Over the past fifteen years, chiropractic organizations have made a concerted effort to restrict physical therapists from practicing and/or advertising spinal manipulation and to limit such activity to chiropractors alone or, at most, to chiropractors, osteopaths and medical doctors. This effort has essentially taken a three-pronged approach as chiropractors have: (1) lobbied state legislatures to enact legislation that would make the practice of spinal manipulation by physical therapists illegal, (2) sought advisory opinions from state attorney generals and administrative boards stating that, under existing state laws, the practice of spinal manipulation by physical therapists is unlawful, and (3) initiated legal action in state courts against individual physical therapists alleging that those physical therapists’ use of spinal-manipulation techniques is unlawful. These attempts by chiropractic boards and/or associations to monopolize spinal manipulation as a uniquely chiropractic technique have generally been rebuffed; however, some change has been effected and physical therapists currently practicing spinal manipulation, or those with plans to expand their practice to include it, should to be aware of the legal considerations related to doing so, as well as the ongoing developments in this controversial arena.
Of all the various arenas, it is perhaps most important that physical therapists be engaged in the legislative process as courts and attorney generals are presumably limited to interpreting the statutes enacted by their respective state legislatures. In the past two years, physical therapists in several states have faced legislative efforts to bar them from performing spinal manipulation and countered them with different strategies. As can be seen, the results vary according to the strategy taken.
In California, Senate Bill 381 (SB 381) was introduced on February 20, 2013, and would have prevented any healthcare provider from performing “a joint manipulation or joint adjustment” unless licensed as a chiropractor, medical physician, or osteopath. The California Physical Therapy Association and individual California physical therapists actively opposed SB 381 and attempted to counter the misinformation spread by the California Chiropractic Association, which sponsored the bill. SB 381 was ultimately referred to the Senate Committee on Business, Professions, and Economic Development, and, following a hearing at which both physical therapists and chiropractors showed up en masse to express their views, that committee voted 6-1 not to pass SB 381. A subsequent hearing was scheduled but it was thereafter postponed indefinitely and SB 381 effectively died in committee, preserving the status quo in California.
Nevertheless, shortly after the defeat of SB 381 in California, physical therapists in Indiana effectively traded their right to practice spinal manipulation for “direct access.” As a result of the enactment of House Bill 1034 (HB 1034), which was signed into law by the Indiana governor on April 29, 2013, physical therapists in Indiana are now able to treat patients without a referral under limited circumstances, but they ironically may no longer perform spinal manipulation at all without a referral. Specifically, Ind. Code § 25-27-1-2.5 now provides:
“(a) Except as provided in subsection (b), a physical therapist may evaluate and treat an individual during a period not to exceed twenty-four (24) calendar days beginning with the date of the initiation of treatment without a referral from a provider described in section 2(b) of this chapter. However, if the individual needs additional treatment from the physical therapist after twenty-four (24) calendar days, the physical therapist shall obtain a referral from the individual’s provider, as described in section 2(b) of this chapter.
“(b) A physical therapist may not perform spinal manipulation of the spinal column or the vertebral column unless:
“(1) the physical therapist is acting on the order or referral of a physician, an osteopath, or a chiropractor; and
“(2) the referring physician, osteopath, or chiropractor has examined the patient before issuing the order or referral.”
While the Indiana chapter of the American Physical Therapy Association lauded the passage of HB 1034 and most physical therapists in Indiana probably stand to benefit by its passage, for physical therapists that have a highly specialized practice treating musculoskeletal spinal disorders (admittedly, likely a small percentage of all physical therapists in Indiana), this new statute could prove to be problematic and a costly trade. The passage of similar bills in other states would also prove harmful to physical therapists’ attempts to claim spinal manipulation as a fundamental part of their scope of practice.
Finally, in January 2014, the Washington House of Representatives passed House Bill 2160, which purported to provide a pathway for physical therapists to lawfully practice spinal manipulation. The Washington Senate thereafter passed a companion bill and, on March 11, 2014, the Washington governor signed the bill and it is due to go into effect on July 1, 2015. However, while the passage of this bill was praised by the Physical Therapy Association of Washington, it is doubtful that a single physical therapist in Washington State currently possesses, or will be able to attain, the necessary hours of training required by the law to perform spinal manipulation without having to first enroll in and complete chiropractic school. Upon examination, HB 2160 allows a physical therapist to perform spinal manipulation, but only after being issued a “spinal manipulation endorsement.” In order to apply for the endorsement, a physical therapist must first complete 250 hours of “didactic and practical training related to the delivery of spinal manipulative procedures,” 100 hours of training in differential diagnosis, 150 hours of training in spinal diagnostic imaging, and 300 hours of supervised clinical practical experience in spinal manipulative procedures performed under a licensed chiropractor, osteopathic physician, or an individual who holds a “spinal manipulation endorsement” issued pursuant to this law.
HB 2160 further provides that physical therapists in Washington “shall not advertise that they perform spinal manipulation or manipulative mobilization of the spine” and are prohibited “from billing a health carrier for spinal manipulation.” Physical therapists practicing spinal manipulation are further allowed only six sessions of spinal manipulation before the physical therapist must consult with a chiropractor, osteopath, nurse practitioner, podiatrist or dentist. Oddly enough, HB 2160 also states that a physical therapist “may not have a practice in which spinal manipulation constitutes the majority of the services provided.” This would seem to violate ethical principles inasmuch as it appears to be an attempt to regulate what kind, what volume, and what proportion of patients a physical therapist is allowed to treat in their practice. Certainly, chiropractors would not be expected to agree to a requirement that they consult with physical therapists after using six exercise sessions with their patients.
Thus, while HB 2160 may be a “victory” in theory inasmuch as it generally recognizes that spinal manipulation is within the field of physical therapy, its practical effect will likely be insignificant as the requirements for a physical therapist to become qualified under Washington law to perform spinal manipulation are sufficiently onerous that few can be expected to do so. It is likely for this reason that the chiropractic lobby in Washington did not oppose the bill.
James Dunning, DPT, MSc (Manip Ther), MMACP (UK), FAAOMPT
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
President, Alabama Physical Therapy & Acupuncture
Raymond Butts, PhD, DPT, MSc (NeuroSci), Cert. DN, Cert. SMT
Senior Instructor, Spinal Manipulation Institute & Dry Needling Institute
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Lars Longnecker, JD
Attorney, Montgomery, AL
For purposes of SB 381, “joint manipulation” and “joint adjustment” would be synonymous terms “that describe a method of skillful and beneficial treatment where a person uses a direct thrust to move the joint of a patient beyond its normal range of motion, but without exceeding the limits of anatomical integrity, as taught in chiropractic schools or colleges.”
SB 381 was sponsored by the California Chiropractic Association and authored by State Senator Leland Yee. The San Jose Mercury News subsequently published an article detailing Senator Yee’s history of crafting legislation benefitting special interests groups that supplied him with campaign contributions. See Kinney, A., and Calefati, J., Leland Yee case: Disgraced California state senator’s legislative efforts fueled cash for campaigns. San Jose Mercury News, Apr. 19, 2014 (noting that SB 381 “died after one hearing before the Senate Business and Professions Committee, where Yee failed to win a single vote. He nonetheless received $8,300 from the chiropractic association and $2,700 from individual practitioners”).
Of note, within the context of the statute it seems this 250-hour requirement does not include training in non-thrust mobilization procedures.