PTAs and Joint Mobilization – Where Are We Today?

The Debate

The topic of physical therapist assistants (PTAs) performing joint mobilizations has been one that is not new to this profession.  It is one that often causes the hair to raise on the necks of both manual therapists and PTAs alike.  There is a deep history of where this debate has come, but recently it has been conversations with colleagues, many of them PTAs, that has sparked the question:  where are we today with PTAs performing joint mobilization?

 

The Personal History

I feel I should add some personal history here with my experience with PTAs.  As a clinician, my experiences with working with PTAs spanned from both the inpatient to outpatient setting.  I saw value where they assisted in my role as a PT, but I also saw where the quality of care was less than optimal.  I saw PTAs who blindly followed the same exercises/interventions for a given patient presentation/diagnosis, particularly in the outpatient setting.  At the time, I placed the blame on PTAs. I thought they sucked.

However, isn’t it the PT who owns the plan of care – the very plan that guides the PTA?  Isn’t it the PT who is supposed to ensure the PTA is appropriately treating the patient?

 

The Professional History

With this is mind, I felt that I should have some stake in trying to improve both ends of this situation, so I got involved in PTA education.  This is where my exposure on the entry-level side to the topic of PTAs and joint mobilization was reinvigorated.  I had been very familiar with the APTA and AAOMPT position statements regarding this topic, which clearly state that joint mobilization (peripheral/spinal mobilization) is only for the PT to perform.  However, CAPTE has muddied the waters in 2012/13 when releasing a position statement essentially stating that PTAs can perform Grade 1 and Grade 2 mobilizations because it doesn’t require the expertise of a PT (see more about this here, here and here).  If this doesn’t make the water  even muddier.

Now if you are asking why these changes have occurred, they were based off of a FSBPT survey study published in 2011 regarding PTA practice where they found that a small percentage of PTAs were using peripheral and spinal joint mobilizations (43% and 28%, respectively).  Thus, CAPTE stated that they support the training of Grade 1 and 2 joint mobs.

 

So, where does this lead us to today?

 

FSBPT has recently published an updated 2017 survey study regarding PTA practice, an update to the 2011 study.  When looking at the data (skim to appendix D-5, under manual therapy techniques), they found that:

  • 56% used peripheral joint mobilization (n=266)
  • 36% used spinal joint mobilization (n=267)
  • Interestingly, 26% performed peripheral thrust manipulation and 15% performed spinal thrust manipulation
  • Of those using these techniques, they were performed “a few times per year” on average
  • The PTAs surveyed stated that these techniques were moderately to very important for entry-level safe and effective performance

 

So, now what?

 

Hopefully you can see the deep debate, history and little clarity we have with this topic.  This has sparked many recent conversations with colleagues on where we are and what the future holds and I felt that it would be good to get some input from our readers.  I feel as though I have more questions than answers, here are a few:

  • Are we doing more harm than good when completely ignoring the fact that PTAs are using joint mobilization?  This becomes the wild west where we leave their education up to whoever whenever which will lead to much practice variation.
  • Are we putting manual therapy up on a pedestal by saying it is an intervention that requires constant evaluation/assessment when exercise requires a fair bit of this as well and PTAs perform all types of exercises with our patients?
  • What defines manual techniques?  Isn’t manual stretching manual therapy?  That looks a lot like physiologic mobilizations.

Please, share your thoughts on here or tweet me @ShepDPT.

 

39 responses to “PTAs and Joint Mobilization – Where Are We Today?

  1. I bet that this great post will generate a ton of useful(and unuseful!) commentary. Question: if physicians assistants can inject tendons, and perform surgery to certain degrees, and if our profession supports innovation, then why shouldn’t qualified PTAs perform mobilization(and perhaps even manipulation?)?

  2. Drew says:

    1st, that FSBPT survey is skewed. You will not get a straight answer to that question as long as so many clinicians feel it is contrary to APTA statements. I feel the numbers are much higher than the survey showed.
    2nd, you are dead in with the educational aspects. With no minimum standard of education, and no requirement from CAPTE to teach mobs, there is a large variation in the profession when it comes to the education of PTA’s pertaining to joint mobs. Some schools teach it to competency, others teach concepts only with no competency, while others don’t teach mobs at all. That leaves the education to the PT in the clinic with verification of competency.
    PTA’s are skilled enough to perform joint mobs and would benefit many clinics by being able to perform these techniques openly, without worry of violating APTA, or CAPTE standards. To do this, we must fix the educational aspect first, as this foundation of knowledge is what builds technical proficiency and trust with patients and clinicians alike.

    1. Mark Shepherd says:

      Thanks, Drew. I agree that the FSBPT survey is skewed. The sample of those answering the questions appears, if I read it correctly, really low (only around 260 folks). That is not a large sample to base data off of, but it is something. I can say from my own experiences, almost every PTA I have come in contact with has performed joint mobilizations. Agree with your thoughts on foundational skills and variation. If we avoid any instruction, I just worry that PTAs will get taught onsite without a good foundation. Let’s be honest, this happens anyway, but at least they would have something to compare their experience to. Appreciate the comment.

  3. Brendon Larsen, PTA says:

    My 2¢. It’s inconsistent to send patients home with self-mobilization exercises (patellar mobs, for example) but then wring our hands regarding whether or not trained healthcare professionals. ‍♂️

    Give your patient a quick quiz regarding bony landmarks, mob grades, and end feels and see how they do. Then ask any PTA the same questions.

    1. Brendon Larsen, PTA says:

      P.S. that emoji was allegedly a facepalm on my phone.

      1. Mark Shepherd says:

        Thanks Brenden. PS – I still like the emoji. Thanks for reading.

    2. Stephen McDavitt says:

      Difference is, patients feel and control what they do to themselves. Arthrokinematic induction loads during manual techniques are not controlled by the patient. During joint mobilization /manip the competent clinician will continuously and carefully assess patient, joint and tissue responses to forces on tissue load, tolerance, component joint motions and end feel.

      1. Mark Shepherd says:

        Steve – with this thought in mind, I wanted to get your perspective on something I have been pondering. What is your viewpoint when someone states that PTAs can transfer patients in a hospital setting per the POC, many of whom are moderate to max assist and have many comorbidities. These patients also may not have full control themselves and the risk is high if not skillfully done. Curious to see what your thoughts are on this as it relates to this topic!

        1. Stephen McDavitt says:

          I assume you consider this transfer your describing as a therapeutic intervention. So I say based on comorbidities and risk such as ventilated or some other pathological fragility “that requires immediate and continuous examination and evaluation throughout, it would not be exclusively delegated to a PTA but a PTA would assist the PT. The issue of the event or induced intervention being delegated rests on; ” does it require immediate and continuous examination and evaluation throughout the intervention”? So in manual therapy I say a simplified model might be if you can meaure the induced movement with a goniometer, likely you can delegate. since arthrokinematic load delivery reqquires immediate and continuous examination and evaluation throughout and you can’t directly measure arthrokinematics with a goniometer.

  4. Jody Wolowicz says:

    The PT profession and education has grown to allow direct access requiring PT’s to thoroughly screen pts. rather than having them go to the MD. PA’s inject tendons, assist in surgery (sometimes performing part of)…. Why shouldn’t a properly trained PTA be able to perfrom joint mobilization? The majority already are.
    The PTA profession is growing not going away, so should the skill set and education. We should be advancing this profession like we do PTs, not keeping it in the dark ages

  5. Brian D'Orazio DPT, MS, OCS says:

    This is a complicated topic and embodied in that topic is the question of how we view the role of the PTA. Are they an assistant, as originally conceived, or are they a substitute as the PA has become in medicine? Do we direct a PTA in a specific mobilization for a specific purpose, or do we allow them to use their judgement as they see patients with a large degree of autonomy?
    In my experience, PTA’s are more commonly used as a PT substitute than as an assistant, which I view as a problem. But, can we teach a PTA to mobilize with direction from the PT…yes, in some cases. Should we allow a PTA to use their own judgement as to how, why, when and with what patient they mobilize/manipulate? In my opinion, we need to first answer the question of how we utilize a PTA for patient care in general.

    1. I am A PTA of 25 years, first and for most no matter how long I have practiced I still discuss with PT concerning any mobilization techniques. . I never decide to do anything that is not on PT POC, it is not in our scope to make that call. It’s not that I do not feel I may not have good judgment but again not in my scope. I do spine mobiliztion in the clinic I work in even up to grade 3 and 4 if it is in POC, or discuss with PT my thoughts.. I have been trained by PT’s and been given consent to perfom and I do feel confident in doing so.

      1. Mark Shepherd says:

        Thanks for posting, Annette. I was wondering if you feel you have had opportunities to learn joint mobilization outside the PT clinic? Do you feel like there is large variability in how joint mobilization is performed by PTAs because of this?

  6. Laura Miele says:

    Mark, Drew, Brendon and Jody, I concur with your insightful commentary. I also believe It is time for the profession of physical therapy (PTS and PTAs) to move beyond encapsulated points of view that focus on internal turf wars versus the larger picture of healthcare provision and improving access to under served populations. Consider that an EMT-Basic provider with approximately 6 weeks or 150 hours of training provides basic life support under the supervision of a physician medical director. Who argues whether or not the EMT performs continuous evaluation and treatment? Now contrast this with a PTA with an average of 77 weeks of formal training and a profession asserting these PTAs are insufficiently qualified to mobilize a joint. This PTA has been fortunate to work with outstanding PTs, willing to advance not only the profession, but the skill level of those extending the provision of their services. I am of the opinion that a PT as an autonomous healthcare practitioner is quite capable of safely delegating PT interventions of their choosing to PTAs. Are we serious about being a “doctoring” profession? IF so we need to seriously rethink these longstanding position statements of the APTA and AAOMPT that go beyond attempting to limit the scope of a PTA but also seek to limit the education of PTAs.

  7. Phi Gainan says:

    I have worked with PTA’s that in my opinion were better clinicians than many PT’s . I have worked with PT’s that I would be afraid to send my own family to. I think it is really case by case as who the therapist is and their experience and aptitude. Some individuals just ‘get it’ and conversely, some don’t. I heard this many years ago that the graduate (either a PTA, or PT) is entry level. I believe this is the case. it is up to the individual as to how they want their career to unfold.

    1. Mark Shepherd says:

      Agree. If this is the case, I feel there is little to nothing out there to meet the PTA to help frame joint mobilization. Maybe this is because of the position statements from our professional organizations, but is interesting to think about.

  8. Most of the joint mobilization /manual skills that I use, I learned after formal PT education in the 80’s. In most CE courses, I learned side by side PTAs . I don’t recall courses being closed to PTAs. I believe the best use of a PTA is to treat as appropriate according to the plan of care, as directed by PT. Meaning it’s up to each PT to teach, verify and direct those skills if the treatment plan requires it. Perhaps the survey and the position statements do not accurately reflect what’s happening in the trenches.
    CMS plans to de-value PTA skills in the future by reducing payment of PTA provided care. That doesn’t help us either.

    1. M. DePutron says:

      I have long believed that the PTA program should be a Bachelor’s Degree, allowing them to learn skills such as jt mobilizations, along with other manual techniques. They take time and direction to learn correctly and with the ongoing changes in the PT profession, we have less time to work with our patients and perform in depth documentation, let alone having the amt of time to teach many of the manual techniques properly and safely. There are CEU courses that PTA’s can and should take. Finally, with the proposed actions of the CMS, don’t be surprised if other ins companies follow. Let’s face it, we consistently get paid less for our services while the costs of doing business continue to rise. If PTA treatment payments are decreased, they will become obsolete. We increased the educational demands of PT’s to obtain the title of Doctor, but we seem to ignore the progression of the PTA profession. And isn’t it about time that the APTA came up with national standards/rules/procedures/laws instead of having different rules for PT’s, PTA’s, ATC’s in different states. We are in need of national standards to improve the credibility of the profession.

  9. Stephen McDavitt says:

    What is the bottom line in this issue?
    1. We need to remember that it is the physical therapist that has the scope of practice and it is the physical therapist assistant that works under the direction and supervision of the physical therapist that performs a scope of work under the physical therapist practice.
    2. Silence in practice acts does not provide a sanctioning indication as to what a physical therapist or PTA “can do”. Competency is king. Competency is what enhances patient safety and efficacy. Peer-sanctioned competency therefore should be the determining element in authorization for the application of clinical interventions.
    3. Is it that physical therapist assistants are performing peripheral joint mobilization or the performing passive ROM (PROM)? These two interventions are quite different since peripheral joint mobilization/manipulation is delivered via arthrokinematic principles which require multidimensional immediate and continuous examination and evaluation throughout the intervention as compared to (PROM), which is applied through osteokinematic movements. The competencies and issues relevant to applied science and patient safety and efficacy are far apart for these techniques. For instance, when arthrokinematics are applied in mobilization/manipulation the patient has little to no control on therapeutic force induction, where as in applying osteokinematic principles in PROM, the patient can assist, control or block induced forces.

    What seems to confuse some individuals and has shown up in follow-up survey investigations is that both types of movement interventions move joints and can be billed under manual therapy which in some cases certain individuals would consider both being the same, yet again, the indications, requirements for competency, safety and efficacy are very different.

    4. The question then becomes can a PTA already fully scheduled within the two-year program attain the appropriate knowledge, skills and abilities to demonstrate competency with mobilization/manipulation techniques? If you believe that, there are other issues and fallout concerns for physical therapists and others with a scope of practice that need to be considered and are described below.

    What is the PT: PTA direction and supervision algorithm as defined by APTA?

    PTA Direction and Supervision Algorithms Step-by-step problem-solving diagrams to guide PTs and PTAs.

    Controlling Assumptions

    • The PT integrates the 5 elements of patient/client management-examination, evaluation, diagnosis, prognosis, and intervention-in a manner designed to optimize outcomes. Responsibility for completion of the examination, evaluation, diagnosis, and prognosis is borne solely by the PT. The PT’s plan of care may involve the PTA assisting with selected interventions.

    • The PTA has the knowledge, skills, and value-based behaviors needed to help the PT provide selected interventions as described in the plan of care. PTAs are clinical problem-solvers who ensure patient/client safety and comfort, as well as completion of interventions selected to achieve desired outcomes. Other than PTs, PTAs are the only valid providers
    of physical therapy services.

    • The PT directs and supervises the PTA consistent with APTA House of Delegates positions, including Direction and Supervision of the Physical Therapist Assistant;2 APTA core documents, including Standards of Ethical Conduct for the Physical Therapist Assistant;3 federal and state legal practice standards; and institutional regulations.

    • All selected interventions are directed and supervised by the PT. The PTA does not perform interventions that require immediate and continuous examination and evaluation throughout, as described in APTA House of Delegates position Procedural Interventions Exclusively Performed by Physical Therapists.4 Procedural interventions within the scope of PT practice that are performed exclusively by the PT include, but are not limited to, spinal and peripheral joint mobilization/manipulation (which are components of manual therapy), and sharp selective debridement (which is a component of wound management). The PT also is responsible for ensuring the PTA has the knowledge and skills required to safely and effectively complete the intervention.

    • The PT remains responsible for physical therapy services provided when the PT’s plan of care involves the PTA assisting with selected interventions.

    • Selected intervention(s) include the procedural intervention, associated data collection, and communication-including written documentation associated with the safe, effective, and efficient completion of the task.

    • The algorithm may represent decision processes employed for either a patient/client interaction or an episode of care.

    • Communication between the PT and PTA regarding patient/client care is ongoing. The algorithm does not intend to imply a limitation or restriction on communication between the PT and PTA.
    http://www.apta.org/PTinMotion/2010/9/PTAsToday/

    What is mobilization/manipulation?

    The APTA Guide to Physical Therapist Practice defines mobilization/manipulation as “a manual therapy technique comprised of a continuum of skilled passive movements that are applied at varying speeds and amplitudes, including a small amplitude/ high velocity therapeutic movement.”

    I was personally involved in developing this definition 20 years ago. It is defined by being “linked” because it describes how these techniques are executed in actual practice (in a continuum from examination / assessment to application). The definition went through several years of debates having a history that involved multiple stakeholders reviewing all US practice acts and education programs as well as research on PT education to universally describe these manual techniques across our eclectic representation in legislation / regulation, education and payment policies. The definition has stood the test of time and has been utilized successfully in countless advocacy and regulation debates to protect physical therapist practice and acquire direct access. [FYI: Having been involved with defending this practice by PTs for over 20 years in legislative debates within most of states, the confrontation arguments from Chiropractors in regulatory debates have focused not only on PT competency but also on their concern for PT’s not appreciating the necessary skills and delegating to PTA’s.]

    From: Physical Therapists and Direction of Mobilization/Manipulation: An Educational Resource Paper
    PRODUCED BY THE APTA PUBLIC POLICY, PRACTICE, AND PROFESSIONAL AFFAIRS UNIT
    SEPTEMBER 2013
    Since 1998, APTA’s Guide to Physical Therapist Practice has defined mobilization/manipulation as “a manual therapy technique comprised of a continuum of skilled passive movements that are applied at varying speeds and amplitudes, including a small amplitude/ high velocity therapeutic movement.” To achieve a common language for describing this area of the physical therapist’s scope of practice, the terms “thrust” and “non-thrust” manipulation were established to replace the previous terms “manipulation” and “mobilization,” respectively. The APTA Manipulation Education Manual for Physical Therapist Professional Degree Programs further defines thrust manipulation as a “high velocity, low amplitude therapeutic movement within or at the end range of motion” and non-thrust as manipulations that do not involve thrust. These definitions emphasize that these procedures are applied on a continuum, which requires ongoing examination and evaluation to determine how to proceed along the continuum with modification of speed, amplitude, and direction of forces for optimal clinical outcomes.

    What are relevant APTA and CAPTE positions that come into play as it pertains to PTA competencies and roles in manual therapy and mobilization/manipulation?

    1. PROCEDURAL INTERVENTIONS EXCLUSIVELY PERFORMED BY PHYSICAL THERAPISTS HOD P06-00-30-36 [Position] The physical therapist’s scope of practice as defined by the American Physical Therapy Association Guide to Physical Therapist Practice includes interventions performed by physical therapists. These interventions include procedures performed exclusively by physical therapists and selected interventions that can be performed by the physical therapist assistant under the direction and supervision of the physical therapist. Interventions that require immediate and continuous examination and evaluation throughout the intervention are performed exclusively by the physical therapist. Such procedural interventions within the scope of physical therapist practice that are performed exclusively by the physical therapist include, but are not limited to, spinal and peripheral joint mobilization/manipulation, which are components of manual therapy, and sharp selective debridement, which is a component of wound management.
    http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/ProceduralInterventions.pdf#search=%22Positional%20interventions%22

    2. PROVISION OF PHYSICAL THERAPY INTERVENTIONS AND RELATED TASKS HOD P06-00-17-28 [Amended 06- 99-10-12] [Previously titled: Position on Physical Therapy Intervention] [Position] Physical therapists are the only professionals who provide physical therapy interventions. Physical therapist assistants are the only individuals who provide selected physical therapy interventions under the direction and at least general supervision of the physical therapist. Physical therapy aides are any support personnel who perform designated tasks related to the operation of the physical therapy service. Tasks are those activities that do not require the clinical decision making of the physical therapist or the clinical problem solving of the physical therapist assistant. Tasks related to patient/client management must be assigned to the physical therapy aide by the physical therapist, or where allowable by law, the physical therapist assistant, and may only be performed by the aide under direct personal supervision of the physical therapist, or where allowable by law, the physical therapist assistant. Direct personal supervision requires that the physical therapist, or where allowable by law, the physical therapist assistant, be physically present and immediately available to direct and supervise tasks that are related to patient/client management. The direction and supervision are continuous throughout the time these tasks are performed. The physical therapist or physical therapist assistant must have direct contact with the patient/client during each session. Telecommunications does not meet the requirement of direct personal supervision. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/ProvisionInterventions.pdf#search=%22Positional%20interventions%22

    3. CLINICAL CONTINUING EDUCATION FOR INDIVIDUALS OTHER THAN PHYSICAL THERAPISTS AND PHYSICAL THERAPIST ASSISTANTS HOD P06-02-26-49 [Initial HOD 06-01-28-28] [Position] Physical therapists and physical therapist assistants conducting clinical continuing education courses are obligated to identify target audiences and indicate in the printed, lecture, and advertising materials that course content is not intended for use by participants outside the scope of their license or regulation. Furthermore, they should make it clear when teaching elements of physical therapist patient/client management that subsequent use of those elements is physical therapy only when performed by a physical therapist or by a physical therapist assistant under the direction and supervision of a physical therapist, in accordance with Association policies, positions, guidelines, standards, and the Code of Ethics. In the interest of public safety, physical therapists and physical therapist assistants should not conduct clinical continuing education courses that teach elements of physical therapist patient/client management to individuals who are not licensed or otherwise regulated, except as they are involved in a specific plan of care, and in accordance with Association policies, positions, guidelines, standards, and the Code of Ethics. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Education/ClinicalContinuingEducationOtherThanPTPTA.pdf#search=%22Position%20on%20continuing%20education%22

    4. CONTINUING EDUCATION FOR THE PHYSICAL THERAPIST ASSISTANT HOD P06-01-22-23 [Position] Physical therapist assistants may participate in continuing education that includes and teaches subject matter and interventions that differ from the description of entry-level skills as described in the Normative Model of Physical Therapist Assistant Education. Physical therapist assistants may use the interventions taught in continuing education only as consistent with the American Physical Therapy Association [policies, positions, guidelines, standards, and the Code of Ethics] and under the direction and supervision of the physical therapist. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Education/ContinuingEducationPTA.pdf#search=%22Position%20on%20continuing%20education%22

    5. The following information is out of the most current CAPTE standards for PTA Education:
    Intervention49

    7D23 Demonstrate competence in implementing selected components of interventions identified
    in the plan of care established by the physical therapist. Interventions include:
    1. Airway Clearance Techniques: breathing exercises, coughing techniques and secretion mobilization
    2. Application of Devices and Equipment: assistive / adaptive devices and prosthetic and orthotic devices
    3. Biophysical Agents: biofeedback, electrotherapeutic agents, compression therapies, cryotherapy, hydrotherapy, superficial and deep thermal agents, traction and light therapies
    4. Functional Training in Self-Care and in Domestic, Education, Work, Community, Social, and Civic Life
    5. Manual Therapy Techniques: passive range of motion and therapeutic massage
    f. Motor Function Training (balance, gait, etc.)
    7. Patient/Client Education
    8. Therapeutic Exercise
    i. Wound Management: isolation techniques, sterile technique, application and removal of dressing or agents, and identification of precautions for dressing removal

    Test and Measures50
    7D24 Demonstrate competence in performing components of data collection skills essential for
    carrying out the plan of care by administering appropriate tests and measures (before, during and after interventions) for the following areas:
    5. Joint Integrity and Mobility: detect normal and abnormal joint movement
    6. Muscle Performance: measure muscle strength by manual muscle testing; observe the presence or absence of muscle mass; recognize normal and abnormal muscle length, and changes in muscle tone
    7. Neuromotor Development: detect gross motor milestones, fine motor milestones, and righting and equilibrium reactions
    8. Pain: administer standardized questionnaires, graphs, behavioral scales, or visual analog scales for pain; recognize activities, positioning, and postures that aggravate or relieve pain or altered sensations

    6. The following is out of CAPTE’s position paper page 19 January 2018:

    Likewise, CAPTE expects education programs for the PTA to select the appropriate depth and breadth of knowledge and skill needed to perform interventions that are consistent with the PTA’s responsibilities. These skills not only include specific intervention procedures but also the data collection skills needed to monitor and assess a patient’s response to an intervention. These data collection skills are outlined in the Standards and Required Elements. Regardless of the relative simplicity or complexity of the procedure itself, CAPTE also believes that those interventions which require more extensive foundational knowledge, manual skill, and/or complex monitoring than a PTA is educated to provide should only be performed by the physical therapist.

    What has APTA done toward endorsing advancing the PTA roles?

    1. In March 5-7, 2007 the APTA Board of Directors had a Mega Issues Discussion on the roles of the PTA. The results that discussion in summary revealed the following:

    That APTA develop and communicate best practice service delivery models for a variety of practice settings that promote safe, effective, and efficient utilization of the Physical Therapist Assistant. The models should also clearly define the roles and responsibilities of the Physical Therapist and Physical Therapist Assistant in assuring effective communication, professional relationships, competent service delivery, assessment of ongoing clinical competence; and skill development.

    2. From that the APTA board established the PTA Education Pathways Task Force including board members, PTAs and PTAs to determine appropriate post entry-level pathway education for the PTA considering APTA positions, policies, standards etc. the final report back in 2011. This later developed into the framework for the Advance Proficiency Pathways Program whose purpose was provide a core group of courses with knowledge exams including content specific courses and mentored clinical experience for the Physical Therapist Assistant.

    3. During the fall of 2012 a call-out letter came from APTA BOD Shawne Soper then, Speaker of the House and Chair, PTA Education Pathways Task Force to Section presidents to meet at CSM 2013 in a workshop directed creating content that should be included for PTAs working specialty areas of physical therapist practice.

    4. In 2011 Jay Irrgang then the Orthopaedic Section President announced the Orthopaedic Section was committed to this initiative and through the Orthopaedic Section Board of Directors assigned me as the chair of a task force authorized to complete the orthopaedic specialty framework for the program. The task force considered not only all relevant APTA documents including the APTA PTA practice algorithm etc. but also the framework within 3rd revision of the Guide to Physical Therapist. The task force worked on this project for 5 years including the development and analysis of a survey delivered to the Orthopaedic Section’s 20,000 members. From the results of that survey, the task force reviewed the data and developed an educational content format from what Orthopaedic Section members validated as advanced proficiency skills they expected for the physical therapist assistant to perform within an orthopaedic setting. By the way, no data showed any support for meeting the threshold to develop any level of manual therapy education or skills for physical therapist assistants other than within the domains of passive range of motion and soft tissue mobilization.

    5. The Orthopaedic Section delivered that material to APTA for their development of the PTA advance proficiency pathway content for orthopedics.

    6. Currently, the advance proficiency pathways opportunities are available for PTAs including Acute Care, Cardiopulmonary, Geriatric, Oncology, Orthopedics, Pediatrics and Will Management.

    7. When I took office as President of the Orthopaedic Section I met with the PTA Caucus along with several others to let the Caucus know that the Orthopaedic Section was committed to helping the PTA through its completion of the Advance Proficiency Pathways opportunities and as well as development opportunities including within its PTA Educational Interest Group Structure.

    8. Thus far in my 5 ½ year tenure as president of the Orthopaedic Section, our PTA development initiatives have included:
    a. Providing 5 years of manpower and financial support to complete our practice survey/analysis for advancing postgraduate physical therapist assistant education for the orthopaedic setting.
    b. Developed and delivered an educational format for the APTA PTA Advance Proficiency Pathways Program.
    c. Created improved information for our PTA Educational Interest Group on our website.
    d. Offered publishing opportunities to physical therapist assistants.
    e. Provided presentation programming opportunities at CSM.
    f. Opened meeting opportunities at CSM to meet face to face with members to inquire about accommodating to their needs through correspondence, the website and other opportunities for face-to-face and conference call meetings.
    g. Over the past 3 years we opened-up our advanced conference programming traditionally for physical therapists to include the physical therapist assistants within the framework of the APTA PT: PTA team algorithm.
    i. We integrated that information on our website and within the framework of our advanced clinical annual meeting.
    ii. This level of commitment included integrating different educational objectives and special orientation to all physical therapist assistants before programing, so they were well informed of expectations throughout the delivery of the educational experience. Additionally, we had face-to-face lunchtime meetings with our physical therapist assistant participants to get feedback on meeting their needs.

    What about “just allowing” PTAs Grade 1-2?

    Every component requires immediate and continuous examination and evaluation throughout the intervention. The fact of the matter is, whether you believe you can truly separate and can even find an instrument to measure and objectively demarcate GRI and GRII from the other 3 grades, all the absolutely necessary examination, evaluation assessment and clinical decision-making competencies for actions preceding and on-going across the continuum of mobilization/manipulation including the psychomotor applications, requires competencies for clinical skills that are not and cannot be provided in a two-year PTA curriculum.

    Also, consider that the APTA House of Delegates has stated in multiple documents that only PTs can examine, evaluate, diagnose and prognose. The House has also sanctioned that a PTA can only judge a patient’s response to treatment and progress a treatment only within established parameters.

    Does it follow then that if the House were to authorize PTA’s to perform joint mobilization / manipulation or any other intervention that is currently acknowledged as requiring immediate and continuous examination and evaluation throughout the intervention, it will be supporting that on-going elements of examination and evaluation are not inherently immediate in those categories of interventions? For example, based upon the way we define “Joint Integrity and Mobility” examination, it is very different than what we mean by “Range of Motion”. If the House allows, explicitly or implicitly, PTAs to perform any sort of mobilization / manipulation, as opposed to Range of Motion (a part of Therapeutic Ex – see stretching in Guide), we will be saying something about the evaluative component inherent (or not inherent) in the intervention. We will also have to look at a revaluation of the codes that reimburse for those interventions because the level of judgment that goes into them should routinely be deemed less critical if they are well established, by House decisions, within the purview of PTAs.

    When considering the APTA Position on Direct Interventions Exclusively Performed by Physical Therapists one might want to consider the science and practice of the issue and not be distracted by the delegation part. It is a far more decisive philosophical move to say why interventions such in this case mobilization / manipulation should never be delegated that says something about the nature of it. The intervention mobilization / manipulation is one of many interventions that falls into a unique class, defined as an intervention that always and in every case involves immediate judgment in order to be; applied, efficacious and safe and is not supported by the structure of the PTA curriculum or competencies.

    It might also be pointed out that PT professional education is not merely the teaching of discrete skills. There is the transmission of an entire theoretical basis for action that accompanies the “how to do it.” That is why the argument that not every PT learns “how to” is weak. Physical therapists exit with the theoretical framework to support such learned behaviors. You cannot plant a specific skill set on a less than a relevant and competently qualified foundation.

    CONCLUSION /THOUGHTS

    I ask, if you really believe and support mobilization / manipulation can be delivered by the PTA from a 2-year curriculum then, where are we and who are we with all our doctoral, residency, specialty and fellowship training? Isn’t it our knowledge and skills in examination, evaluation, assessment, diagnosis and prognosis that is specific to our professional expertise and clinical decision making as movement specialists what we profess gives us our independent and collaborative identity and value to society? Along those lines aren’t there interventions we decide to utilize that requires our high- level expertise to decide upon and personally apply? Wouldn’t those interventions especially be the ones that require immediate and continuous examination and evaluation throughout? If not, then in this case we are either training to exclusively be diagnosticians and not touch patients while excepting the PTA can totally replace our hands, or we only need an Associates Degree for our current practice. If we are going to be exclusively diagnosticians, then the PTA will need to move to be trained more as a PT and that will require advancing their degree and debt service. We will then be adding the challenging debt for PTs to PTAs in the presence of a payment system that doesn’t currently value our current PT: PTA team model, never mind a PT diagnostician: PTA model. What support then will the PTA need? A PTA trained AIDE? Isn’t that where we started with the PTA for the PT in the 60’s to begin with?

    Let’s think about what we need to do now. Our bigger concerns should be directed at narrowing physical therapist variance in practice and enhancing societies appreciation for our added value and designated expertise in rehabilitation of movement dysfunction. There is a big role there for the PTA as well.

    As far as this debate is concerned, contemporary practice of mobilization/manipulation has not changed in requirements for competency and safety or the requirement for providing immediate and continuous examination and evaluation throughout the intervention for probably longer than the history of physical therapy. Likely the only change in contemporary practice is due to newer research that has expanded the available evidence for physiological explanations for the mechanisms and validations for the clinical benefits and effectiveness of mobilization/manipulation.

    Physical therapist assistants have no scope of practice and practice under the direction and supervision of the PT within the PT’s scope of practice. When appreciating the necessary competencies supporting safety and efficacy in mobilization / manipulation, other than PTAs squeaking in a weekend con-ed course or two, which we would not sanction as providing all necessary competencies, conventional PTA education does not provide the required competencies and the House / Board positions and policies have not changed to support this provision by PTAs since the PTA’s inception in 1969.

    Practice competencies are not drawn on “what you can do” but drawn on what you are skilled in supported by education, related skill sets and authorization. Practice competency reflects in patient safety and efficacy which in turn enhances outcomes and isn’t that what we should be most concerned about?

    See also:
    1. http://www.apta.org/search.aspx?q=manipulation%20debate
    2.http://www.apta.org/PTinMotion/2012/12/Feature/TheJointManipulationDebate/ including Blog responses

    Stephen McDavitt PT, DPT MS
    Fellow, American Academy of Orthopaedic Manual Physical Therapists
    Cathereine Worthingham Fellow APTA

    1. Mark Shepherd says:

      Steve – thanks for the in depth response. The history is deep here and I respect that. You bring up many good points. I completely agree with your points on competencies being the key focus here. I also agree that there is really no room in PTA entry level education for this for the reasons you state. My challenge here is that I see so much variation in how PTAs use joint mobilization – some use it, some don’t, etc., etc. What I get concerned about is that some PTs out there are allowing PTAs to do whatever joint mobilizations fit under the POC. There has been great work done to educate PTs on how to better delegate to the PTA, but I still feel as though this is lacking in our profession. I know in PT education there is a big push for interprofessional education which is great, but we can’t even effectively work with PTAs who are part of our profession.

      I am neither supporting one way or the other with this discussion, rather wanting to bring some thoughts to the open here to get perspectives and add to the history of what is out there. I appreciate you bringing in much of what has been done – much of which you have personally been involved in.

      1. Stephen McDavitt says:

        To be clear. The story is old, but the facts are current. We can’t control what PT’s do with their decisions for various level of risk in opportunistic delegation. Whether in their mind such delegation is “legal” or not, the issue for deciding what is to be done for the patient and how it should be done should be based on competency.
        APTA positions are just that, positions, and they are not punitive tools. That is until there is a legal contest where the lawyer looks to the national association’s opinions and values. Many PTs do not even appreciate that they are directly responsible for the PTAs action on their behalf. Also, in considering delegating GR1 and 2 where PTs argue those mob/manip techniques are thought to be “harmless”, in reality those techniques not only require the same on-going assessment but are used on the more complex patients that require more oversight. The management issue on this is self-policing for appreciating competency and delivery of care for what is safest and most effective for the patient’s experience and outcomes, not what’s most convenient.

        1. Mark Shepherd says:

          Steve – this statement resonated with me: “The management issue on this is self-policing for appreciating competency and delivery of care for what is safest and most effective for the patient’s experience and outcomes, not what’s most convenient.”

          Thanks for your input, engagement, and advocacy and leadership you provide for our profession!

          1. Stephen McDavitt says:

            Yes, but to keep clear in context, my reference to self-policing competency does NOT apply to saying the PT should self-judge or validate the competency of the PTA. What I meant here is that a PT should self-police their SANCTIONED competencies for themselves and the VALIDATED AUTHORIZATION of competencies of who they share the application of interventions with, always looking to the safest and most effective decisions for the patient’s experience and outcomes, not what’s most convenient.

  10. Joe Donnelly says:

    Just to be clear that the curriculum standards for manual therapy for the PTA by CAPTE only includes massage and PROM. CAPTE position paper states all skilled interventions and assessments that require assessment and higher level manual skills should only be performed by the Physical Therapists. CAPTE does not support the PTA performing joint mobilization but supports the PTA performing PROM.

    1. Mark Shepherd says:

      Joe – correct. The recent FSBPT survey concluded that this was not a critical issue to be included in PTA education. Thanks for reading and commenting.

  11. Colleen Louw says:

    Steve – I applaud the time you have put into responding to this post. Wow. I read all of it and am keeping it for reference because there is so much to know about this issue beyond the preliminary questions.. I know first hand – and very much appreciate – the energy you and others have spent through the years on this. Most who are “debating” or questioning this have no idea the time and thought processes (which are, as you pointed out, on-going) that have gone into this. It is not a new issue but seems to keep coming up, and there is a history here within the APTA that needs to be known. I would love to see your response posted beyond this blog to reach a larger audience.

    Again – thank you, thank you, thank you – for all you have done and continue to do for our PT and PTA profession. We are very lucky to have you involved at the levels you are, not to mention the value you are as a resource of information.

    1. Mark Shepherd says:

      Indeed!

  12. Adriaan Louw says:

    I typically don’t read or reply to blogs and do this anxiously, since it would require me to “come back” and see the comments…which I likely won’t
    First: I am big fan of Steve McDavitt and all he has done/is doing and will continue to do for the APTA, Orthopedic Section and manual therapy.
    I do, however, want us to also see the big picture here:
    • While we’re squabbling over “who does what” 127 Americans are dying from prescription opioids today and many can/should be helped by PTA’s – possibly, including manual therapy. As we head to Capitol Hill and talk to legislators about a highly skilled army of hands-on professionals, capable and able to help people in pain, we MUST include the PTA.

    • Maybe I’m just not smart enough but didn’t clinical prediction rules teach us – “it’s not that complicated” and inclusion is better than exclusion? I pinch myself every day over the result of the CPR research and how if catapulted manipulation in US PT with numerous positive benefits…

    • Manual therapy in 2018 surely now surpasses the notion of “arthrokinematics” and is now defined as a complex interplay between neurophysiological effects, placebo, patient expectation and therapeutic alliance (Mintken JMMT 2018) – which can be done by a PTA as well. If PTA’s are allowed to do passive ROM – I’d argue it fits in this category.

  13. Stephen McDavitt says:

    Thanks Adriaan. The respect and appreciation for your work is mutual. I agree on our priorities. We also have a PT practice sustainability issue as well needing to address debt service, patient pathway and public identification and value for PT, narrowing unwarranted variation in practice and reducing clinical burdens and overload.
    Getting to this issue, PROM I believe to be a component of care that is appropriate for the PTA for the reasons I have explained, mainly that the patient has a greater opportunity to control or counter force the forces applied to them. No matter what one calls it or the clinical evidence or reasoning they claim, when forces are used to mobilize tissues or joints in passively induced leverage under advantages by the clinician over the patient for whatever reason, the bottom line for me is does the procedure require immediate and continuous examination and evaluation throughout? If so, the clinician needs to have the competencies to apply and monitor the technique. That is why the current APTA position is written the way it is, to provide a selection of examples of such interventions and prevent a laundry list. It’s not rocket science. The problem historically becomes when this delegation issue is dealt in the clinic exclusively by self-serving empirical validation and providing psychomotor “on-the job training” at the expense of the necessary vast and integrative cognitive and affective behaviors that provide the clinical reasoning that determines the indications, safety and efficacy for implementation of the intervention. If anyone, PT or PTA has authorized training, clinical reasoning, and the skill to provide the intervention great! In all practicality though, if the PT places hands on to determine the need for the procedure then why not just perform the intervention? The problem in this debate always comes back to less training and competency to do more. If that is acceptable then our Doctoring of PT, arguments for Direct Access, leadership for identity in collaborative patient pathways and current payment valuing is all for not since 2 years of training will give us all we need.
    No matter what we “believe” makes sense, the question before regulation or liability hearings as it relates to practice privileges comes down to, is or was there validated competence to protect the public? That we also must attend to. We also have to be able to defend our scope when during regulation hearings competing practitioners point to what we delegate to less trained individuals who don’t even carry a scope of practice. We could also drag in the necessity for payment revaluing here as well. I only challenge this from history and what we need to consider as we discuss these issues. Again, patient safety and efficacy is what’s most important. Thanks for allowing me to share my thoughts.

  14. Elaine Lonnemann says:

    Hi Mark,
    I appreciate this opportunity for conversation about this important topic. Manipulation, regardless of grade, requires competency in examination and evaluation. Examination and evaluation are not part of the PTA curriculum.

    From the 2018 CAPTE Position Paper “CAPTE expects education programs for the PTA to select the appropriate depth and breadth of knowledge and skill needed to perform interventions that are consistent with the PTA’s responsibilities. These skills not only include specific intervention procedures but also the data collection skills needed to monitor and assess a patient’s response to an intervention. These data collection skills are outlined in the Standards and Required Elements. Regardless of the relative simplicity or complexity of the procedure itself, CAPTE also believes that those interventions which require more extensive foundational knowledge, manual skill, and/or complex monitoring than a PTA is educated to provide should only be performed by the physical therapist.”

    In 2008, Bialosky reported that “Current mechanistic models for spinal manipulative therapy suggest an interaction between biomechanical and neurophysiological mechanisms.” As Mintken suggested relying simply on biomechanical mechanisms is a recipe for failure, but they didn’t recommend throwing biomechanics out.

    I don’t think our profession is placing this intervention on a pedestal. Manipulation/mobilization is an intervention that always requires immediate judgement to be performed effectively and safely. Interventions such as these differentiate the PT from the PTA. There is a long list of other interventions that have similar requirements, we should carefully consider the potential future implications of changing the model.

    1. Stephen McDavitt says:

      Yes! Absolutely!

  15. Brian D'Orazio DPT, MS, OCS says:

    Mark,

    This is the discussion of our times. Your post has initiated a discourse that goes to the heart of many issues faced by the profession and the patients we serve. My guess is that 99% of PT’s are not fully aware of the regulatory issues presented by Stephen McDavitt, and I include myself in that group. I wonder if Evidence in Motion has a means of expanding this blog discussion to a vehicle that is capable of reaching many more in the profession? In asking this, I admit not know exactly what vehicle best accomplishes this task. The request is based on the premise that moving our profession forward requires these higher level debates. This blog is a great beginning to that broader debate about practice; issues like regulation, defense of scope of knowledge and practice, use of extenders in practice, residency training as a means of reducing variation in practice patterns, financial realities in PT based on the stresses imposed by drastic CMS cuts over the past 20 years and the practical aspects of how we practice in our profession and how that necessarily differs from MD practice. This blog highlights the need for education of all PT’s and PTA’s. Thank-you for offering this opportunity to begin the education process.

  16. Jake Magel says:

    Interesting discussion. Little that I can add that Steve, Elaine, Joe and others have not already said.

    Mark, I pulled this directly off the EIM website on PTA education:

    “To maximize the effectiveness of the PT/PTA team our program enhances knowledge of evidence-based interventions, pain neuroscience education, and emphasizes mastery in delivering therapeutic exercises. We teach PTAs manual techniques related to ROM acquisition, stretching and exercise, but not joint mobilization.”

    Then the advertisement further states:

    “Significant time is dedicated to enhancing manual techniques and exercise, while respecting the position statements of the APTA and AAOMPT.”

    What do you think about EIM’s position on PTAs and joint mobilization? In your opening statement you said “Are we doing more harm than good when completely ignoring the fact that PTAs are using joint mobilization?”

    What do you think?

    1. Mark Shepherd says:

      Hey Jake – thanks for reading and sorry for the delay here. I actually helped write that statement for the program! Part of this blog came from helping develop this program in a way that helps strengthen PTA but also respects the boundaries within the position statements. I have to say, it was challenging because passive ROM can be seen as manual to some and we really had to define that line, thus the statements you have posted. Faculty have actually talked about this with the PTAs regarding the topic and we mention that there are these position statements and try not to “ignore” the fact that this is happening. Hope this clarifies things a bit.

  17. Jim Rivard PT, DMT, OCS, FAAOMPT says:

    My perspective on this issue deviates away from “are PTA’s capable of providing mobilization/manipulation”, but why this is desirable and whom is really requesting this? The origins of this issue to not organically start from PTAs, PTA educators or PTA associations. At the beginning of this discussion is the unstated desire to pay individuals less for the same work. This seems like a very uncomfortable statement but nevertheless is a reality that that should not be avoided. The defensible argument is that a PTA is capable of doing the same work as a PT, yet there is not desire or discussion for equal pay for the PTA. Start this blog and you typically see the reverse discussions, from similar people, on the limitations of a PTA’s education and capabilities. This compensation issue represents a continued business strategy in the US—moving work from skilled to unskilled labor, moving domestic to foreign work forces, and more recently moving from human to a less expensive virtual workforce. Driverless Uber anyone? This is an economic force driving what is described as “innovation”, but is more typically focused on profitability. For-profit healthcare has always pushed volume for profitability, though is not the only solution. As a business owner, I am sensitive to all of these challenges and appreciate their consideration for survival and growth. I am not free of this thinking, nor innocent in employing innovation for profitability. Having said that, I see few discussions on PTA qualifications that don’t appear to be related to the ability to deliver the “same” product to the consumer while having less exposure to the cost of professional salaries and benefits.
    The push for increased PTA responsibility, I believe, started in the hospital systems, wanting to increase the responsibilities of their less expensive staff. This issue was not generated out of the PTA profession, nor the private outpatient orthopedic clinics that seem to recirculate these discussions.
    Recently my state, Washington State, considered legislation presented by the private practice section to increase the number of non-PT staff members that a PT could supervise providing patient care from 2 to 4. The justification for this was similar to the discussions in this blog, with the additional argument that rural clinics had more difficulty finding staff and needed more PTAs to provide patient care. Absent from this political discussion where these said rural clinics that apparently had the issue of needing more PTA staff members, with the major push coming from larger corporations in the more affluent counties of the state. With very little push back from PTs, a modified bill was passed allowing supervision of 3 staff members and some vagueness in their duties. Economics where not part of the debate on this issue, though they are the driving force for it. To no discuss these economic issues is disingenuous and not something we should be afraid to do. We are in the “business” of healthcare, we can have a business discussion related to these economic issues of survival.
    The discussion of educate was also touched on in the above conversation, suggesting increasing PTA’s education to include additional time with mobilization/manipulation. There are many issues to consider here, but I will introduce a different perspective. The APTA has struggled to increase the diversity of the PTs in the US, being predominantly white. Again, there are many issues to consider with diversity. But at the end of the day, moving from a Bachelor’s education to Master’s and now Doctorate has resulted in reducing the diversity of the our PT workforce. PTA’s, however, have improved in diversity over this time period. Part of this is related to a 2-year technical eduction, compared to undergraduate and then professional DPT education. Increasing the PTA education from a 2-year to a 3-year or 4-year will unintentionally exclude many potential applicants that, for whatever reason(s), would not want to spend the extra time and money starting a career. I am not presenting this as an issue of only diversity. I am not stating that PTAs reflect only diverse and lower income individuals, that for whatever reason, could not complete a PT education. But this has been the measurable outcome since the move to a graduate degree and worthy of consideration.
    As a profession, it seems we are squeezed more economically every year. The cost of doing business continually increases: rent, utilities, taxes, inflation, health insurance, as well as salary/benefit expectations. Insurance rates do not track these increases in costs adequately, as insurance companies are a for profit industry as well, despite many having non-profit status. Thriving, rather than surviving, should come from continued advocacy for higher reimbursement, best-business practices, reasonable profit expectations of ownership and certainly improvements in the product we deliver. I would argue that focusing on these areas, rather than increasing the PTA’s perceived skill set, would have a greater impact on the issues being discussed here. The dues we pay to the APTA give us a powerful voice for advocacy on much of this, with reimbursement being the most obvious. I appreciate the opportunity to share my thoughts and hope to not offend by my comments. My wish is to simply put a little light on these issues for consideration and broadening of the discussion, welcoming additional perspectives on these economic drivers. I have great respect for our profession, being proud of it’s intensions and impact, as well as great faith in the values that drive it’s leadership.

    1. Stephen McDavitt says:

      I agree Jim. Thanks for sharing your valuable and informative thoughts!

  18. Burt says:

    It’s mostly just a damning indictment of manual therapy in that it really isn’t rocket surgery. Come on folks, be honest. This is such a crock of ego-driven tribal nonsense, it makes me sick to think of how hollow the profession really is.

    1. Stephen McDavitt says:

      Thanks for the feedback and based on your thoughts, what do you suggest?

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