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Fischer - Final Research Essay
Fischer - Final Research Essay
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
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
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
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Doctorate of Physical Therapy programs. This training has resulted in physical therapists
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
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
Physical therapists have been using this technique since the profession began. The first
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,
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
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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
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
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
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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
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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.
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.
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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
ebruary 2011.
criteria for safety and adequate competence.” APTA.org. F
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
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.
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
A Case Report.” Journal of Manual & Manipulative Therapy, vol. 15, no. 1, Mar. 2007,
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search.ebscohost.com/login.aspx?direct=true&db=aph&AN=25071933&site=ehost-live.