Jumping on the Manipulation Bandwagon

It seems as if the controversy about physical therapists encroaching on chiropractic territory is not over. The courts decided that only chiropractors can perform manipulations to correct a subluxation, but physical therapists can still perform adjustments because they do not address subluxations.

A recent article¹ posited that the problem in spinal manipulation research literature lies in the selection of which patients to include as research subjects. David Kietrys, MS, PT, OCS, assistant professor in the Department of Developmental and Rehabilitative Sciences at the University of Medicine and Dentistry in New Jersey stated, “There have been papers that have shown equivocal results of manipulation versus other interventions, some have shown it to be superior, and still others say that it’s no better than placebo.” Kietrys himself uses spinal manipulation in his private practice, but only on patients who have been selected after their physical examinations deemed them to be ideal candidates.

Kietrys presented a lecture titled “An Updated Systematic Review of the Efficacy of Spinal Manipulation for Patients with Low Back Pain” at the American Physical Therapy Association annual meeting. The large number of lecture attendees demonstrated that there is a strong interest in adapting the spinal manipulation modality into PT practice.

According to Kietrys, effective clinical decision-making standards are not based on pathoanatomy, such as sprain, strain, disk bulge, and facet joint lock, which can be misleading in determining the proper treatment. He suggests using inclusion parameters based on clinical signs and symptoms as determined by an examination. One study by Flynn et al² followed these protocols and increased the probability of a favorable outcome from 45% to 95%.

Kim D. Christensen, DC, CP’s Rehabilitation Adviser columnist, notes that “it is common among nonchiropractic researchers to speak of manipulation as if it is performed exactly the same by everyone, which is a problem with the manipulation literature. Chiropractic researchers generally recognize this and describe the manipulation event in terms of forces, duration, and/or technique. For example, a patient may respond better to a manipulation of low force/long duration and not respond to one of a high force/short duration. Without describing the manipulation event, it is difficult to discuss the pros and cons as suggested.”

This shows that Kietrys’ research just scratches the surface of spinal manipulation. Chiropractic has gone deeper and many steps farther in spinal manipulation research and practice. Yes, research supporting spinal manipulation is good news for chiropractic, but what happens if a spinal manipulation to correct a subluxation becomes the purview of PTs? Will patients prefer to visit a PT over a chiropractor? And what if medical doctors begin to refer their patients to PTs? If this becomes acceptable, these are some points that all chiropractors should start thinking about and find ways to overcome these obstacles.

Even Kietrys admits that “PTs have always performed spinal manipulations, though historically not as much as some other health care disciplines.” By other health care disciplines, if he is referring to chiropractic, then he should have incorporated some of the existing research. To me, the glaring glitch in his research is in ignoring this.

Reference
1. Kietrys D. A new look at spinal manipulation: Is there an inherent glitch in the research literature? Advance for Physical Therapists and PT Assistants. 2004;15(17):61–62.
2. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27(24):2835.