Saanichton Physical Therapy Blog

Physiotherapists are the safest providers of Manipulation

Physiotherapists are the safest providers of Manipulation

Thanks to Dr. Rob Landel and the California Orthopaedic Manual Physical Therapy Special Interest Group for the following post.

 In my last post, I made it clear that physical therapists are more than adequately prepared, through their education and clinical experiences, to perform thrust joint manipulation (TJM). In this post, I like to address the issue of safety, more specifically, the claim that allowing physical therapists to perform spinal manipulation will prove harmful to the public.
 The two issues are closely interrelated.
The safe application of any technique requires the use of clinical judgment, specifically, determining not only who is appropriate for the technique, but also for whom the technique is contraindicated. This must occur prior to the procedure being performed. Adequate clinical judgment is based on knowledge of anatomy, pathoanatomy, biomechanics, pathomechanics, pathology, and a differential diagnostic process. Even the most skillfully applied technique can be harmful if done in the wrong circumstances. Also, the decision of whether or not to perform a manipulation must be evidence-based, i.e. taken into account the best available evidence, the clinician’s experience, and the patient’s needs and goals.
As I noted in my last post, all of these aspects are basic components of any Doctor of Physical Therapy program. Furthermore, this knowledge and clinical judgment is tested extensively through written, oral, and practical examinations, as well as put into practice during as much as one year of supervised clinical experiences. Finally, in order to become licensed in the state of California, every physical therapist must pass their licensure exam, which includes testing their knowledge and clinical judgment on manipulation, as required by the Federation of State Boards of Physical Therapy.
Thus it is clear that physical therapists are well prepared to safely perform manipulation techniques, and in fact are required to be safe in their application before being allowed to practice. But is that what actually happens?
Well, let’s look at the evidencewho poses a greater threat to harm a patient by performing manipulations, chiropractors or physical therapists?
Published reports show a very low probability that physical therapists who use TJM will cause harm; the vast majority of serious complications from manipulation are NOT caused by physical therapists.
Summary of scientific reports on TJM complications by profession:
  •            61% of complications due to chiropractic and only 5% (12/220) due to PT (1)
  •           87% of complications due to chiropractors and only 6% (6/98) due to PT (2)
  •           70% of complications due to chiropractors and only 2% & no deaths due to PT (3)

Published review of medical literature over a 77‐year period found only 10 reports of cauda equina syndrome (a medical emergency lower spinal cord injury) after lower back TJM; none of those injuries were caused by PTs (4)

These numbers speak poorly for the chiropractors on their own, but are even worse when you consider that practicing PT’s outnumber chiropractors 4 to 1. (5)
Further evidence of the safety of physical therapists practice can be seen in the cost of our malpractice and liability insurance. A basic tenet of liability insurance is that the riskier the practice, the higher the fees. My California malpractice insurance is $361/year; in 2008, the typical chiropractor paid nearly $2700/year. (6) According to HPSO (largest liability insurance carrier for PTs in the US) there are no higher claims losses related to PT use of TJM than other PT treatment techniques.
The evidence is clear: ensuring public safety is not a valid reason for SB 381. Physical therapists pose no greater threat to patient safety than do chiropractors; in actual fact, the opposite is true!
I propose the following solution: introduce a bill that, in the interests of public safety, chiropractors are no longer allowed to “adjust” the spine.
As always, comments are welcome and encouraged!
  1. Assendelft WJJ, Bouter L.M., Knipschild PG. Complications of spinal manipulation. A comprehensive review of the literature. The Journal of Family 
Practice 1996; 42(5):475‐480.
  2. Patijn J. Complications in manual medicine: a review of the literature. J Man Med 1991; 6:89‐92.
  3. DiFabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999;79(1):50‐65.
  4. Haldeman S, Rubinstein SM. Cauda Equina Syndrome in patients undergoing manipulation of the lumbar spine.Spine. 1992;17(12):1469‐1473.