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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                                                                                                                                                                                                    

         ----------------------------------------------------------------------- 
        |Hearing Date:April 15, 2013        |Bill No:SB                         |
        |                                   |381                                |
         ----------------------------------------------------------------------- 

                      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, 

                                                                         SB 381
                                                                         Page 4

                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:

                                                                         SB 381
                                                                         Page 6

                  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
                                                                         Page 7

                  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
                                                                         Page 8

            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  

                                                                         SB 381
                                                                         Page 9

           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
                                                                         Page 10

          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  

                                                                         SB 381
                                                                         Page 11

           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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6 replies »

  1. 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

  2. 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.

  3. 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.

  4. 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?

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