Manual Therapy Online: Current Column


    I'd like to thank Steve McDavitt for the following submission (actually it wasn't so much a submission but more of me begging him to let me use it). Steve is Practice Affairs Chair of the American Academy of Orthopedic Manual Therapy (AAOMPT) and Practice CoChair Orthopaedic Section of the American Physical Therapy Association (APTA).



Defend Skilled PT Practice Scope or Perish: A Need to Take A Stand.
A personal opinion revisited.
Stephen McDavitt PT, MS


In Orthopaedic Practice (Vol. 11:1:99) I wrote a letter to the editor entitled "Defend Skilled PT Practice Scope or Perish": A Need To Take A Stand. The letter focused on the philosophy that it is time we take a stand on teaching manipulation and manual therapy procedures to support personnel including physical therapist assistants. Even though the descriptions of practice standards in The Guide to Physical Therapist Practice, position statements from the American Academy of Orthopaedic Manual Physical Therapy (AAOMPT) and Orthopaedic Section of the APTA, and those standards described in the Description of Advanced Clinical Practice (DACP) from the AAOMPT do not support the teaching or practice of manipulation or mobilization by physical therapist assistants, this continues to be an unresolved issue in the practice of physical therapy today. It is time we begin to resolve practice issues of skilled vs. supportive practice scopes and related practice affairs especially as they apply to manipulation / mobilization in this upcoming APTA House of Delegates 2000.

I recently received a copy of the most recent APTA Board of Director's minutes dated November 13-15, 1999 and I would like to share some of that relevant information. This information directly addresses this issue of education of supportive personnel as it relates to delegation and separation of skilled and non-skilled practice and remuneration. I am going to provide the information along with the support statements for five different motions.

    Board of Director's minutes dated November 13-15, 1999

    V-80: PASSED (work group 3).
    That the following motion be presented to the 2000 House of Delegates:
    That the following position be adapted: Position on Direct Interventions Exclusively Performed by Physical Therapists.

    The physical therapist's scope of practice as defined by the Guide to Physical Therapist Practice includes all interventions performed by physical therapists. These interventions include procedures performed exclusively by physical therapists and selected procedures that can be performed by the physical therapist assistant under the direction and supervision of the physical therapist. Direct interventions within the scope of the physical therapist practice that are performed exclusively by the physical therapist include, but are not limited to, spinal and peripheral joint mobilization/manipulation, which are components of manual therapy techniques, and selective sharp debridement, which is a component of wound management.

    SS: The Association should not delineate those interventions which, due to their clinical complexity and the sophistication of judgment required to perform them, precludes delegation to para-professionals or others. This position is consistent with the House of Delegates endorsed Guide to Physical Therapist Practice and the Normative Model of Physical Therapist's Education.

    V-55: PASSED (work group 2).
    That the Normative Model of Physical Therapist's Professional Education, version 2000, be consistent with the guide to physical therapist practice.

    SS: All APTA documents should be consistent with manipulation (grades 1-5) as defined by the Guide to Physical Therapist's Practice, revised edition, July 1999 (program 19, exhibit U, BOD 11/99).

    V-56 PASSED (work group 2)
    The APTA undertake efforts to encourage the State Boards/Regulatory agencies to utilize part I of the Guide to Physical Therapist's Practice as a reference for issues related to the scope of practice.

    SS: Having State Boards/Regulatory Agencies familiar with the Guide helps the profession successfully protect manual issues including manipulation. APTA will distribute the Guide to State Boards/Regulatory Agencies as a reference work.

    V-65 PASSED (work group 2)
    That all APTA sponsored educational programs be reviewed for consistency with the Guide to Physical Therapist's Practice.

    SS: APTA has distributed copies of the Guide to Physical Therapist's Practice to third party payors. APTA holds the Guide as being the template or benchmark against which physical therapist practice is measured. By requiring educational program consistency with the Guide, the Association will further emphasize the importance of the Guide to help practitioners justify reimbursement for physical therapy services. This supports goal 1, objective 1, of the strategic plan for reimbursement (program 37, exhibit 26, B-D 11/99).

    V-64 PASSED (work group 2)
    That APTA pursue incorporation of the services provided by physical therapist assistants into the practice expense component of the resource base relative value scale (RBRVS) payment methodology, with associated review and recommendation for modification to relative value for work of the physical medicine and rehabilitation family of codes.

    SS: The Advisory Panel on Reimbursement recommends that the Board of Directors not remain silent on the issue of potential different valuing of physical therapist assistant's services. Physical therapist assistants do not provide physical therapy services but rather assist in the provision of physical therapy services. Physical therapist assistants therefore must be supervised by a physical therapist and should then be considered part of the practice expense component of RBRVS. By incorporating physical therapist assistant's services into the practice expense component, APTA can develop strategies to reevaluate the relative value of the work expense component in relation to time, physical effort, mental effort/judgment and provide a risk.


I believe it was said best under VD-64. "Physical therapist assistants do not provide physical therapy services but rather assist in the provision of physical therapy services." In addition to this, the Guide to Physical Therapist Practice clearly explains that manipulation and mobilization are skilled components of physical therapy services. They are clearly outside the scope of the physical therapist assistant. That concept was clearly supported in the proposed RC-35 presented to the House of Delegates in 1999 (co-sponsored by the Orthopaedic Section and APTA BOD) and that endorsed by the Board of Directors (V-80) to be provided as an RC before the House of Delegates in 2000.

Another consideration along these lines is that if we are looking at physical therapist assistant's services in the practice expense component in treatment then the RBRVS value could be further diluted by providing the physical therapist assistant with the ability to provide manual manipulative therapy at a less "skilled" level. Where do we carve that out in practice standards?

We must also consider the signal that we are giving the physical therapist assistant. It is disillusioning to them to be allowed to take certain manual manipulative therapy courses and not others or not actually practice what they learn. Beyond inappropriate, any physical therapist with the philosophy of delegating those services is also unfair to the PTA's vision of their future in the practice of physical therapy. Consider also potential impacts on legislation and public safety.

It is time that we begin to draw the line in the sand separating out those services that are supportive in providing physical therapy services and those which are skilled and need to be practiced exclusively by the physical therapist.

The Guide to Physical Therapist Practice defines manipulation and mobilization as;

Manipulation: A skilled passive hand movement that usually is performed with a small amplitude at a high velocity.

Manual therapy techniques: A broad group of skilled hand movements, including but not limited to mobilization and manipulation, used by the physical therapist to mobilize or manipulate soft tissues and joints for the purpose of modulating pain; increasing range of motion; reducing or eliminating soft tissue swelling, inflammation, or restriction; inducing relaxation; improving contractile and non-contractile tissue extensibility; and improving pulmonary function.

Mobilization : A skilled passive hand movement that can be performed with variable amplitudes at variable speeds. Manipulation is one type of mobilization. (Guide to Physical Therapist Practice American Physical Therapy Association July 1999)

The AAOMPT Description of Advanced Clinical Practice further defines manipulation / mobilization as "the skilled passive movement to a joint and or the related soft tissues at varying speeds and amplitudes including a small amplitude, high velocity therapeutic movement."

The psychomotor (demonstration) component of manipulation / mobilization may be realistic to teach a PTA. The cognitive and affective learning domains that provide the skilled clinician with the ability to diagnose and manage the clinical decisions in practice of manipulation however require a physical therapists knowledge base. Considering what has been presented by the APTA Board of Directors, promoted by the Orthopaedic Section BOD and clearly from what is represented in the Guide to Physical Therapist Practice, physical therapist assistants should not be allowed to practice manual manipulative therapy or take manual manipulative courses. If PTAs want such skills I recommend they consider a physical therapy education and competency.

From what I have described above, I don't see anything that supports even remotely the concept that we should be supporting physical therapist assistants practicing or being educated in manual mobilization / manipulative techniques. Delegating out such skilled services to supportive personnel in my opinion is as detrimental to physical therapy as is giving up components of physical therapy scope of practice in legislative compromise to achieve direct access. The impact and risk of further blemishing our skilled competencies in the eyes of an already contentious legislative climate is also a necessary consideration.

All of this may seem small now, but on the long scale multiplied over the number of years, it will be devastating to our scope of practice and remuneration for our skilled practice as physical therapists. Just ask those States involved in defending 22 pieces of legislation last year directed at contesting the physical therapists competency in providing manipulation and mobilization manual therapy techniques.

As these skilled practice issues mentioned here develop into debates throughout the component caucuses and House of Delegates 2000 I hope my personal opinion and discussion here will facilitate constructive dialogue, support and resolution for those related positions presented from the APTA Board of Directors, the Orthopaedic Section and the AAOMPT.

I feel physical therapists need to act and take a formal stand NOW. Our scope of practice, remuneration and professional survival are dependent on our position. We need to defend skilled physical therapy practice by "drawing the line in the sand" separating skilled from supportive scope in practice, or perish.

Stephen McDavitt, PT, MS



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