Soon, physical therapists (PTs) will all graduate as doctors of physical therapy (DPTs). The American Physical Therapy Association's vision stance is: "By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health."1 The PT profession should be commended for continually seeking to improve itself.
When this subject is brought up, I often hear that many PTs don't necessarily desire to practice on their own and many don't want diagnostic responsibility; but that doesn't necessarily mean the majority of PTs will feel this way in the future, especially when you read the APTA vision statement. When chiropractors are asked about PTs learning to use "chiropractic" manipulation, many say that they (the PT) will never be as competent as a DC. It appears to me that chiropractors, who at this stage are the ultimate spinal and joint manipulators and are achieving the maximum results that can be obtained by manipulation, should wake up about their future regarding their status in the world of neuromusculoskeletal disease (NMSD).
First of all, our profession should be at the forefront of research on manipulation, which we are not. Second, we should realize that manipulation is not the end-all regarding the treatment of NMSD. Third, we must pay attention to literature, which states, for example, that manipulation plus soft-tissue evaluation and treatment is more beneficial than manipulation alone.2-3 And fourth, we must pressure our colleges to include more subjects in their curriculum that deal with soft-tissue subjects and the more dynamic, biomechanical-type evaluations of human movement.
What initiated my thoughts on this subject was a research report that recently appeared in the Journal of Orthopedic & Sports Physical Therapy.4 The randomized study involved the treatment of 107 patients with neck pain between the superior nuchal line and first thoracic spinous process, regardless of duration. Fifty-six patients received both cervical and thoracic high-velocity, low-amplitude (HVLA) thrust manipulation specifically to C1-C2 and T1-T2 spinal segments; and 51 patients received a non-thrust mobilization to the same region.
For the HVLA group, if no popping or cracking were heard, the HVLA thrust was repeated. For the non-thrust mobilization group, Maitland5 grade IV PA mobilizations to both the cervical and thoracic areas were performed for 30 seconds each. The key finding of this study is that HVLA treatment resulted in greater improvement in disability, pain, atlantoaxial ROM and motor performance of the deep cervical flexor muscles at a 48-hour follow-up versus non-thrust mobilization. What is also informative is that the HVLA treatment of cervical pain benefited from HVLA treatment of the adjoining thoracic spine.
Unfortunately, this study did not evaluate long-term effects, but at least it is another study that substantiates the value of HVLA manipulation. The battle for our future, of course, involves much more than proving that our "adjustments" work for neck or lumbar pain. It is necessary to incorporate every type of manual treatment that proves its worth in our armamentarium. Chiropractic has been around for about 122 years. We still have problems, as we will probably always have, but time is catching up with us. Creating a bright future for our profession requires some instant thinking out of the box.
References
- American Physical Therapy Association: Vision 2020. www.apta.org/Vision2020/
- Gross AR, et al. Conservative management of mechanical neck disorders: a systematic review. J Rheumatology, 2007;34:3.
- Harrison D, et al. Effect of spinal vs. soft tissue manipulation in restoring cervical lordosis, JMPT, 1994;17(7):454-464.
- Dunning JR, Cleland JA,Waldrop MA, et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. JOSPT, 2012;42(1):5-17.
- Maitland GD. Vertebral Manipulation. 5th Edition. London, UK: Butterworth & Co Ltd., 1986.
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