ManipulationSafety&PhysicalTherapistPractice

TheBackground,theDebate&theEvidence
Background
Manipulationtechniquesaremanual(handson)skilledpassivemovementtreatmenttechniquesusedbyPhysicalTherapists, Physicians, Osteopaths and Chiropractors. Manipulation was first used in health care by Hippocrates (460355 B.C.), the Father of Medicine1; Physical therapists (PTs) in the US have used manipulation and other manual techniques since the profession was established in the US in the 1920s.2 Europeanphysicaltherapistshaveusedmanipulationsincethe1800s.2 Traininginmanipulation(thrust&nonthrust)isarequiredcomponentofentrylevelphysicaltherapisteducationprogramsin the US.3 Some PTs complete Residency and Fellowship programs that provide advanced training in manipulation techniques.Residencies&Fellowshipsareapartofthepostprofessionalphysicaltherapyeducationsystem,consistentwith how advanced specialty training occurs in other health professions. For PTs, manipulation is one of many treatment techniquesusedtoaddressavarietyofmuscleandjointconditions.

TheDebate
Manipulation,particularlythrustjointmanipulation(TJM),hasfordecadesbeenthecenteroflegislativeturfbattlesledby thechiropracticprofessionagainstthephysicaltherapyprofessiontoattempttorestricttheuseofmanipulationbyphysical therapists. Chiropractors argue that physical therapists are not trained to practice TJM; Chiropractors also claim that manipulation provided by PTs place the public at risk for serious injury. Evidence strongly refutes BOTH of these charges.A Chiropracticpublicationimpliesthatthelegislativewarbeingwagedagainstphysicaltherapistsuseofmanipulationisbased onaneconomicagenda.4EvidencealsoshowsaverylowprobabilitythatPhysicalTherapistswhouseTJMwillcauseharm; thevastmajorityofseriouscomplicationsfromManipulationareNOTcausedbyphysicaltherapists(Table1).5,6,7,8,9
100 90 80 70 60 50 40 30 20 10 0 Study1 Study2 Study3 Study4 PhysicalTherapists Chiropractors

Table1:PercentageofTJMcomplicationsduetochiropractorsversusthepercentageofTJMcomplicationsduetophysicaltherapists(Study1 ,Study2 , 8 9 Study3 ,Study4 ).Averageofthe4studiesshowsthat68%ofTJMcomplicationsareduetochiropractic,11%areduetoPT,and21%areduetoother practitioners.

Terminology
Mobilization/Manipulationskilledpassivemovementstothejointsand/orrelatedsofttissuesthatareappliedatvarying speedsandamplitudes,includingasmallvelocityandhighamplitudetherapeuticmovement.10 Thrustjointmanipulation(TJM)highvelocity,lowamplitudetherapeuticmovementswithinoratendrangeofmotion11

TheFacts
PhysicaltherapistsintheUShaveusedmanipulationandothermanualtechniquessincetheprofessionbeganinthe1920s
Traininginmanipulationisrequiredforallphysicaltherapisteducationprogramsbynationalaccreditationstandards
3 2

Many governmental agencies (The Veterans Hospital Association, US Department of Health and Human Services, & the

VirginiaBoardofMedicine)acknowledgethatManipulation,includingTJM,iswithinthePTscopeofpractice
AccordingtoHPSO(largestliabilityinsurancecarrierforPTsintheUS)therearenohigherclaimslossesrelatedtoPTuseof TJMthanotherPTtreatmenttechniques

emergencylowerspinalcordinjury)afterlowerbackTJM;noneofthoseinjurieswerecausedbyPTs5 SummaryofscientificreportsonTJMcomplicationsbyprofession(Table1): *61%ofcomplicationsduetochiropracticandonly5%(12/220)duetoPT6 *87%ofcomplicationsduetochiropractorsandonly6%(6/98)duetoPT7 *70%ofcomplicationsduetochiropractorsandonly2%&nodeathsduetoPT8

9 ManipulationSafetyStudyfromNewZealand(Table1):

Publishedreviewofmedicalliteratureovera77yearperiodfoundonly10reportsofcaudaequinasyndrome(amedical

*morethanonehalfTJMcomplications(54%)causedbychiropractors(23/42) *onlyonethird(14/42)ofallcomplicationsreportedwereresultofPTtreatments *onetenththenumberofpractitioners(i.e.thenumberchiropractorscomparedtoPTsinNewZealand)produced nearlytwice(164%)asmanycomplications. 12 IntheUS,practicingPTsoutnumberchiropractorsbya4to1ratio

TheBottomLine

Claims that the public is at risk when PTs use manipulation have no factual basis and are refuted by high level scientific studies and insurance reports.PTsarewelltrainedtousemanipulationincludingTJM.AttemptstolimitPTsfromusing TJMappeartobebasedoneconomicconcernsnotpatientsafety.4 PTsusearesearchbasedapproachintheuseofTJM thatisproventobebothsafe&effective;infact,researchindicatesthebestapproachtomanycommonpainfulconditionsis usingacombinationofmanipulationwithexerciseandotherPTtreatments.13,14,15

References
1. ParisSV.AHistoryofManipulativeTherapy.JMMT.2000;8(2):6677. 2. McMillanM.MassageandTherapeuticPractice.2nded.Philadelphia,Pa:WBSaundersCo;1925. 3. CommissiononAccreditationinPhysicalTherapyEducation.EvaluativeCriteriaforAccreditationofEducationalProgramsforthePreparationof PhysicalTherapists.Alexandria,Va:CommissiononAccreditationinPhysicalTherapyEducation;2007. 4. InstituteofAlternativeFutures.TheFutureofChiropracticRevisited,20052015.Alexandria,Va:InstituteofAlternativeFutures;January2005. Availableathttp://www.altfutures.com/docs/FutureofChiropracticRevisited.pdfAccessedonJanuary23,2009. 5. HaldemanS,RubinsteinSM.CaudaEquinaSyndromeinpatientsundergoingmanipulationofthelumbarspine.Spine.1992;17(12):14691473. 6. AssendelftWJJ,BouterL.M.,KnipschildPG.Complicationsofspinalmanipulation.Acomprehensivereviewoftheliterature.TheJournalofFamily Practice1996;42(5):475480. 7. PatijnJ.Complicationsinmanualmedicine:areviewoftheliterature.JManMed1991;6:8992. 8. DiFabioRP.Manipulationofthecervicalspine:risksandbenefits.PhysTher.1999;79(1):5065. 9. RivettDA,MilburnP.ComplicationsarisingfromspinalmanipulativetherapyinNewZealand.Physiotherapy1997;83(12):626632. 10. GuidetoPhysicalTherapistPractice.Revised2nded.Alexandria,Va:AmericanPhysicalTherapyAssociation;2003. 11. APTAManipulationEducationManualforPhysicalTherapistProfessionalDegreePrograms.Alexandria,Va:AmericanPhysicalTherapy Association;2004. 12. http://www.bls.gov/oco/ocos080.htmandhttp://www.bls.gov/oco/ocos071.htmaccessedJanuary12,2010. 13. JullG,TrottP,PotterH,ZitoG,NiereK,EmbersonJ,MarschnerI,RichardsonC.Arandomizedcontrolledtrialofphysiotherapymanagementfor cervicogenicheadache.Spine.2002;27:183543. 14. HaldemanS,CarrollL,CassidyD,SchubertJ,NygrenA.TheBoneandJointDecade20002010TaskForceonNeckPainandItsAssociated Disorders,SPINE33(4S),2008 15. GrossAR,HovingJL,HainesTA,GoldsmithCH,KayT,AkerP,BronfortG.2004ACochranereviewofmanipulationandmobilizationformechanical neckdisorders.Spine29(14):15411548.