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.