Position on Thrust Joint

Manipulation Provided by
Physical Therapists

 
 
www.apta.org/manipulation
 thrust & non-thrust technique
Manipulation
Guide to PT Practice-
Mobilization/Manipulation = “A manual therapy technique
comprised of a continuum of skilled passive movements to joints
and/or related soft tissues that are applied at varying speeds and
amplitudes, including a small amplitude/high velocity therapeutic
movement”

Manipulation Education Committee, June 2003-

Thrust Joint Manipulation (TJM)- high velocity, low amplitude
therapeutic movements within or at end range of motion.
 Legislative Challenges
• Opposition to PTs performing TJM started in
1960s
• Opposition intensified in the 1990s in response
to PT professions movement toward direct
access and Doctoral education
– 23 states had legislative challenges in 1998
• Number of legislative challenges is less per year
(typically 4-8 states), but the intensity of the
legislative and regulatory challenges continues
 PT profession response
• Orthopaedic Section of APTA was founded in
part in 1974 to mobilize an organized response
to chiropractic challenges
• AAOMPT founded 1992 partially for the same
purpose and to meet international standards of
residency/fellowship training in OMPT
• APTA Manipulation Task Force formed in 1999
to further coordinate APTA/AAOMPT response
to chiropractic legislative challenges
 APTA Manipulation Task Force

• AAOMPT, Orthopaedic Section, Education Section,

APTA State Governmental Affairs, & APTA Education
department
• 1999 strategic planning meeting goals
– Support state chapters and APTA in dealing with threats from
chiropractors in scope of OMPT practice
– Develop consistency in AAOMPT & APTA documents
– Enhance level of instruction in OMPT in professional education
National Chiropractic Agenda to
Own Manipulation
And eliminate the competition…
Evidence of a Coordinated National
Chiropractic Agenda
• Multiple states encounter the same
chiropractic challenges in the same year
• Shift in strategy the following year
• 2003 and 2004 prime examples
 2003 Chiropractic legislation in the states

• Used strategy of education-based prohibition

on manipulation.
• 2003 states: Hawaii, Iowa, Louisiana, New
Mexico, North Dakota, Texas, and Tennessee
Example of ’03 Chiropractic Legislation in
the states

• A person may not perform a spinal manipulation or spinal

adjustment without first having the legal authority to
differentially diagnose and have received a minimum of four
hundred hours of classroom instruction in spinal manipulation
or spinal adjustment and a minimum of eight hundred hours of
supervised clinical training at a facility where spinal
manipulation or spinal adjustment is a primary method of
treatment.
 2004 Chiropractic/Manipulation

In 2004, legislation moved back toward flat out

prohibition
– Iowa, New York, New Jersey, Oklahoma, South
Carolina
 South Carolina
HB 4676/SB 1035

• Only a licensed chiropractor may perform a specific spinal

adjustment/manipulation on a patient.

• 'Adjustment or manipulation' means the forceful movement of

joints or tissue to restore joint function, in whole or part, to
increase circulation, to increase motion, or to reduce\ interosseous
disrelation.
 Chiropractic motivation
• Economics seems to be the primary reason for
the legislative challenges
• “The biggest competitive threat will come
from physical therapists”
– The Future of Chiropractic Revisited: 2005-2015
 Chiropractic Arguments
• TJM is outside of PT scope of practice
• PTs lack training in TJM
• Patient safety is compromised when TJM is
performed by physical therapists
History of Manipulation

The History is on our side

 History of Manipulation
• Hippocrates, Father of
Medicine
– 460-355 B.C.
– Wrote “On Setting Joints
by Leverage”
– Spinal Traction
– Reduction of dislocated
shoulders
 Bone Setters
• Friar Moulton
– published, “The Complete
Bone-Setter”, 1656
• Bone setting flourished in
Europe during the period
of 1600-early 1900’s
– No formal training
– Techniques passed down
within families
– Clicking sounds thought to
be due to moving bones
back into place
 History of Manipulation
• Wharton Hood
– 1871, “On Bone-setting”
• first such book by an
orthodox medical
practitioner
• Hood thought snapping
sound was due to breaking
adhesions
• PT evolved from Medicine
• Precedes Osteopathy and
Chiropractic
– In 1887, PTs were given official
registration by Sweden’s
National Board of Health and
Welfare
– 1899 Chartered Society of
Physiotherapy founded in
England
 Osteopathy
Andrew Still founded
Osteopathy in 1874
– 1896 founded the first school
of Osteopathy in Kirksville,
Missouri
– “Rule of the Artery”-
Manipulate the spine to
restore blood flow and restore
body’s innate healing ability
– Osteopaths currently licensed
to practice medicine in all
states
 Chiropractic Founded 1895
• “Chiropractors do not
manipulate; they do not use
the process of manipulating;
they adjust.”

D. D. Palmer (1845 - 1913),

founder of Chiropractic.
"The Chiropractor's
Adjuster," 1910.
 History of Chiropractic
• DD Palmer, a magnetic healer and green
grocer applied an “adjustment” to Harvey
Lillard in September 1895 to the T4 vertebra
that resulted in restoration of lost hearing
• Concept of “subluxation” as a causal factor in
disease and the revelation that adjustments
can restore the body’s innate healing abilities
• Palmer School of Chiropractic founded in 1897
in Davenport, Iowa
 Chiropractic Philosophy
• Belief in body’s innate ability to heal itself
• Presence of a “subtle” energy within the
organism
• “The Law of the Nerve”
– Adjust spinal “subluxations” to restore nerve flow
and facilitate the body’s innate healing ability
 Chiropractic History
• 1904, BJ Palmer (1881-
1961) gained operational
control of the School and
continued until 1961
• BJ is considered the
“Developer” of
chiropractic and defender
of “straight” chiropractic
• “Staights” adhere to
original philosophy
• “Mixers” incorporate
other modalities
 Chiropractic Heritage Belief
• Chiropractors claim to be the first
professionals to develop manipulation
• Chiropractors have a 110+ year history of
practicing and protecting their right to
manipulate
• All other professions are infringing on the
chiropractic scope of practice who wish to use
manipulation
Physical Therapy
in Sweden (1813)
Per Henrik Ling “Father of Swedish
Gymnastics” founded Royal Central
Institute of Gymnastics (RCIG) in
1813
Medical gymnastics
Educational gymnastics
Military gymnastics

Swedish word for physical therapist

is “sjukgymnast” = “gymnast of the
sick”

Practitioners came from throughout

Europe to learn PT techniques at
RCIG including Jonas H. Kellgren
(1837-1916)
(Grandfather to James Cyriax)

Anders Ottoson
www.chronomedica.se
 What does US Physical Therapy history say about
"manipulation"?
• Mary McMillan, 1st
president of APTA
(founded 1921)

• The four branches of

physiotherapy: “namely-
manipulation to muscle and joint,
therapeutic exercise,…
electrotherapy, and
hydrotherapy."
– McMillan M. Change of name
[editorial]. P. T. Review.
1925b;5(4):3-4.
McMillan’s 1921/1925
book is based on the
teachings of Ling and RCIG
in Sweden
“Medical gymnastics” and
“therapeutic exercise” are
synonymous terms

Massage (manipulation) are

“movements done upon the
body”

Exercise are “movements done

with a part of the body”

McMillan uses the word

“manipulation” throughout
her book to describe
techniques such as effleurage,
tapotement , friction
massage, paddle technique

Mary McMillan  from Massage and Therapeutic Exercise, Philadelphia and

London, W. B. Saunders Company, 2nd edition, 1925.
 Manipulation in American PT
• 1925 – 1939: Yearly publications in Physical
Therapy literature on Manipulation and
related topics
• 1940 – mid 1970’s: The word “manipulation”
is not widely used in the literature
– Mobilization/articulation used to separate PT
from chiropractic
Physical Therapists who advanced
practice of manipulation
• Freddy Kaltenborn
– The Spine, …Mobilization 1961
– Nordic approach
– First to relate manipulation to
arthrokinematics
• Geoffrey Maitland
– “Vertebral Manipulation”,
1964
– Treats “reproducible signs”
– Oscillatory techniques (Grades
I-V)
Physical Therapists who advanced
practice of manipulation
• Stanley Paris
– Spinal Lesion, 1965
– Educated PT’s in U.S. in manual
therapy
– Founding member of AAOMPT
and first president of the
Orthopaedic Section
– Founder of University of St.
Augustine
• Maitland, Kaltenborn, and Paris
established long term Manual
Therapy education programs
for PTs in the USA and abroad
 Current History and the Future
• Evidence Based Practice
• Physical Therapists are the leaders in the
diagnosis and management of “Movement”
Disorders
– Evidence shows that manipulation and exercise
are PTs most useful tools
• Professional Associations promote and
protect scope of practice
 Historical Summary
• No one profession invented or owns
Manipulation
• Traditional Chiropractic is based on unproven
theories
– “Law of the nerve”
– “Subluxation theory”
• Manipulation has been a vital part of the scope
of PT practice since the inception of the
profession
TJM and PT training
 Professional Education & Legislation
We can show;
• Manipulation is within the scope of physical
therapy practice.
• The entire continuum of manipulation
procedures (thrust and non-thrust) are taught
in professional physical therapist education.
 CAPTE
• The Commission on Accreditation in Physical
Therapy Education (CAPTE) is the sole
accreditation agency recognized by the United
States Department of Education (USDE) and
the Council for Higher Education Accreditation
(CHEA) to accredit entry-level physical
therapist and physical therapist assistant
education programs.
 Physical Therapist Curriculum
• CAPTE Evaluative Criteria requires physical therapist
education programs to teach thrust and non-thrust
manipulation of the spine and extremities
• Manipulation Education Manual (APTA/AAOMPT)
developed in 2004 to further enhance level of instruction
in manipulation
• Textbooks such as “Manual Physical Therapy of the Spine”
(Saunders, Elsevier 2009) written by Physical Therapists
– http://www.us.elsevierhealth.com
– CDMNP.mp4
 PT education
• Emphasis on problem solving and an
Evidence-based approach
• PT education focuses on clinical decision
making and meeting educational objectives
• TJM is integrated into clinical science courses
rather than stand alone courses
• Advanced specialty PT training is obtained
through long term fellowship programs
 Spinal Manipulation in Physical Therapist
Professional Degree Education: A Model for
Teaching and Integration into Clinical Practice

Timothy W. Flynn, PT, PhD, OCS, FAAOMPT

Robert Wainner, PT, PhD, ECS, OCS, FAAOMPT
Julie Fritz, PT, PhD, ATC

Flynn, JOSPT 2006

 PT students employed mobilization and
manipulation in episodes of care for lumbar
impairments and achieved excellent outcomes
70
60
50
Frequency %

40 Eval
WK1
30
DC
20
10
0
Manipulation Mobilization

Flynn, JOSPT 2006

 Student Outcomes
Eight first year PT students treated patients with LBP:
• N = 61 patients with LBP
• Age = 34
• Duration Symptoms = 112 days
• Prior Episode = 65%
• 50% with butt/thigh or leg symptoms
• Total Visits = 6.2 (+/- 4 visits)
Results:
• Pain rating initial: 6.0 +/- 1.7 and at d/c: 1.8 +/- 1.2
• ODI initial: 33.8 and at d/c: 13.4
Flynn, JOSPT 2006
 PTs receive training in TJM
• PT education emphasizes movement sciences
and analysis
– Expertise is grounded in anatomy, physiology,
biomechanics, and pathology
– Provides foundation for determining clinical
decision making needed for TJM
• Students receive psychomotor training and
testing required for safe TJM
 Physical Therapists Clinical Decision
Making
• PTs are trained to recognize indications,
contraindications, and red flags to
performance of manipulation
• PTs function as part of a health care team and
are trained to refer to the appropriate medical
professional if further diagnostic testing is
indicated
TJM and Patient Safety
 Credentialing/Licensure
• State licensure and state licensing boards are
in place to assure physical therapists practice
within their scope of practice and to protect
the public
– Thrust and non-thrust manipulation are included
in the PT licensure exam
 Malpractice
• Maginnis and Associates liability Insurance
carrier has provided a letter to APTA stating
that there is no evidence of higher claims
losses due to PTs utilizing manipulative
procedures
– (APTA Manipulation Action Packet)
 Radiology Training
• “It is critical to be able to read and interpret x-
rays, MRI’s, and CT scans in order to make a
proper diagnosis for indication for
manipulation, as well as contraindication for
manipulation”
• “Physical Therapists have no training in
radiology interpretation”
Daniel M. Wik MD, DC
Nebraska mediation
hearing on manipulation,
July 2008
 Imaging
• Excessive use of imaging has been cited as a
cause of escalating health care costs
• Clinical practice Guidelines have
recommended to refrain from ordering
radiographs in the absence of red flags
– Van Tulder M, Tuut M, Pennick V, Bombardier C, Assendelft W. Quality of Primary Care
Guidelines for Acute Low Back Pain. Spine. 2004;29(17):357-362.
PTs screen for Red Flags and refer for further
diagnostic testing indicated prior to treatment
 Significant trauma
 Weight loss
 History of cancer
 Fever
 Intravenous drug use
 Steroid use
 Patient over 50 years
 Severe, unremitting night-time pain
 Pain that gets worse when lying down

New Zealand Acute Low Back Pain Guide 2003/

www.nzgg.org.nz
 What Are the Risks of serious
complications from lumbar TJM?
Haldeman and Rubenstein (Spine, 1992)
– Reviewed the literature over 77 year period

– Ten episodes of cauda equina syndrome following

lumbar manipulation reported (none from PTs)

– Estimated risk: < 1 per 10 million manipulations

 Potential
Procedure Reported Risk Est # / 10,000
Complication

Lumbo-Sacral Cauda Equina

1 / 10,000,000 0.001
Manipulation

Exercise 1 / 1,500,000 0.007 Sudden Death

NSAIDS 1- 3 / 100 100 – 300 GI bleed

ESI (w/ Intravascular

8 – 11 / 100 800 - 1100
fluoroscopy) Injection
Vascular
Disc Surgery 1.6 – 17 / 10,000 1.6 – 17
perforations

Disc Surgery 3.8 / 10,000 3.8 Visceral injuries

Fusion 17 / 100 1700 Varied

Discectomy,
laminectomy, +/- 0.2-0.3 / 100 20 – 30 Death
fusion
Neurovascular Injury from Cervical
Spine TJM
• What are the risks?
 What are the Risks?
(Di Fabio, Phys Ther, 1999)

• 177 patients (1925-1997) who experienced adverse

events with manipulation
• 39.6 years (4 months - 87 years), even distribution
between males and females (80 males, 90 females)
• Primary diagnoses included arterial dissection/spasm
and brain stem lesions
• 32 cases (18%) resulted in death
• <2% adverse events caused by PTs (no deaths
caused by PTs)
 Mechanism of VBI
(Haldeman, Spine, 1999)
• 367 cases between 1966-
1993 involving vertebral Mechanism No. (%) of
artery dissection and/or cases
occlusion, regardless of the
mechanism of injury Spontaneous 160 (43)
• Major trauma – MVA, fall,
direct impact, contact sport
injuries, etc. Cervical manip 115 (31)
• Trivial trauma – sudden head
movements, sporting
activities, sustained rotation Trivial trauma 58 (16)
and/or extension, backing out
of driveway
• Spontaneous – non-recent Major trauma 37 (10)
trauma, past VBI, driving in
car, pregnancy, standing up
briskly after a nap Total 367
 Quantifying the Risk?

• Impossible to determine the precise risk

– Not all events published in peer-reviewed literature
– No accepted standard for reporting these injuries
• Risk of serious complications approximately 6 per
10 million* (Hurwitz, Spine, 1996)
• Risk of death estimated at 3 in 10 million*
manipulations (Hurwitz, Spine, 1996)

*Adjusted risk based on assumption that only 1 in 10

reported in literature
 Summary - safety
• Benefits outweigh the risks as long as clinical
decision making is based on thorough
examination and Evidence-based impairment-
based approach
– Screen for red flags
– Consider contraindications
– Modify techniques when appropriate
• More risk with other common medical and
surgical interventions than manipulation
• Physical Therapists clinical decision-making
philosophy facilitates safe practice
Research Supporting Use of TJM
 Hierarchy of Evidence for Treatment

Higher levels of study Systematic

design allow you to Reviews & Meta-
have increased analyses of RCTs
confidence in the
conclusions drawn Multiple RCTs
from the study.
Randomized Controlled Trial (RCT)

Systematic Review of the studies below

Observational Cohort or Case Control
Studies, Large Case Series

Case Reports, Small Case Series

Unsystematic Clinical Observations
 LBP Clinical Practice Guidelines

• AHCPR (‘94) - Manipulation can be helpful

for patients with acute low back problems without
radiculopathy when used within the first month of
symptoms. (Strength of Evidence = B)
–First major clinical guideline to recommend TJM for
LBP
What profession provided the Manipulation in
the referenced Randomized Controlled Trials?

Physical Therapy. 2000; 80 (8):820-823

Totals for all reports cited by either AHCPR or

RAND treatment guidelines that support
manipulation

•Chiropractors: 5 (18%)
•MD: 10
•Osteopath: 3
•PT: 12 (40%)
 LBP Clinical Practice Guidelines

• NZGG (‘98)- Manual loading of the spine using short or long

leverage methods is safe and effective in the first 4-6 weeks of acute
low back symptoms. (Strength of Evidence = Moderate)

• RCGP (’96 & ‘01)- Within the first six weeks of onset of acute
or recurrent low back pain, manipulation provides better short-term
improvement in pain and activity levels and higher patient
satisfaction than the treatments to which it has been compared.
(Strength of Evidence = )
 Manipulation/Mobilization Systematic Review
(Gross, Cochrane Collaboration, 2004)

• Strong evidence supporting thrust and/or non-

thrust manipulation plus exercise to improve
short- and long-term outcomes of care for
patients with neck pain disorders
The Bone and Joint Decade 2000–2010 Task Force
on Neck Pain and Its Associated Disorders
Executive Summary

Scott Haldeman, DC, MD, PhD,* Linda Carroll, PhD,† J. David Cassidy,
DC, PhD, DrMedSc,‡ Jon Schubert, CMA,§ and Åke Nygren, DDS, MD,
DrMedSc¶

SPINE Volume 33, Number 4S, pp S5–S7

©2008, Lippincott Williams & Wilkins
The Bone and Joint Decade 2000–2010 Task Force on
Neck Pain and Its Associated Disorders

• Educational videos, mobilization, manual therapy,

exercises, low-level laser therapy, and perhaps
acupuncture appeared to have benefit.

• WAD and other neck pain without radicular symptoms,

interventions that focused on regaining function and
returning to work as soon as possible were relatively
more effective than interventions that did not have
such a focus.
 Summary-Evidence
• Greater evidence for spinal manipulation than most
other PT interventions
– Strong evidence for Thrust manipulation for subgroup of
patients with Acute LBP
– Strong evidence for mobilization /manipulation combined
with exercise for subgroup of patients with neck pain
• Clinical predictions rules (CPR) have been developed by
physical therapists to help guide clinical decision-
making in use of TJM
• CPRs should be integrated with an impairment-based
approach
 Summary--Value
• Billions of $ spent to treat musculoskeletal
conditions each year.
• Exercise combined with Manipulation
provided by physical therapists may be part of
the solution
• Chiropractors feel threatened and are fighting
back with regulatory and legislative strategies
 PT are educated, effective, and
Safe at TJM
• Non-PT agencies have investigated PT
competence in TJM and have determined that
TJM is within PT scope of practice including:
– Veterans Hospital Association
– US department of Health and Human Services
– Virginia board of Medicine
Attempts to limit PTs from using
Manipulation is based on
Economics---not patient safety

The health and welfare of the public

is best served by physical therapists
providing manipulation!
olsonpt@comcast.net
 Contributors to presentation
• Bill Boissonnault PT, DHSc
• Josh Cleland PT, PhD
• Tim Flynn PT, PhD
• Stephen McDavitt PT, DPT
• Ken Olson PT, DHSc (chair)
• Stanley Paris PT, PhD
• Bob Rowe PT, DPT