California Senate Say's NO to SB381

03senator-yee-discusses-supreme-court-ruling.preview

Today was a victory for Physical Therapists.  In an overwhelming decision, California’s congress voted to NO to support SB381 which would exclude Physical Therapists from the ability to manipulate.

The vote: Senators Price, Corbett, Block, Hill, Padilla & Galgiani said NO.    Senator Yee was the sole YES. 
Abstains – Hernandez, Wyland, Emmerson

This stated, this CRAP needs to stop NOW!   I understand that professionally, we pose a major threat to chiropractors.   But bills of this nature, without unsubstantiated cause, demonstrate a child-like behavior by a so-called professional organization.  I recommend every PT and DC reads the below transcript and decides if this was necessary:

BILL ANALYSIS                                                                                                                                                                                                    
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        |Hearing Date:April 15, 2013        |Bill No:SB                         |
        |                                   |381                                |
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                      SENATE COMMITTEE ON BUSINESS, PROFESSIONS
                               AND ECONOMIC DEVELOPMENT
                          Senator Curren D. Price, Jr., Chair
                           Bill No:        SB 381Author:Yee
                    As Introduced:     February 20, 2013 Fiscal:No
        SUBJECT:  Healing arts: chiropractic practice.
        SUMMARY:  Prohibits health care practitioners, other than
        chiropractors, physicians, surgeons or osteopathic physicians, from
        performing joint manipulation or joint adjustments.
        Existing law:
        1) Establishes the California Board of Chiropractic Examiners (BCE),
           under the Department of Consumer Affairs (DCA), and authorizes the
           BCE to license and regulate chiropractors. (Chiropractic Act of
           1923 (CA), § 1 et seq.; Governor's Reorganization Plan No. 2 of
           2012)
        2) Authorizes a chiropractor to practice chiropractic as taught in
           chiropractic school or college.  (CA § 7)
        3) Specifies the schedule of minimum education requirements to enable
           any person to practice chiropractic in California includes:  (CA §
           5)
                  Group 1- Anatomy, including embryology and histology;
                  Group 2- Physiology;
                  Group 3- Biochemistry and clinical nutrition;
                  Group 4- Pathology and bacteriology;
                  Group 5- Public health, hygiene and sanitation;
                  Group 6- Diagnosis, dermatology, syphilology and geriatrics,
                  and radiological
                                  technology, safety, and interpretation;
                  Group 7- Obstetrics and gynecology and pediatrics; and
                                                                         SB 381
                                                                         Page 2
                  Group 8- Principles and practice of chiropractic, physical
                  therapy, psychiatry, and
                                  office procedure.
        4) Establishes the Medical Board of California (MBC), under the DCA,
           and authorizes the MBC to license and regulate physicians and
           surgeons.  (BPC § 2000)
        5) Establishes the Physical Therapy Board of California (PTB) under
           the DCA, and authorizes the PTB to license and regulate physical
           therapists and physical therapy assistants.  (BPC § 2602)
        6) Establishes the Osteopathic Medical Board of California (OMB),
           under the MBC, and authorizes the OMB to license and regulate
           osteopathic physicians.  (BPC § 2450)
        7) Establishes the Veterinary Medicine Board of California (VMB),
           under the DCA, and authorizes the VMB to license and regulate
           veterinarians.  (BPC § 4800)
        This bill:
        1) Defines "joint manipulation" and "joint adjustment" as synonymous
           terms that describe a method of skillful and beneficial treatment
           where a person uses a direct thrust to move the joint of a patient
           beyond its normal range of motion, but without exceeding the limits
           of anatomical integrity, as taught in chiropractic schools or
           colleges.
        2) Prohibits a health care provider, other than a chiropractor,
           physician, surgeon or osteopathic physician from performing joint
           manipulation or adjustment.
        3) Indicates that a health care practitioner who engages in the
           unlawful practice of chiropractic is subject to their license being
           revoked or suspended and/or other disciplinary action.
        4) Specifies that the legislation will not prevent veterinarians from
           practicing within the scope of their license.
        5) Specifies that the legislation is not intended to restrict
           providers working within their scope of practice from treating a
           dislocated extremity joint.
        FISCAL EFFECT:  Unknown. This bill has been keyed "non-fiscal" by
        Legislative Counsel.
                                                                         SB 381
                                                                         Page 3
        COMMENTS:
        1.Purpose.  This bill is sponsored by the  California Chiropractic
          Association (CCA)  .  According to the Author, there are currently
          health care practitioners performing manipulations that should not
          be, and that are doing so under the argument that their scope does
          not say they cannot perform these procedures.  Scope is about what
          you can do, not what you cannot.  There have been reports of
          physical therapists performing these manipulations, and even when
          reported to the Physical Therapy Board they are not being
          reprimanded.  This bill would clarify that it is unlawful for those
          not trained and educated to perform these procedures.  This bill is
          needed to provide additional consumer protection against providers
          who are currently operating outside their scope of practice by
          performing manipulation.
        2.Background.
           a)   Chiropractor Education, Training and Scope.   Since 1923,
             California has licensed chiropractors.  Chiropractors are health
             care practitioners who provide drug-free and non-surgical health
             care.  Based on the beliefs that the body has an inherent power
             to heal itself and health depends on a properly-functioning
             nervous system, chiropractic care focuses on adjustment of the
             spinal column to remove hindrances to the nervous system.
             Chiropractors earn a four year doctorate degree and participate
             in a year long clinical internship.  Chiropractors may also
             pursue post graduate specialty training.  The scope of practice
             for chiropractors is defined in California Code of Regulations
             Title 16 § 302:
                1) A duly licensed chiropractor may manipulate and adjust the
             spinal column
                and other joints of the human body and in the process thereof
                a chiropractor
                may manipulate the muscle and connective tissue related
                thereto.
                2) As part of a course of chiropractic treatment, a duly
             licensed chiropractor
                may use all necessary mechanical, hygienic, and sanitary
             measures incident to
                the care of the body, including, but not limited to, air,
                cold, diet, exercise, heat,
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                light, massage, physical culture, rest, ultrasound, water, and
                physical therapy
                techniques in the course of chiropractic manipulations and/or
                adjustments.
                3) Other than as explicitly set forth in section 10(b) of the
                Act, a duly licensed chiropractor may treat any condition,
                disease, or injury in any patient, including
                a pregnant woman, and may diagnose, so long as such treatment
                or diagnosis
                is done in a manner consistent with chiropractic methods and
                techniques and
                so long as such methods and treatment do not constitute the
                practice of
                medicine by exceeding the legal scope of chiropractic practice
                as set forth in
                this section.  b)   Physical Therapist Education, Training and Scope.  Physical
             therapists have been regulated in California since 1953.
             Physical Therapists help restore function, improve mobility,
             relieve pain and prevent or limit permanent physical disabilities
             of patients with injuries or disease.  They treat patients
             including accident victims and individuals with disabling
             conditions for back conditions, arthritis, head injuries, carpal
             tunnel syndrome, hip fractures, as well as rehabilitation after
             surgery, a serious injury or a stroke.  Physical therapists
             graduate from accredited physical therapist educational programs
             that offer degrees at the master's degree level and above.  A
             physical therapist may also seek specialty certification offered
             by the American Board of Physical Therapy Specialties.  The scope
             of practice for physical therapists is outlined in BPC § 2620 as
             follows:
                  Physical therapy means the art and science of physical or
                  corrective
                  rehabilitation or of physical or corrective treatment of a
                  bodily or mental
                  condition of any person by the use of the physical,
                  chemical, and other
                  properties of heat, light, water, electricity, sound,
                  massage, and active, passive
                  and resistive exercise, and shall include physical therapy
                  evaluation, treatment planning, instruction and consultative
                  services.  The use of roentgen rays and radioactive
                  materials, for diagnostic and therapeutic purposes, and the
                                                                         SB 381
                                                                         Page 5
                  use of electricity for surgical purposes, including
                  cauterization, are not authorized
                  under the term 'physical therapy' as used in this chapter,
                  and a license issued pursuant to this chapter does not
                  authorize the diagnosis of a disease.
           c)   Grade 1-5 Exercises.  According to information obtained from
             the Physical Therapy Board and the Board of Chiropractic
             Examiners, both physical therapists and chiropractors are trained
             to utilize oscillatory and peripheral joint mobilization.
             Peripheral joint mobilization is defined as mobilizing the joints
             of the periphery or limbs.  There is a grading system, created in
             the mid 1900's, for completing a mobilization.  The mobilization
             technique used is based on the amount of available joint play.
             Thus, the clinician must know what the total range is by
             examination through passive movement.  The first common
             mobilization techniques are sustained joint play movements that
             have three grades.  These mobilizations aid in decreasing pain
             and increasing mobility.  Within these three grades the stretch
             or hold is approximately five to seven seconds.  A description of
             the three grades include:
                  Grade 1.  The clinician applies passive movement in a very
                  small range, approximately 15-25% of the available joint
                  play range.
                  Grade 2.  Bone is passively moved in a moderate range to 50%
                  or half of the available joint play range.
                  Grade 3.  Passive force by the clinician causes one bone to
                  move on the other to the end of the available joint play
                  range.
             The other common mobilization technique is termed oscillatory
             mobilization.  Oscillatory mobilizations have five grades
             associated with them.  Grades one to two are used to help
             decrease pain within a joint.  Grades three to five are used to
             increase mobility of joint play.  Grade five mobilization is
             called a manipulation.  The following are grades for oscillatory
             mobilizations:
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                  Grade 1.  Slow oscillations within the first 20-25% of the
                  available joint play range.
                  Grade 2.  Slow oscillations within 45-55% of the available
                  joint play range, or from the beginning to the middle of
                  available joint play range.
                  Grade 3.  Slow oscillations from the middle of the available
                  joint play range to the end of available joint play range.
                  Grade 4.  Slow oscillations at the end of the available
             joint play range.
                  Grade 5.  Bone is passively moved to the end-range, and a
                  fast thrust is performed.  This technique is considered a
                  manipulation.
         3. Attorney General Opinion.  In 1976, California Attorney General
           Evelle J. Younger was asked to provide an opinion regarding the
           Chiropractic Act.  One question asked, "Are there any circumstances
           under which a physical therapist can manipulate or adjust the hard
           tissue (i.e., the spine)?  If so what are those circumstances?"
           The Attorney General (AG) replied in his written legal opinion,
           "Adjustment is not a term used in physical therapy.  It is a
           chiropractic word."  He further stated,  "?adjusting the spine by
           hand for the curing of disease constitutes the practice of
           chiropractic and under the Chiropractic Act is beyond the
           permissive activity of a physical therapist?Therefore, we believe
           that the adjustment and manipulation of "hard tissues," that is
           bones and bone structures, is peculiarly a chiropractic technique
           beyond the scope of authorized activity for a physical therapist."
         
         4. Department of Consumer Affairs Opinion.  In 1980, then Board of
           Chiropractic Examiners Executive Secretary, Garrett Cuneo, sent a
           letter to Richard Spohn, Director of Consumer Affairs at the DCA.
           Mr. Cuneo posed the question, "Can physical therapists engage in
           spinal manipulation which is the practice of chiropractic?"  The
           Chief Legal Counsel at DCA's Legal Office, Mr. Gus E. Skarakis,
           received the letter and replied to Mr. Cuneo:
                  Mobilization of the spine and other joints through the use
               of rotation and other
                                                                         SB 381
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                  physical pressure constitutes in our opinion the use of
                  physical properties
                  including passive exercise for the treatment of physical
                  conditions and is
                  specifically authorized in the physical therapist's scope of
                  practice.  Therefore,
                  we do not believe that a physical therapist is practicing
                  beyond his or her legal scope of practice by utilizing such
                  technique?  In our opinion the performance
                  of joint mobilization by a physical therapist is not the
                  adjustment and manipulation of hard tissues as a
                  chiropractic technique.   We primarily view this controversy
                  not as a matter of legal interpretation, but an
                  interprofessional squabble, often referred to as a 'turf
                  battle.'
         5.Confusion Regarding the Term "Manipulation."  Though the AG and DCA
          opinions specify that chiropractors manipulate hard tissue and
          physical therapists utilize joint mobilization techniques, there
          remains much confusion about the term "manipulation."  Many physical
          therapists describe their work as "physical therapy manipulation" or
          "joint manipulation" which reportedly differs from "chiropractic
          manipulation" of hard tissues.  In addition, other professionals,
          such as naturopathic doctors, dentists, veterinarians and physician
          assistants use the term manipulation to describe some of the
          techniques they use with their patients.  In fact, naturopathic
          doctors are also taught Grades 1-5 exercises during their training,
          but are prohibited by California law from performing Grade 5
          exercises in practice.  Dentists manipulate the jaw when treating
          Temporomandibular Joint Disorders (TMJ).  Additionally, physicians
          and surgeons specifically use the term manipulation to describe the
          manual loosening a stuck joint often performed under sedation or
          anesthesia.    Thus, it becomes quite difficult to allow any one
          profession to exclusively own or define the term.
        
         6. Lack of Consumer Complaints.  The CCA reports they have received
           "hundreds" of complaints from the chiropractors they represent.
           CCA purports that individual chiropractors report they see patients
           who complain about receiving "manipulation" or "adjustments" from
           professionals who are not licensed by the Board of Chiropractic
           Examiners.  In response, the CCA has forwarded these complaints to
           the Physical Therapy Board (PTB).  However, the CCA indicates that
           the PTB reports that they never received such complaints.  The CCA
           is unable to provide any data regarding the number of complaints
           received which were reportedly forwarded to the PTB.
           
                                                                         SB 381
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            According to the PTB, however, their Consumer Protection Services
           program  rarely  receives complaints that involve physical therapists
           performing manipulation.  Since 1990, there have only been 5
           complaints against physical therapist(s) performing mobilization or
           manipulation.   The PTB indicates, "In all cases, the allegations
           were not substantiated as the physical therapist(s) were deemed to
           be practicing within a physical therapist's scope of practice.
           Moreover, the 5 identified complaints were not submitted as a
           result of patient harm, but rather by chiropractor(s) concerned
           with the physical therapist(s) practicing outside their scope of
           practice."  Also, the Board of Chiropractic Examiners reports that there have
           been  no complaints  on record of a licensed chiropractor reporting
           that a licensed physical therapist in their practice setting is
           performing manipulations.  There have also been  no consumer
           complaints  against physical therapists performing manipulations
           received by the BCE.
           Both the Physician Assistant Committee and the Massage Therapy
           Council report that there have been  no complaints  on record of a
           physician assistant or a massage therapist performing manipulation.
            7.Arguments in Support.  The  Sponsor  indicates, "Patients must be
          adequately protected from unauthorized, unqualified and improper
          application of manipulation or adjustment.  By defining that only
          doctors of chiropractic, physicians and surgeons and osteopathic
          physicians and surgeons are allowed to perform joint manipulation or
          spinal adjustment you are ensuring that patients seeking this form
          of treatment receive it from providers best trained to perform it."
        8.Arguments in Opposition.  The  Independent Physical Therapists of
          California  (IPTs) indicate physical therapists have been training
          extensively to provide joint mobilization/manipulation.  They note,
          "Physical therapists have been performing manual therapy safely for
          decades, including all degrees of joint mobilization/manipulation.
          IPT recognizes that some patients with spinal disorders prefer to
          seek care from chiropractors, some prefer acupuncture, some prefer
          physical therapy and some may prefer medications, injections and
          surgery.  The physical therapy profession in California has never
          attempted to restrain the trade of any of these health care
          professions by attempting to pass legislation overturning the
          legality of their treatment methods."
           The  California Naturopathic Doctors Association opposes the bill
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           unless amended.  They argue, "Naturopathic Doctors receive almost
           400 hours of combined physical medicine joint manipulation in
           California?In fact, joint manipulation classes are often taught at
           naturopathic medical schools by Chiropractic Doctors?The lack of
           inclusion of NDs in SB 381 would serve as an obstacle for the newly
           opened Bastyr University California as it would prohibit
           naturopathic medical students from the ability to learn and train
           in joint manipulation, which is currently part of the required
           curriculum at all naturopathic medical schools."
            Mount St. Mary's College  notes in their opposition letter, "MSMC
           strongly opposes SB 381 because research on manipulation supports
           physical therapists performing joint manipulation as among the
           safest of all health care providers? The physical therapy
           professional liability insurance program has not identified any
           trends relative to manipulation that would indicate the procedure
           presents a risk factor that should be considered in determining
           professional liability rates for physical therapists.  The
           Legislature should require evidence of public harm or risk before
           introducing legislation that restricts previously authorized
           practice?further, graduates of physical therapy education programs
           are required to be examined with respect to their knowledge of
           joint manipulation in order to become licensed as a physical
           therapist in California?Treatment interventions do NOT fall under
           the exclusive domain of any one specific profession or group of
           practitioners?SB 381 is an attempt to legislate clinical practice,
           which is the purview of the Professional [licensing] Boards."
        9.Policy Issues for Consideration.  Though the Sponsor has stated that
          the intent of the bill is to protect the public from all
          unscrupulous professionals, there appears to be a specific focus on
          restricting the professional activities of physical therapists as a
          result of this legislation.  For example, the Sponsor and Author's
          office indicate in written materials submitted to the Committee,
          "There have been reports of physical therapists performing these
          manipulations, and even when reported to the Physical Therapy Board
          they are not being reprimanded."  However, the Physical Therapy
          Board reports to the Committee that it has no record of such
          complaints.  The Sponsor also reports there have been "hundreds of
          complaints" received from chiropractors that have been forwarded to
          the Physical Therapy Board.  However, the Sponsor is unable to
          provide any data to substantiate these complaints.  Moreover, when
          the Committee checked with other licensing boards under the DCA,
          including the Board of Chiropractic Examiners,  the boards reported
          little to no complaints from consumers or disciplinary action taken
          against a licensee relating to the issue of manipulation or
                                                                         SB 381
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          adjustment .  If there are in fact consumers who complain to their
          chiropractors about prior treatment from non-chiropractors, it is
          plausible that these patients may not fully understand the
          difference between the adjustment and manipulation of hard tissues
          authorized for chiropractors and the mobilization and manipulation
          of joints authorized for physical therapists to perform.
           This appears to be a long-standing disagreement as evidenced by the
           opinions dating back to 1976.  Arguments from both sides seem to be
           based on anecdotal evidence and discrepancies about semantics.  As
           noted in the 1980 DCA opinion, "We primarily view this controversy
           not as a matter of legal interpretation, but an inter-professional
           squabble, often referred to as a 'turf battle.'"   Is making the
                                            proposed changes in statute to define joint manipulation and
           adjustment the appropriate avenue to take in order to clarify this
           scope battle  ?
            As noted in the 1976 Attorney General opinion, "The definition
           adopted by the Board of Chiropractic Examiners in section 302,
           Title 16, California Administrative Code, reveals that  physical
           therapy and chiropractic each involve the use of physical agent
           used by the other  .  We do not believe that this common use of
           agents presents a major problem because a chiropractor is
           prohibited by section 2630 from practicing physical therapy as such
           and a physical therapist is prohibited by section 15 of the
           Chiropractic Act from practicing chiropractic."  As such, it
           appears that the intent of the manipulations is what matters.  The
           intent of chiropractic manipulation of hard tissues, such as the
           spine, is to cure disease.  The intent of physical therapy
           mobilization and manipulation is to provide physical or corrective
           rehabilitation to reduce pain.
           There obviously exists serious contention between the two
           professions which has led to reactive stances regarding this
           legislation.  Perhaps the most judicious way to proceed is to
           concede that both professions are concerned with consumer
           protection, thus the specific activities of each profession need to
           be clarified.  Specifically, both chiropractors and physical
           therapists are trained during their educational programs to perform
           Grade 1-5 exercises, which has led to considerable confusion about
           which profession is allowed to perform joint manipulation and joint
           adjustments, specifically since Grade 5 is considered a
           manipulation.   The Committee may wish to consider whether it should
           direct the Board of Chiropractic Examiners and the Physical Therapy
           Board to collaborate and review the Grade 1-5 exercises to clarify,
           according to each profession's scope of practice, if it is in fact
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           appropriate for both professions to teach these exercises.  If the
           two Boards are unable to reach a conclusion, a legal opinion may
           help to clarify this issue.  
        SUPPORT AND OPPOSITION:
        
        Support: 
        California Chiropractic Association (Sponsor)
        Los Angeles College of Chiropractic
        65 letters from licensed chiropractors
        21 letters from individuals
        
        Oppose Unless Amended:
        
        California Naturopathic Doctors Association
        
        Opposition: 
        Independent Physical Therapists of California
        Mount St. Mary's College
        104 letters from licensed physical therapists
        Over 300 letters from individuals
        Consultant:Le Ondra Clark, Ph.D.
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All Comments

  • Joe,
    Thank you again for your support from the other side of the country! I still think neurophysiological manipulations are a better idea than constantly fighting for what we already have! Keep on thinking in the right direction.
    Always Evolve,
    Mike

    mscottdpt April 16, 2013 1:28 am Reply
  • This was definitely a win for physical therapists. Joint manipulation is a very useful tool, along with a solid home exercise regime and other therapy techniques. As a physio I don’t care if Chiros prescribe home exercise, why should they be concerned when well trained physical therapists choose to adjunct their practice with the use of joint manipulation? THey should be happy that we aren’t just calling them quacks anymore for cracking backs.

    Brandon Goulding MscPT April 16, 2013 10:49 am Reply
  • As a physio in Australia I can’t believe this stuff still goes on, the chiro’s are lucky they don’t practice in the UK were they basically have been called quacks! Let them prescribe exercise if they want to but physios who have the training should be able to use manipulations in their clinical repetoire. Well done to those involved in defeating this bill.

    Taso lambridis April 16, 2013 10:54 pm Reply
  • Love this part: “This bill would clarify that it is unlawful for those not trained and educated to perform these procedures.” Did they not bother to read CAPTE regulations regarding what physical therapists are required to be taught in school?

    Zach Long April 18, 2013 10:10 pm Reply
  • Pingback: California’s Congress voted NO to excluding Physical Therapists from the ability to manipulate- | Physiotherapy Gujarat

  • I constantly emailed this web site ppost page to all my contacts,
    because iff like to read it next my links will too.

    Roderick August 26, 2014 11:53 am Reply

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