Fischer- Final Research Essay
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Julie Fischer Mr. Rudebusch English Composition IV 7 January 2019 Who are the Safest and Most Effective Providers of Spinal Manipulation: Chiropractors or Physical Therapists? When you experience back pain, your first instinct is to schedule an appointment with the chiropractor. Your chiropractor will use “adjustments,” otherwise known as manipulation, to ease your pain. According to the American Physical Therapy Association, or APTA, “[m]anipulation techniques are manual (hands on) … treatment techniques used by [p]hysical [t]herapists, [p]hysicians, [o]steopaths and [c]hiropractors” (American Physical Therapy Association). There are two types of manipulation, thrust and non-thrust. Thrust manipulation, or specifically thrust joint manipulation, uses quick movements across small regions either at or near joint sites. Non-thrust manipulation uses slower, softer movements. Since chiropractors specifically specialize in spinal manipulation, people believe that they are the only treatment option. But what if there was another professional who could provide a safer and more effective manipulation treatment? Fortunately, there is, and they’re called physical therapists. Physical therapy, or PT, has been simply known as using various exercises to treat diagnoses. However, physical therapists have been using other forms of treatment, such as spinal manipulation, since the profession began, and when combined with exercises, manipulation is the best form of treatment. Because of the higher education requirement for the profession in today’s society, physical therapists are also taught proper manipulation techniques when completing their
Fischer 2
Doctorate of Physical Therapy programs. This training has resulted in physical therapists recording fewer manipulation-related injuries than chiropractors. Therefore, physical therapists provide safer and more effective spinal manipulation than chiropractors. Along with exercise, manipulation is the best form of treatment for pain. Paul Shekelle, director of the Southern California Evidence-Based Practice Center site at the RAND Corporation, led a study that found that “[t]he risk of cauda equina syndrome from lumbar manipulation has been estimated to be on the order of 1 in 100 million manipulations.” Cauda equina syndrome is a condition in which the bundle of nerves located right below the spinal cord is damaged. While the risks of complications caused by manipulation are low, people still look to prescription drugs to aid their pain. However, two independent studies, one led by Robyn Tamblyn, professor in the Department of Medicine at McGill University, and the other led by Dr. Hyman Tannenbaum, a rheumatologist from Montreal, QC, found that “the risk of serious gastrointestinal bleeding from nonsteroidal antiinflammatory [sic] drugs is 1-3 per 1000 and an estimated 76,000 hospitalizations and 7600 deaths (per year) may be attributable to these medications” (Manipulation Education Committee APTA Manipulation Task Force). This means that some pain medications can lead to bleeding in various abdominal organs involved in digestion, which shows that the risks of manipulation are far lower than prescription drugs. Manipulation alone, however, isn’t the best treatment for back pain. A case report written and performed by Jacqueline van Duijn, instructor and Director of Clinical Education- Physical Therapy at the Marieb College of Health and Human Services at Florida Gulf Coast University, used “various thrust and non-thrust manipulations, soft tissue mobilizations, postural re-education, and exercise” to treat “a patient diagnosed with cervicogenic headache.”
Fischer 3
Cervicogenic headache is a headache caused by pain in the cervical, or neck, area of the spine. At the end of treatment, the patient reported having no more headaches or symptoms related to neck pain (van Duijn). This shows that manipulation is more effective when combined with exercise, education, and mobilizations performed by physical therapists, rather than being performed on its own. Physical therapists have been using this technique since the profession began. The first organized professional physical therapy association, the American Women’s Physical Therapeutic Association, was founded in 1921. Mary McMillan, the first president of the American Women's Physical Therapeutic Association, recorded in her book Massage and Therapeutic Practice the techniques and methods used during that time period. “Physical therapists (PTs) in the US have used manipulation and other manual techniques since the profession was established in the US in the 1920s” (American Physical Therapy Association). This shows that manipulation has always been a part of the physical therapy scope of practice, even before doctorate degrees were required for the profession. Physical therapists receive training in thrust and non-thrust manipulation while in physical therapy school. According to the Commission on Accreditation in Physical Therapy Education (CAPTE), “[t]raining in manipulation (thrust & non thrust) is a required component of entry level physical therapist education programs in the US” (American Physical Therapy Association). Even at the beginning of the professional physical therapy program, students are taught about manipulation techniques and usage. During the program, students are taught the different techniques used for manipulation. For example, students would be given lab instruction for “lumbar spine neutral ‘gapping’ manipulation” including a description and pictures of the
Fischer 4
techniques used for that particular type of manipulation. At the end of the professional program, students are required to complete a clinical experience, in which the students’ therapy techniques are practiced under the supervision of clinical instructors. The purpose of this experience is to ensure that the students are successfully prepared to “select and safely perform interventions,” including spinal manipulation, when they begin their career as a practicing physical therapist (Manipulation Education Committee APTA Manipulation Task Force). There are fewer thrust joint manipulation, or TJM, injuries when physical therapists use this technique. Willem Assendelft, researcher at Radboud University Medical Centre, led a study specifically focusing on spinal manipulation complications and found that “61% (135/220) of complications [are] due to chiropractic and only 5% (12/220) [are] due to PT.” A separate study led by Jacob Patijn, researcher at Maastricht University Medical Centre’s Department of Anesthesiology & Pain Management, found that “87% (85/98) of complications [are] due to chiropractors and only 6% (6/98) [are] due to PT” (APTA Manipulation Task Force). Again, another independent study led by Richard Di Fabio, researcher at the University of Minnesota’s Department of Physical Medicine and Rehabilitation, found that “70% of complications [are] due to chiropractors and only 2% ... [are] due to PT.” Darren A Rivett and Peter Milburn, senior lecturers in the School of Physiotherapy at University of Otago, also support this claim with the results of their study. This study found that ”more than one-half [of] TJM complications (54%) [are] caused by chiropractors (23/42)” and that “only one-third (14/42) of all complications reported were result[s] of PT treatments” This data suggests that “chiropractors compared to PTs … produced nearly twice (164%) as many complications.” A graph comparing the results of these four studies is found labeled as Table 1 below with Assendelft’s study as Study 1, Patijn’s
Fischer 5
as Study 2, Di Fabio’s as Study 3, and Rivett and Milburn’s as Study 4 (American Physical Therapy Association). Table I
All 4 of these independent studies support the idea that physical therapists perform safer manipulation than chiropractors. However, people will still be reluctant to receive manipulation from any healthcare provider because they hear and read stories of the injuries manipulation can cause. Kelly Kennell, researcher at the University of Illinois College of Medicine, led a study to determine how dangerous manipulation really is. During this study, patient cases associated with cervical artery dissection, a condition in which an artery in your neck is torn open due to excessive force or quick movements, were examined. She concluded that the “[i]njuries reported … most commonly follow[ed] chiropractic manipulation.” After completing the study, she found that out of the 141 patients diagnosed with cervical artery dissection, “no cases [were] associated with manipulation by other health professionals” (Kennell). When people hear of the injuries
Fischer 6
caused by manipulation, they often only hear about the injuries caused by chiropractors. This is because chiropractors cause significantly more injuries than physical therapists do. In conclusion, when compared to chiropractors, physical therapists provide safer and more effective spinal manipulation to patients experiencing back pain. They are able to combine manipulation treatments with exercise and education, have been practicing manipulation for the last 100 years, are taught the proper techniques in professional programs, and have reported fewer manipulation-related injuries than chiropractors. So, the next time you experience back pain, schedule an appointment with your physical therapist to get the best treatment possible.
Fischer 7
Works Cited American Physical Therapy Association. “Manipulation Safety & Physical Therapist Practice.” APTA.org.http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Manipula tion/ManipulationSafetyandPTPractice.pdf APTA Manipulation Task Force. “Review of the “Federation of Chiropractic Licensing Boards High-velocity, low amplitude spinal adjusting / manipulation performance: Minimum criteria for safety and adequate competence.” APTA.org. F ebruary 2011. http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Manipulation/Revie wofFCLBPaper.pdf Kennell, Kelly A., et al. “Cervical Artery Dissection Related to Chiropractic Manipulation: One Institution’s Experience: This Study Suggests That Patients Considering Chiropractic Cervical Spine Manipulation Should Be Advised of the Risks of Potential Arterial Dissection and Stroke.” Journal of Family Practice, vol. 66, no. 9, Sept. 2017, pp. 556–562. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=124918189&site=ehost-live. Manipulation Education Committee APTA Manipulation Task Force. “Manipulation Education Manual For Physical Therapist Professional Degree Programs.” APTA.org. 2004. http://www.apta.org/uploadedFiles/APTAorg/Educators/Curriculum_Resources/APTA/M anipulation/ManipulationEducationManual.pdf van Duijn, Jacqueline, et al. “Orthopaedic Manual Physical Therapy Including Thrust Manipulation and Exercise in the Management of a Patient with Cervicogenic Headache: A Case Report.” Journal of Manual & Manipulative Therapy, vol. 15, no. 1, Mar. 2007,
Fischer 8
pp. 10–24. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=25071933&site=ehost-live.
Julie Fischer Mr. Rudebusch English Composition IV 7 January 2019 Who are the Safest and Most Effective Providers of Spinal Manipulation: Chiropractors or Physical Therapists? When you experience back pain, your first instinct is to schedule an appointment with the chiropractor. Your chiropractor will use “adjustments,” otherwise known as manipulation, to ease your pain. According to the American Physical Therapy Association, or APTA, “[m]anipulation techniques are manual (hands on) … treatment techniques used by [p]hysical [t]herapists, [p]hysicians, [o]steopaths and [c]hiropractors” (American Physical Therapy Association). There are two types of manipulation, thrust and non-thrust. Thrust manipulation, or specifically thrust joint manipulation, uses quick movements across small regions either at or near joint sites. Non-thrust manipulation uses slower, softer movements. Since chiropractors specifically specialize in spinal manipulation, people believe that they are the only treatment option. But what if there was another professional who could provide a safer and more effective manipulation treatment? Fortunately, there is, and they’re called physical therapists. Physical therapy, or PT, has been simply known as using various exercises to treat diagnoses. However, physical therapists have been using other forms of treatment, such as spinal manipulation, since the profession began, and when combined with exercises, manipulation is the best form of treatment. Because of the higher education requirement for the profession in today’s society, physical therapists are also taught proper manipulation techniques when completing their
Fischer 2
Doctorate of Physical Therapy programs. This training has resulted in physical therapists recording fewer manipulation-related injuries than chiropractors. Therefore, physical therapists provide safer and more effective spinal manipulation than chiropractors. Along with exercise, manipulation is the best form of treatment for pain. Paul Shekelle, director of the Southern California Evidence-Based Practice Center site at the RAND Corporation, led a study that found that “[t]he risk of cauda equina syndrome from lumbar manipulation has been estimated to be on the order of 1 in 100 million manipulations.” Cauda equina syndrome is a condition in which the bundle of nerves located right below the spinal cord is damaged. While the risks of complications caused by manipulation are low, people still look to prescription drugs to aid their pain. However, two independent studies, one led by Robyn Tamblyn, professor in the Department of Medicine at McGill University, and the other led by Dr. Hyman Tannenbaum, a rheumatologist from Montreal, QC, found that “the risk of serious gastrointestinal bleeding from nonsteroidal antiinflammatory [sic] drugs is 1-3 per 1000 and an estimated 76,000 hospitalizations and 7600 deaths (per year) may be attributable to these medications” (Manipulation Education Committee APTA Manipulation Task Force). This means that some pain medications can lead to bleeding in various abdominal organs involved in digestion, which shows that the risks of manipulation are far lower than prescription drugs. Manipulation alone, however, isn’t the best treatment for back pain. A case report written and performed by Jacqueline van Duijn, instructor and Director of Clinical Education- Physical Therapy at the Marieb College of Health and Human Services at Florida Gulf Coast University, used “various thrust and non-thrust manipulations, soft tissue mobilizations, postural re-education, and exercise” to treat “a patient diagnosed with cervicogenic headache.”
Fischer 3
Cervicogenic headache is a headache caused by pain in the cervical, or neck, area of the spine. At the end of treatment, the patient reported having no more headaches or symptoms related to neck pain (van Duijn). This shows that manipulation is more effective when combined with exercise, education, and mobilizations performed by physical therapists, rather than being performed on its own. Physical therapists have been using this technique since the profession began. The first organized professional physical therapy association, the American Women’s Physical Therapeutic Association, was founded in 1921. Mary McMillan, the first president of the American Women's Physical Therapeutic Association, recorded in her book Massage and Therapeutic Practice the techniques and methods used during that time period. “Physical therapists (PTs) in the US have used manipulation and other manual techniques since the profession was established in the US in the 1920s” (American Physical Therapy Association). This shows that manipulation has always been a part of the physical therapy scope of practice, even before doctorate degrees were required for the profession. Physical therapists receive training in thrust and non-thrust manipulation while in physical therapy school. According to the Commission on Accreditation in Physical Therapy Education (CAPTE), “[t]raining in manipulation (thrust & non thrust) is a required component of entry level physical therapist education programs in the US” (American Physical Therapy Association). Even at the beginning of the professional physical therapy program, students are taught about manipulation techniques and usage. During the program, students are taught the different techniques used for manipulation. For example, students would be given lab instruction for “lumbar spine neutral ‘gapping’ manipulation” including a description and pictures of the
Fischer 4
techniques used for that particular type of manipulation. At the end of the professional program, students are required to complete a clinical experience, in which the students’ therapy techniques are practiced under the supervision of clinical instructors. The purpose of this experience is to ensure that the students are successfully prepared to “select and safely perform interventions,” including spinal manipulation, when they begin their career as a practicing physical therapist (Manipulation Education Committee APTA Manipulation Task Force). There are fewer thrust joint manipulation, or TJM, injuries when physical therapists use this technique. Willem Assendelft, researcher at Radboud University Medical Centre, led a study specifically focusing on spinal manipulation complications and found that “61% (135/220) of complications [are] due to chiropractic and only 5% (12/220) [are] due to PT.” A separate study led by Jacob Patijn, researcher at Maastricht University Medical Centre’s Department of Anesthesiology & Pain Management, found that “87% (85/98) of complications [are] due to chiropractors and only 6% (6/98) [are] due to PT” (APTA Manipulation Task Force). Again, another independent study led by Richard Di Fabio, researcher at the University of Minnesota’s Department of Physical Medicine and Rehabilitation, found that “70% of complications [are] due to chiropractors and only 2% ... [are] due to PT.” Darren A Rivett and Peter Milburn, senior lecturers in the School of Physiotherapy at University of Otago, also support this claim with the results of their study. This study found that ”more than one-half [of] TJM complications (54%) [are] caused by chiropractors (23/42)” and that “only one-third (14/42) of all complications reported were result[s] of PT treatments” This data suggests that “chiropractors compared to PTs … produced nearly twice (164%) as many complications.” A graph comparing the results of these four studies is found labeled as Table 1 below with Assendelft’s study as Study 1, Patijn’s
Fischer 5
as Study 2, Di Fabio’s as Study 3, and Rivett and Milburn’s as Study 4 (American Physical Therapy Association). Table I
All 4 of these independent studies support the idea that physical therapists perform safer manipulation than chiropractors. However, people will still be reluctant to receive manipulation from any healthcare provider because they hear and read stories of the injuries manipulation can cause. Kelly Kennell, researcher at the University of Illinois College of Medicine, led a study to determine how dangerous manipulation really is. During this study, patient cases associated with cervical artery dissection, a condition in which an artery in your neck is torn open due to excessive force or quick movements, were examined. She concluded that the “[i]njuries reported … most commonly follow[ed] chiropractic manipulation.” After completing the study, she found that out of the 141 patients diagnosed with cervical artery dissection, “no cases [were] associated with manipulation by other health professionals” (Kennell). When people hear of the injuries
Fischer 6
caused by manipulation, they often only hear about the injuries caused by chiropractors. This is because chiropractors cause significantly more injuries than physical therapists do. In conclusion, when compared to chiropractors, physical therapists provide safer and more effective spinal manipulation to patients experiencing back pain. They are able to combine manipulation treatments with exercise and education, have been practicing manipulation for the last 100 years, are taught the proper techniques in professional programs, and have reported fewer manipulation-related injuries than chiropractors. So, the next time you experience back pain, schedule an appointment with your physical therapist to get the best treatment possible.
Fischer 7
Works Cited American Physical Therapy Association. “Manipulation Safety & Physical Therapist Practice.” APTA.org.http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Manipula tion/ManipulationSafetyandPTPractice.pdf APTA Manipulation Task Force. “Review of the “Federation of Chiropractic Licensing Boards High-velocity, low amplitude spinal adjusting / manipulation performance: Minimum criteria for safety and adequate competence.” APTA.org. F ebruary 2011. http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Manipulation/Revie wofFCLBPaper.pdf Kennell, Kelly A., et al. “Cervical Artery Dissection Related to Chiropractic Manipulation: One Institution’s Experience: This Study Suggests That Patients Considering Chiropractic Cervical Spine Manipulation Should Be Advised of the Risks of Potential Arterial Dissection and Stroke.” Journal of Family Practice, vol. 66, no. 9, Sept. 2017, pp. 556–562. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=124918189&site=ehost-live. Manipulation Education Committee APTA Manipulation Task Force. “Manipulation Education Manual For Physical Therapist Professional Degree Programs.” APTA.org. 2004. http://www.apta.org/uploadedFiles/APTAorg/Educators/Curriculum_Resources/APTA/M anipulation/ManipulationEducationManual.pdf van Duijn, Jacqueline, et al. “Orthopaedic Manual Physical Therapy Including Thrust Manipulation and Exercise in the Management of a Patient with Cervicogenic Headache: A Case Report.” Journal of Manual & Manipulative Therapy, vol. 15, no. 1, Mar. 2007,
Fischer 8
pp. 10–24. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=25071933&site=ehost-live.
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