No You Don't, Yes We Do: The Challenge From Chiropractors

By William Boissonnault, Academy Practice Committee Chair

During manipulation legislative debates and negotiations, Chiropractic organizations frequently express the attitude of ownership; "Manipulation is ours" is their message. Of course, we respond that manipulation has been a part of our practice since the 1920s and have references to prove it. As many of you have experienced, the ensuing discussion takes on the form of a merry-go-round with no-one willing to get off the ride. This dialogue represents a good old fashion turf battle, just the thing legislators DO NOT want to participate in. So, what are the merits of the argument "No you (physical therapists) don't," meaning its not a part of our practice and "Yes we do" meaning it is a part of our practice?

The chiropractor argument is typically based on patient safety concerns, a concern shared by all health professions no matter the discussed intervention or test. But many times the patient being at-risk concern is simply a smoke-screen for the real issue-economics. The Institute for Alternative Futures recently released a document titled The Future of Chiropractic Revisited: 2005-2015. This report was heavily supported by chiropractic communities and all 18 members of on the advisory panel responsible for the document's content were either chiropractors or executive directors of chiropractic associations. The advisory panel was charged with revisiting the analysis and forecasts focusing on issues and trends in the chiropractic field that were presented in their previous document published in 1998. Physical therapists are mentioned in the current document on 26 different pages! In well over 90% of the notations physical therapists are mentioned in the context of an economic competitor. For example, on page i of the Introduction; "The biggest competitive threat will come from physical therapists."; on page iv "Other providers offer spinal manipulation for lower back, neck, and chronic pain. DPTs and massage therapists take over a large percentage of the cash market for back pain."; On page vii "Chiropractors will face more competition, especially from the growing number of physical therapists who are pursuing direct access in all 50 states and are upgrading their educational programs to graduate Doctors of Physical Therapy." On page 13 "Probably the most serious competitive threat on the horizon is from physical Therapists."; and so on and so on. No where is it mentioned that they must take action to protect the patient.

Why should legislators believe our side of the "Yes I do" turf argument any more than the No side? Do we have evidence from a source other than the mouths of physical therapists that manipulation is a part of our practice? Can we find sources beyond our own documents listing manipulation as an intervention for confirmation of our claim (The Guide To Physical Therapist Practice, Normative Model of Physical Therapist professional Education, CAPTE Evaluative Criteria etc.)? The answer is yes-even the Chiropractors say so! The Future of Chiropractic Revisited: 2005 to 2015 frequently acknowledges that physical therapists utilize manipulation techniques. In 2004 the Veterans Health Administration (VHA) recognized physical therapists as a provider of manual therapy services including spinal mobilization/manipulation within the VHA. In 1999 Dr. Tom Gustafson, Director of Center for Health Plans and Providers, Department of Health and Human Services stated that physical therapists provide services including manipulative treatment of the spine and other areas for Medicare recipients. In 1998 a code to be used by physical therapists reading; "manual therapy techniques (mobilization/manipulation, lymphatic drainage, manual traction" was approved by the American Medical Association's Common Procedural Terminology (CPT) code panel. In 1999 the Virginia Board of Medicine Department of Health Professions was charged to study spinal manipulation and the risk of harm to the public. After intense data gathering, the task force concluded that no limitations regarding the use of manipulation be placed on physical therapists. Documents and details of each of the decisions and others are available through APTA Governmental Affairs. Lastly, and maybe most importantly, the research provides evidence that manipulation is part of our practice. Dave Johnson and Mike Rogers published a Letter-to-the Editor in Physical Therapy Journal (August, 2000) on the topic of spinal manipulation. They described the AHCPR guidelines on Acute Low Back Pain and the RAND meta-analysis on low back pain. Of the 27 research papers cited in these two landmark reports, the manipulative services were provided by physical therapists in 12 of the studies compared to only 4 for chiropractors! In addition, over the past 10 years physical therapists have been at the forefront of research initiatives investigating manipulation. Numerous articles authored by physical therapists can be found in the top refereed health professions' journals.

When negotiating with chiropractic organizations we should make it clear who besides us states manipulation is a part of our practice. We should also make it clear to the chiropractic representatives that we will share with legislators the documents/articles that refute their claim that manipulation is not a part of physical therapist practice. This strategy will not necessarily end the turf battle scenario, but providing evidence that prominent organizations have concluded that physical therapists provide manipulation services will only strengthen our position.

From the AAOMPT official newsletter: Articulations (2005)