve system. This manifests in various forms of application (art) and within multiple current scientific models of subluxation (dys-afferentation, dys-autonomia, axoplasmic flow, etc..)

    The nerve system is the foundation we were built on and what differentiates us from Osteopath profession who were originally blood based.

    Everything we do is nerve system orientated. You think we just sit and look at bones for 3.5 years? haha

    You should probably take a look at our curriculum and find out what we actually do.
    http://www.lifewest.edu/current/courses.shtml

    If you have any questions I’d love to chat. Collaboration > Competition

    Brett J.
    https://www.facebook.com/brett.jones.568

  14. Cheryl Sparks says:

    Brett J:

    For those who may be unaware, could you please elaborate on removing interference and the validity of identifying a subluxation complex? While thrust manipulation is effective for managing subgroups of patients with certain musculoskeletal complaints, differences exist in theory and practice for physical therapists and for those trained with more of a straight chiropractic philosophy.

    Cheryl

  15. Kevin Wait says:

    Thanks for your comment, Joe. Love the “collaboration > competition” approach. I’m a PT who works quite closely with a DC on an Air Force base, and we have a very functional working relationship built on respect for each others skill-set. He disagrees with some of the things I do, and I similarly disagree with some of his approaches to patient care. At the end of the day though, we’re both trying to make people feel and move better.

    I will encourage people to read the Bellamy “White” paper from 2012 published by the Institute for Science in Medicine. This paper does an outstanding job of using research to disprove the “subluxation” theory that much of chiropractic is based on. Essentially, the independent authors conclude there is zero evidence supporting these subluxations actually exist, much less do any harm to the human body. Further, the paper provides a concise review and refutes many of the foundational elements of chiropractic theories. So, while I think both professions can and do perform manipulations safely, I am waiting for evidence actually supporting the need for a chiropractic “adjustment” to be safely performed in the first place. PT combines manipulations with therapeutic exercise and evidence-based education (among other things) to facilitate a patient’s recovery of function. The benefits of this approach are well supported by a solid foundation of quality clinical research.

    I respect everyone working hard to make their patients better, and I want to collaborate with the chiropractic profession to facilitate that goal, but I also want an honest debate about the research.

    I’m curious what others think about this paper?? E-mail me for a copy if needed…kevinwait@gmail.com

  16. Brett Neilson, PT, DPT says:

    There have been a lot of great comments on this thread, but I think Christopher Dunn, DC brought up a great point. There is a large miscommunication between our two professions. These issues should not end up in our legislative systems wasting tax payer dollars that can be better spent elsewhere, but rather in meeting rooms between the Chiropractic and PT associations.

    I believe I have a unique perspective from my personal experience living and practicing in WA state (the only state with a “prohibition” on manipulation (defined in chiropractic terms in the WA state PT Practice Act)). For more than 5 years the PT Association of Washington has been attempting to work out these issues in a neutral meeting room, however, the Chiropractic Association is not willing to listen, dragging their feet, and forcing this onto the legislative agenda. More Chiropractors like you, Christopher, are needed in Washington State.

    Brett Neilson, PT, DPT

    Quick points about the PT profession and manipulation:

    – Ling started the physical therapy education program in Sweden in 1813, over 80 years before chiropractic was founded. Ling advocated and developed the use of manipulation, massage, and therapeutic exercises to treat human ailments, which he referred to as Medical gymnastics. (Taken from the PTWA respons to the WSCA White Paper)

    – Physical Therapists have been performing manipulation in the US for more than 70 years. In fact the first published work indicating the use of manipulation by PTs dates back to 1928. (Taken from the PTWA respons to the WSCA White Paper)

    – Washington State is the only state where manipulation is currently “prohibited”. They lost their right to manipulation in 1983 as a plea bargain with the Chiropractic Association to gain direct access. PTWA has been working to regain this right ever since.

    – Physical Therapists are not interested in performing chiropractic adjustments or advertising that we do so. We use manipulation as a “tool” in out intervention toolbox to help our patients achieve optimal functional status.

    – All DPT programs in the country must be accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), which conducts periodic, independent, and objective review of physical therapy education in general and of each physical therapy program in particular, including on-site inspections. CAPTE standards require all programs to demonstrate extensive didactic and laboratory education that they have deemed leads to the safe and effective delivery of spinal manipulation. (Taken from the PTWA respons to the WSCA White Paper)

    – It is not possible to compare physical therapy curriculum and chiropractic curriculum due to the significant difference in curricular philosophy where the chiropractic education is based on clocking hours and tabulating number of procedures while the physical therapist professional education is outcome criteria based.8, 42 In other words, the physical therapy education focuses on providing whatever level of instruction method is necessary to assure that the student can demonstrate safe, effective application of treatment procedures before the student is allowed to practice the procedure on live patients. There is also emphasis in the physical therapy curriculum on clinical problem solving.8 The physical therapy profession intentionally chose this model of education to reflect best evidence-based practice and to ensure patient/client protection and safety. Arbitrary numbers of hours of training does not assure safety and competence; demonstration of safety, skill, and clinical decision making as tested on objective testing methods assures safety and competence. (Taken from the PTWA respons to the WSCA White Paper)

  17. Tom Denninger, DPT, OCS, FAAOMPT says:

    Directed to Christopher, I do not think ignorance of the training that is required of doctors of physical therapy is a justification to put fourth erroneous bills in the name of patient safety. Tim’s argument of us as the safest practioner is a bit tongue in cheek given the shortcomings of the data, and you are correct, to date, chiropractors have performed much more thrust manipulation to the spine than PT’s, but this gap is closing. However, something is to be said that the vast majority of all, especially high quality, research coming out of the past 5-10 years demonstrating effectiveness of spinal thrust manipulation has come from the PT profession.

  18. Jacob Melnick says:

    Brett brings up a few great points, and I’d like to add to his list of references – one of which shows how we can work together as well as be safe and effective with our treatment.

    The UK BEAM Trial shows how manipulation in combination with exercise for patients with low back pain can provide significant long-term relief of symptoms. This study is also interesting because the professionals performing the manipulation are chiropractors, physical therapists, and osteopaths. Even with the varying providers there were no adverse events during the study. Do we have different philosophies on what is happening because of the manipulation? Absolutely. But sound clinical judgement and perfecting one’s technique is what keeps this a safe procedure. I feel it is obvious that physical therapists go through rigorous enough training to justify this as a reasonable and useful technique.

    Now that we know physical therapists are reasonable, safe, and effective with these techniques, can we agree that it would be an injustice to society to prevent us from performing manipulation? I think so. Especially when we have studies, such as Childs et al 2006, that report that patients may be eight-fold more likely to experience worsening symptoms if they do not receive manipulation (by physical therapists in this study). By taking manipulation away from physical therapists we risk decreasing quality of care, increasing healthcare costs, and increasing the number of patients with chronic and recurring symptoms.

    UK BEAM Trial – BMJ, doi:10.1136/bmj.38282.669225.AE (published 19 November 2004)

    Childs JD et al. A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain. Manual Therapy. 2006; (11): 316–320

  19. Jason Silvernail DPT, DSc says:

    Excellent contributions by Dr Neilson.

    I always enjoy the ‘why can’t we all just get along’ comments, as they ignore some basic facts that are just not going away:
    1. Regulatory systems (such as medical licensure) are promoted by rich entrenched groups to maintain their monopoly.
    2. These systems are created and sustained with lobbying money to legislatures.
    3. This process has *absolutely nothing* to do with the quality of education, hours of training, competence, or skill of the professionals involved.
    4. As long as these systems are in place, people will lobby to restrict the practice of others to maintain their economic position.
    5. I agree with the Institute of Medicine of the NIH who says that professional groups should have access to patients and clinical privileges consistent with their training and demonstrated expertise. That has yet to happen in any of our 50 states due to the previous points.
    6. In the US Federal system (like the military for example), PTs like me have full access to patients, treatment within our expertise (including manipulation), and privileges for laboratory studies, imaging studies (MRI, Xray, and Nuc Med) and limited prescription writing appropriate to the practice of musculoskeletal medicine. Published data supports the safety and appropriateness of these privileges but nothing anywhere near this is available outside the military. Certainly it isn’t due to training or expertise.

    The state of chiropractic is not good. Our colleagues in chiropractic are struggling hard, they lead the health professions in student loan default rate, they have low academic standards, nontransferable ‘credits’ from chiropractic school that can’t apply to academic universities, no standardized clinical training in health care facilities learning team-based care, no academic university that will host a chiropractic program and they are facing a saturation of the market. My heart goes out to their students. It certainly is the kind of situation that might call for desperate measures. We should have sympathy for them, and a bill like this latest one in California is likely a symptom of that kind of desperation. I don’t get mad when I see these bills, I feel sad for the desperation this must indicate. At least if their programs were accredited the way other healthcare programs are they could transfer credits and move into a new profession, but as things are now, they are stuck with the debt, a degree that isn’t earning them enough money to pay back loans and make a living, and the prospect of having to start over again from a blank educational slate.

    The state of physical therapy, on the other hand, is excellent. We have low levels of student loan default, high employment rates, high academic standards, programs that (like medicine or nursing) are provided by academic universities, high quality clinical education in hospitals learning team-based collaborative care, estimated need for more and more of our services as the population ages, a strong research base for our practice, and a good reputation with the public and with our colleagues in health care. Dr Sam Homola DC briefly compares physical therapy vs chiropractic school in this post as well which is food for thought: http://www.sciencebasedmedicine.org/index.php/following-the-guidelines-of-science-a-chiropractic-dilemma/

    The battles over restrictions, access to patients, and scope of practice are never going away as long as we have the licensure system we have now. Our best hope is to have a level playing field where clinical privileges are determined by demonstrated expertise and training rather than lobbying money, but we are quite far from that ideal currently.

    1. Andrew Government says:

      The state of chiropractic “is not good”. Evidence, or data please. Otherwise conjecture from a long-time chiropractic skeptic (see Soma Simple for Jason’s “impartial” comments of chiropractic.

      1. Jason Silvernail DPT, DSc says:

        Hello Andrew-
        Still president of my fan club I see. Had you read the link you’d see Dr Homola discussing the issues I brought up, and certainly you’ve seen me post links in support of all those points in the past, you just don’t like what the evidence says.

        For those who are interested, five minutes and an internet search engine will quickly bring you substantiated examples of my points. Things like student loan default rate, academic admission standards, transferability of credits, location of training sites, lack of affiliation with academic universities, and no standardized healthcare training are all easily found with the briefest of searches online.

        Don’t take my word for it, people should absolutely do their own research and come to their own conclusions. Starting with Dr Homola’s SBM archive is indeed a good start: http://www.sciencebasedmedicine.org/author/sam-homola/

  20. Bob Boyles, PT, DSc says:

    As a physical therapist, educator in an entry level DPT program, and haveing taught numerous manipulation classes to DPTs in the US, Europe and Asia, I find it interesting that the safety issue keeps coming up. I teach and live in an evidence based practice world, so if there is evidence that PTs are unsafe, I’d like to see it. I have looked extensively for proof in the literature for it, and have yet to find a shred of evidence that PTs pose a threat to the public. And yet, this is the number one reason that Chiropractors use to support their views to the legislators.

    Then other issue is that of not enough hours of manipulation are in our entry level program. We have argued this point until we are blue in the face. Yet, there seems to be a magiacal number of hours before you are safe and proficient. We test safety and proficieny through practical examinations, not by the clock or number of repetitions. You can do something poorly for a long time over many sessions, does that make you safe and proficient? Obviously not. We have our own standards board and closely monitor accreditation (CAPTE). Another profession had no business evaluating our curriculum, nor we theirs.

    I can speak on this issue because I live in Washignton state, where spinal manipulation os prohibited- by the way, it was a self inflicted wound by PTs’ in 1983 bargaining for Direct Access. It wasn’t imposed because there was evidence of harm or risk to the public. Now we are battling to get it back, because of the evidence supporting it’s use and we are trained to perform it; evidence through research by Physical Therapists in the way of prediction rules, large randomized clinical trials and supported through Clinical Practice Guidelines.

    So, if the arguements againsts PTs are as stated above, I find it almost comical that the Chiropractors in California include physicians in their group of practitioners who are able to perform manipulations. Are you kidding me? They have absolutely no training or experience w manipulation and their entire musculoskeletal training is cursory, at best.

    I’ll close w this thought. There are more than enough spine patients to go around. I could argue that the patients that seek chiroprctic care, are not the same ones that seek physical therapy and vice versa. We can get over this, or we can end up w a feud that lasts into the next century. What do you want the “battle field” to look like when this is all settled?

  21. Dennis Mulcahy, D.C. says:

    The authors comments are clearly agendized and have no basis in reality. Suddenly PT’s are the purveyor’s of all good manipulation in spite of the fact that chiro’s have over 100 years history providing safe manipulation. As pointed out by others, your numbers do not reflect reality. Chiro’s provide the overwhelming majority of manipulative care with an exceptionally low frequency of adverse event. As to others who question the diagnostic training provided chiropractic students, I’d challenge any PT on diagnostic accuracy.

  22. Kevin Wait, PT, DPT says:

    Dr. Mulcahy:

    What specifically are you referring to in this challenge of diagnostic accuracy? Is this a blanket statement regarding everything musculoskeletal in nature?

    I often see patient notes at my clinic where a chiropractor is able to identify a pelvic asymmetry of 1/8″. I am a pretty confident guy, but there is absolutely no way I can honestly tell myself something like that exists reliably.

    1. John Merrick, MA, PT, DC says:

      Mulcahy, You could with more training

  23. Brett Neilson, PT, DPT says:

    Excellent comments by Dr. Boyles.

    Dr Boyles stated a very interesting thought “There are more than enough spine patients to go around.” According to Childs et al in 2004, they cited that next to the common cold, low back pain as the most common reason that individuals visit a physician’s office. Yet, the vast body of evidence demonstrates that low back pain is still poorly managed resulting in billions of dollars each year in medical expenditures and lost labor costs (Childs 2004, 2006). I predict that the bill proposed in CA will only restrict patients access, causing more medical visits, poorer outcomes, and utilization of more healthcare dollars. Is this fair to our patients? As Dr. Boyles stated, there is more than enough patients to go around… I say, it is time both professions think more about patients and less about their “turf” and their wallets.

    One last point, there is something to be said about the Physical Therapy profession and its low reported risk with manipulation. Several on this forum have argued that the only reason PT’s do not have more documented adverse events is because we do not perform as many manipulations. On the flip side, if we can perform fewer manipulations and demonstrate safety of these manipulations in the lack of adverse events, it must not be about the hours or repetitions and more about clinical judgement of knowing when to use it…Thoughts?

    Brett Neilson, PT, DPT

  24. Christine Baniewich says:

    As a DPT student, I fully admit that to date I have had limited clinical experience. However, I have had an excellent education in spinal triage, red flag identification and diagnostic decision-making. Therefore, I can safely and effectively perform a spinal manipulation when this is deemed appropriate. Unfortunately in the state of Washington I may not be able to provide my patients with the best evidence based care possible due to some outdated practice language. I am not advocating to limit other medical professions practice. I will not dictate how a surgeon does his or her job nor will I instruct a chiropractor how to best treat their clients. All I ask is for you to do the same. Let me do my job and let me treat my patient according to my education, skill set and current best evidence.

  25. Cheryl Sparks, PT, PhD says:

    Thank you to Dr. Silvernail for illuminating how and why the chiropractic lobby chooses to wage turf battles over manipulation as a means to limit competition from other health care providers in the marketplace. Fortunately policy makers in California, and elsewhere, recognize these transparent attempts are financial in nature and not in the public interest. There does appear to be a sense of desperation as the arguments put forth against physical therapists are unfounded. In the most recent attempt in California, Senator Yee suggested trained professionals performing joint mobilization, other than chiropractors, are engaging in unethical practice. This is completely nonsensical.

    It is difficult to even begin dialogue on ethical practice without an understanding the dogmatic, almost religious, embrace of the subluxation theory on which the chiropractic profession was established. As noted by Dr. Homola DC, this premise has been professed by chiropractic educators for over a hundred years and remains the fundamental rationale for the management of musculoskeletal dysfunction, as well as for conditions such as otitis media, multiple sclerosis, chicken pox, menstrual cramps and infertility, to name a few. In my experience, chiropractors typically are not known for their ethical practices, rather for the loud minority who take out full yellow page ads offering a ‘bait and switch’ of free examinations and x-rays, which low and behold discover a variety of subluxations that can only be “cured” through a series of adjustments. Medical and scientific communities do not support subluxation as a precursor for organic disease. Physical therapists do not “adjust” nor do they use manipulation as a panacea to restore and maintain health. There is a solid base of peer-reviewed literature identifying subgroups of patients most likely to benefit from manual intervention. Physical therapists operate well within their scope, utilizing thrust mobilizations and exercise provided a patient meets certain criteria and is likely to show a predictable positive response based on the available evidence. To suggest that this is unethical practice is preposterous.

    Because the chiropractic profession currently exists in a such a controversial state, physical therapists, and others trained in performing manipulation, (safely, effectively and judiciously,) will continue to see legislative attempts that are cloaked in silly arguments and unfortunately to the detriment of patients.

    1. Dennis says:

      Support your statement that the majority of research in the past few years comes from the PT community. As a PT I doubt you are familiar with, or care to invest time in understanding the contemporary chiropractic literature (as I have little additional time to invest in comprehensively reviewing PT literature). The fact is that we would both benefit from understanding the broader scope of literature, regardless of source, and as long as the data provided hails from a well designed study. Otherwise, I see absolutely no truth or accuracy in your statement.

      1. Cheryl Sparks PT PhD says:

        Dennis,
        Thank you for your comment. I have a keen interest in manipulation and manipulation research, and I am in fact familiar with the breadth and scope of the literature, regardless of the discipline, as are many of the contributors on this thread. At the risk of beginning a debate of limited relevance, the comments by Dr. Denninger and Ms. Campo are reflective of the growing contributions of high quality evidence made by physical therapists. To be clear, by stating high quality, I am referring to those peer-reviewed publications that assist in guiding treatment decisions: meta-analyses, systematic reviews, and randomized controlled trials as indicated by the Center for Evidence Based Medicine. (Although this is not to say that studies lower on the evidence hierarchy do not have value. They do.) I am also referring to the impact factor and the rigor of the journals in which such papers are published. For instance, studies on manipulation are frequently published in peer-reviewed journals with readership in several countries including JMPT, Spine, Manual Therapy, the Journal of Orthopaedic and Sports Physical Therapy, and the Physical Therapy Journal. JMPT carries an impact factor of only 1.4, Spine and Manual Therapy 2.1, JOSPT 3.0 and the Physical Therapy Journal 3.1. For perspective, Annals of Internal Medicine has an impact factor of 16.7. The Journal of Chiropractic Medicine and Journal of Chiropractic Humanities are not ranked.

        I would like to refer you to following publications by Bigos et al (1) and Shekelle et al (2). Of the 27 reports of clinical trials meeting the criteria for review in these studies, physical therapists contributed to the majority (3).

        “Physical therapists provided spinal manipulation in more reports of clinical trials than did medical doctors, more than twice the number than did chiropractors, and in 4 times the number than did osteopaths.”

        A quick search for spinal manipulation in PubMed clinical queries swiftly identifies a number of additional and more recent high quality papers for your review.

        References:

        1. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; December 1994. AHCPR Publication No. 95-0642.

        2. Shekelle PG, Adams AH, Chassin MR, et al. The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Santa Monica, Calif: RAND; 1991. RAND publication R-4025/1-CCR/FCER.

        3. Johnson D, Rogers M. Spinal manipulation. Physical Therapy. 2000;80(8):820-3.

  26. Jennifer Campo says:

    The majority of research in the last several years on spinal manipulation has been done by physical therapists. Physical therapists treat from a different frame of reference than chiropractors. The selection of intervention is based on the specific presentation of each individual patient we evaluate. Furthermore, no interventions are performed until we have done an appropriate history and physical examination to insure that the patient is indeed appropriate for physical therapy care. I am at a loss to understand why the chiropractic community continues to cite published evidence designed and conducted by physical therapists to demonstrate the effectiveness of their interventions?
    PTs do not use spinal manipulation on every patient that walks into our clinic, nor do we expect manipulation to help every patient. It is just one of a number of effective interventions that we provide to our patients. The evidence has clearly demonstrated that Physical Therapists can improve patient outcomes utilizing manipulation in combination with exercise and we should be able to use all effective techniques that we have the expertise, research base, and knowledge base to employ.

  27. Jason Steere says:

    This has been an interesting thread of posts. As a physical therapist, I am of course biased. I think the point of the original post, which was also supported by several others, is that it is getting to be trying to continuously have to defend our right to perform this intervention. While the original post and others provide some good evidence for physical therapists to be confident with our use of manipulation, I think we may want to take some other things away from this discussion. While we can make a point that we do have an adequate history in the utilization of manipulation, the length of this history does not ensure that we provide safe an effective manipulative intervention today. The data supports the fact that through the recorded history, PT’s have provided manipulations safely and effectively, but this also does not ensure that we will continue to do so as our use of the intervention grows in accordance with the supportive evidence. Our training in the psychomotor skills and clinical reasoning needed to provide safe and effective manipulative intervention is improving every year as is the scientific evidence guiding us, but this still does not provide us certainty in how and why we use manipulation. It may create more liberal use throughout physical therapy practice. I think it is very important that as we take a stand and work to support our position, we should be cautious to not become over-confident in our history, our training, and our use of manipulation. This over-confidence may make everything start to look like a nail that we need to use this tool on and could possibly impair our judicious use of the intervention. Should this happen, our numbers of adverse events may rise.

  28. It’s interesting that several PT’s on this page argue that PT’s are the “best choice” to provide manipulation because it is just one tool in their toolbox to help patients. As a evidence-based chiropractic physician, I can affirm that manipulation is only one of my tools as well. Not every patient needs or should be manipulated. There are many of my patients that instead are treated with manual therapies other than manipulation, therapeutic exercises, kinesiotaping, neuromuscular re-education and acupuncture. As for the patients receiving manipulation, 95% of the time their treatment plan is multimodal and includes a home exercise program at discharge. Yes, I discharge patients on a regular basis.

    For the record, I don’t mind PT’s providing manipulation if they are trained to do so. What I do mind is broad-generalizations that seem to do damage to the chiropractic profession, which are not based on the facts. In every profession, there are going to be a few bad apples. I know several “bad” PT’s, MD’s, DO’s, MT’s and DC’s. I do not speak poorly of the profession based on these outliers.

    1. Tim Flynn PT PhD says:

      Erin,
      Thank you for your comment. I agree with your statement that we should not speak poorly of a profession based on outliers. I also applaud your move to an evidence-based care model. Unfortunately the majority of the chiropractic profession still is wedded to subluxation theory including your professional association. In two studies cited by Mirtz et al. 98% of chiropractors believed that “most” or “many” diseases were caused by spinal misalignments and over 75% of chiropractors believed that subluxation was a significant contributing factor to 50% or more of visceral disorders (such as asthma and colic), an implausible idea that is not supported by evidence. I would encourage you to contact your state association and insure that they are not wasting your resources resisting Physical Therapists in Illinois as this has and continues to occur. Our professions will be much stronger as collaborators not as adversaries. It would also be helpful in the future if you would testify to your above statement to state legislators as reasoned debate is frequently lacking.

      1. Josh says:

        Anecdote, but I believe my generation in the profession is working hard to overcome this. Sadly, the easiest way we overcome it is by abandoning the ship and sending those interested to PT and DPT programs. No joke. At least once a month a younger student-athlete asks me about chiro school and I suggest, “If you want to practice like me, get your DPT.” What’s sad is that I’ve spent more money and fought a harder battle with my education than someone who will go through DPT because I’ve had to wade through the excrement.

        Debating with the typical “straight” chiropractors has been like having a religious discussion, but we are gaining ground. Patients demand results and are paying for results, and those that don’t deliver are dying or becoming consultants.

        Joshua VanBuskirk, DC

  29. Dear Dr. Flynn: All health care professsions are moving towards evidence-based care. Evidence based care has three components: Published research, patient preferance and clinician’s experience. As far the first component, most peer-reviewed publications did not come into existence until the late 50’s and 60’s. Some that are out there now just recently have been established. Until the 1987 Wilke et al vs the AMA trial, many medical publications refused to publish articles written by DCs. Chiropractic manipulation (adjusting) has been performed since 1895. There have been some adverse events. Adverse events happen in many health fields. All of us try to reduce the risk as much as possible. Education is one way. Chiropractic education has advanced over the past 100 years, much the same way has physical therapy education. As Dr. Ducat has mentioned, bashing other professions is unproductive. I applaud the PT field for continuing to expand its offerings to the public. The chiropractic field has also expanded. Many DCs do not adjust their patients. They offer other forms of care, within their scope of practice laws. Whether PTs or DCs manipulate ‘safer’ is an arguable point. I have been a practicing DC for over 37 years and have been in chiropractic education for 20 years. You brought up a point about state associations. I am currently the president of the Missouri State Chiropractors Association. It is in our mission statement to work with other professions for the betterment of our patients. Your statement about not being adversaries is a good one. Hopefully, the Missouri PT association will listen to you. Almost three years ago, the PT association took action through the Healing Arts Board to try to limit our ability to provide physiotherapy as an adjunct to chiropractic manipulation. It took a court decision to stop that. I would rather get along with the PT association than fight it.

    1. Tim Flynn PT PhD says:

      Patrick,
      Thanks for your comment. I assume that you do not provide “physiotherapy” since you are not a physical therapist, please correct me if you are. Just as you would not want me to advertise and provide “chiropractic” as I am not a chiropractor. I have no problem with your profession using various physical modalities (if you are adequately trained), however, please do not call that “physiotherapy.” Physiotherapy or physical therapy can only be provided by a licensed physical therapist. Just like “chiropractic” should only be provided by a licensed chiropractor. Having published extensively on manipulation (including in chiropractic journals) I do provide spinal treatments that include manipulation. I do not “adjust” the spine as despite your professional associations stance a subluxation is an illusion without scientific evidence.

  30. Tim, physiological therapeutics have been a part of the chiropractic educational experience since 1916. In a ‘gentlemen’s agreement’ in the 1960’s, the PT profession and the chiropractic profession in Missouri divided the terms, physiotherapy and physical therapy between them. Perhaps in your state, that did not occur. About the word, ‘chiropractic’, unfortunately, some research articles that were published about the adverse events that could occur with manipulation, lumped all manipulation performed by MDs, DOs, PTs and DCs into one category and called it ‘chiropractic manipulation’. I am sure that you weren’t one of those authors. However, your comment does highlight the reason why we need open communication between our professions in order to set proper terminology.

  31. Dr. Sage says:

    I have been I chiropractor of 13 years. Prior to becoming I chiropractor I studied pre-physical therapy. I received a BA from SFSU. I’ve done multiple internships in PT. I also have a certification in massage therapy and have accomplished all levels of ART and Graston techniques. I always aspire to learn more and I am currently enrolled in a 3,000 hr acupuncture program.
    I have a thriving clinic that helps many people in my community. Here’s my advise to a physical therapist insterested in expanding their scope of practice to include chiropractic manipuation. Enroll in a chiropractic college. You will learn so much and help your patients when you understand the science and art of chiropractic. Please do not think that your training in PT college is equivalent to chiropractic college. Chiropractors spend 5,000 hours learning prior being able to sit for a state board examination. There is no way a physcial therapist is able to “adjust patients” without going through the proper training processa physical therapist risks injury to patients.
    Over my years of chiropractic, massage, and kinesiology practice I have become interested in helping patients my using the healing art of acupuncture. I know my chiropractic education does not make me an expert in this profession and this is the reason I’m in the process of EARNING my MSTOM (acupuncture master degree). Signing up for an acupuncture seminar taught in a 100 hour class format does not make me a quaified acupuncturist! And so, physical therapists should not claim to be able to “adjust” their patients with out a chiropractic degree.

  32. josephbrence says:

    Dr. Sage,
    I find it admirable that you are always wanting to learn more. But that stated, aren’t the theoretical foundations of acupuncture and chiropractor at odds with each other? It is more than gaining more “tools for the toolbox” (I actually hate this phrase—), when we begin to take on theoretical constructs that are at odds with each other (especially in biological plausibility). This leads me into your suggestion that those PT’s who want to provide chiropractic manipulation enroll in a chiropractic college. To this I agree. But I think there must be a distinction made between a “chiropractic manipulation or adjustment” and a “thrust manipulation” which we provide as Physical Therapists. The concept of when to provide a HVLAT differs between our professions (this is quite important to distinguish) and the notion of the physiological processes which result also differ. So this stated, we do not provide a chiropractic adjustment and do not subscribe to the notion that the majority of diseases are a result of subluxation of the spine. In my own opinion (based off my interpretation of the best available evidence), manipulations likely have some effectiveness in the reduction of pain (and potentially stiffness) in a subgroup of individuals (who have the expectation that it will work) and the effects are likely a combination of neurophysiological and placebo. To claim they do much more than this is not rooted in the best available evidence (if I am incorrect, I am more than happy to review your articles).

    So this leads me to the contention that that the application of a HVLAT is truly that skilled. Yes, formal education needs to be provided (especially to determine when NOT to provide one), but I would argue it is much easier and requires much less education than many argue. Does one need 5,000 hours (I am taking this as your argument)?—I think this is quite excessive and likely exceeds the number of hours necessary to learn a surgical procedure.

  33. josephbrence says:

    Btw, I am not “anti-chiro” and am currently working on a paper with Peter Thomas (Pittsburgh, PA) and provide research reviews for Research Review Service with Shawn Thistle (Toronto, Canada). We can work together, as Tim contends, but the notion that one is “more skilled” than the other at something that requires little “skill” is absurd.

  34. Jesse Resari, PT, DPT says:

    Dr Sage,

    Thanks for you comment and your commitment to your patients. I must opine however about your argument that for PT’s to manipulate they have to attend chiropractic school. I find that ridiculous. PT’s are not doing “chiropractic adjustments.” This is a common justification by DC’s when they talk about PT’s doing thrust manipulation. Oh PT’s want to do ” adjustments” so theyre invading our scope. I’m sorry but that’s nonsense. No one owns manipulation. Joint manipulation does not equate to chiropractic. I’m not going to elaborate anymore why because its been discussed here many times over. Please see Dr Sparks and other comments. Thanks.

  35. Kevin Lulofs-MacPherson says:

    Before diving into my I thoughts regarding this topic, I will state that I’m a physical therapist that uses educates other individuals on the use of manipulative care. That said, I believe this interprofessional fighting is a complete waste of time. Evidence-based physical therapists provide manipulation to their patients who are deemed appropriate by research. Evidence-based chiropractors provide corrective exercise is based off noted impairments as opposed to reimbursement. While both of our professions have individuals that would/should be deemed quacks by anybody with rational mind, the focus of our professional bodies should actually be on limiting the overutilization of surgical care for back pain, which is been proven to have much higher risk than any of the interventions performed by either of our professions. We squabble with each other while more and more patients are unnecessarily subjected to risks of infection, further disability, and death on a daily basis. It’s time we work together to rid our professions of quacks and work towards our professions’ mutually stated goal, patient health.

    1. Dale Giessman, DC says:

      Sorry I replied under the wrong post. This one is excellent….Why would a patient be subject to surgery before being offered all the conservative options….it should be malpractice.

  36. Bruce C. Carroll, D.C. says:

    What an interesting forum this is. Quite the array of emotion and opinions. I have seen some thrust manipulation techniques, osteopathic manipulation, and many chiropractic adjustment techniques. The Art and Science of adjusting/manipulation is a challenging one, to say the least. Inevitably the physical therapist will in all probability gain access to this market. A market no one wanted for so many years except DC’s and DO’s and perhaps a handful of enlightened PT’s.

    No one knows it all, some know more than others, some will borrow and called it their own. Thirty-two years in private practice has taught me a few things. NO ONE fixes everything. Money motivates too many.
    If you expect to be good at this work and help the really difficult cases, you better respect the spine, and search specifically and correct specifically, the involved segment(s). Otherwise, you will never know what got the patient well or more troubling, why they got worse.
    Research is important, of course, and there is all kinds of it out there. If you can’t find it you aren’t looking hard enough. Chiropractic Colleges all over the country have PHD’s running research projects. So the info is out there. Bottom line research doesn’t fix patients. The practitioner’s, brain and hands do. Those who can find the problem will fix the problem.

    1. Dale Giessman, DC says:

      Kelly, so sorry to hear your problems with the chiro profession. I’m in it now for 25 years and have great relationships with my local community, local physicians, PT’s, massage therapists. Sure I agree with some of your concerns. I also pull my hair out when a patient has been offered surgery prior to a trial of chiropractic or manipulative therapy by someone with great skill in it. Work your circle of influence and provide the best care to your patients that is possible…this political crap is for the birds.

  37. Kelly Hutson says:

    As a practicing chiropractor for 10 years, I wish our profession could learn more from the physical therapists. I’ve been blessed enough to learn from some great PT’s such as Gray Cook, Charlie Weingroff, and Kyle Kiesel, and they’re all very open to chiros and PTs working together.

    The physical therapy profession has their crap together and I wish the DC’s could follow their lead, but the big problem is that the old dogmatic, subluxation based guys that hold the purse strings of the profession. Every time the ACA and independent state organizations try to advance anything for the chiropractic profession, the ICA lobbies against it because it’s not “chiropractic”. You don’t need 3 years of spinal manipulation classes to be a proficient manipulator, just like you don’t need hospital residencies in PT to be proficient with rehab in a general population.

    I really wish our professions could get along. I appreciate the PTs and learn more from them than I do from DCs. I would go back to school and get out of chiropractic altogether if I had any desire to miss my kids growing up, because at this point I’m embarrassed to be associated with many chiropractors and our governing bodies.

    1. Jim says:

      Wow Kelly- sounds like you made an uninformed and ignorant career choice- and now you are spewing the sour grapes you have to eat.

      I am embarrassed to have you, someone who would make such a bad and uneducated career choice, associated with my profession.

      Do yourself and my profession a favor and get out- It is no fault of my profession it’s your fault.

  38. Andrew Welling DC, CCSP says:

    I just read the post on this blog after one of my friends posted it on a facebook page that many of my like minded colleagues use to stay in touch. For the life of me I cannot understand why any profession wants to inhibit another from doing something that they are trained to do.

    The assumptions in this blog are obviously skewed but that is besides the point. I work in a clinic (that is not funded by the government) that has chiropractors and physical therapists working side by side. We all realize that our skill sets are a bit different but when we work together we see our patients get better quicker and usually have longer lasting outcomes. (No there is not published trials on this it is just common sense).

    I would submit to both professions that if we were to spend more time working together that not only would we enjoy our practices more but we would see that the collaboration of our efforts would yield results in the outcome of higher quality patient care that cannot be achieve by either profession alone.

    If you have a clinic and want to own your market. Toss your ego aside and find chiropractors and physical therapists that are great at treating patients and are able to collaborate their care plans in one setting.

    Enough is enough guys/gals, lets work together and break down the walls that prevent our patients from receiving the best care possible that comes from a collaborative effort.

  39. Dale Giessman, DC says:

    Dr. Welling, So I’ve too worked hand in hand with physical therapist over my 25 year career, sharing office space and collaborating on patients. I agree….Please don’t get into the battle of safety because the research posted has bias and there really isn’t research to prove safety difference between providers. I do however believe that a standardized test on clinical knowledge and diagnostic skills should determine who can even use different modalities such as manipulation in their practice. I also believe that DCs should be able to move across boundaries like the DO has been able to do. Why should the letters after your name and not the knowledge and skills you possess determine your scope of practice. This is a little archaic to me.

  40. Of course there are more cases of incidence with DC’s than PT’s involving high velocity low amplitude manipulation. DC’s perform the loin’s share of manipulations. It’s not an accurate representation of literature to use that to say PT’s are more safe. If two kids are picking apples, Johnny picks 5 and drops 2 and Julie picks 300 and drops 3 you wouldn’t say that Johnny is the safer apple picker because Julie dropped more. Julie has a 1% drop rate while Johnny has 40%. I’d go with Julie any day of the week.

    Having said that, there are individuals in every profession that are less knowledgeable, less skillful, or less safe than the public deserves. Those are the sad facts. PT’s, MD’s, DC’s, and other professions have many exemplary practitioners. If you need to assert that you can do something, do your profession and mine a favor and don’t kick dirt on us. Your blog post is like school yard antics.

  41. Dr. William Taylor says:

    Not sure what you need to do to become a “doctor of physical therapy”, but coming from a neurologist who refers many patients for PT and Chiropractic, the manipulation training that a PT received pales in comparison to a DC. No chance I refer 1 of my patients to a PT for spinal manipulation….none, and I don’t care how much skewed data and bogus numbers you post. Stick to what you’re good at, otherwise just comes across as sour grapes.

  42. I have an interesting prospective on this article. I am dual licensed, one in PT, and one in Chiropractic. I have herd the infighting for years and years. The fact is both fields belong in the mix of health care. I think that the PT’s don’t realize the education that a D.C has, and how in so many circumstances PT’s can bill and get paid for some modalities that the D.C. can not.(Medicare for example)My PT brain often thinks that the PT field doesn’t realize or appreciate their ability to get hired in hospitals, clicics, and are more accepted by the US population. The medical profession does refer to D.C’s but not to the extent of the PT field. My opinion of the PT manipulating the spine is to leave this alone. I don’t think taking a weekend seminar on manipulation is adequate. Like Rodney King was quoted as saying “can’t we just get along”

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