Letter to the Editor

In writing a response to “the longest editorial in the history of peer-reviewed literature,” it is tempting to craft the longest response to an editorial in the history of peer-reviewed literature. Alas, Huijbregts has performed nicely in his comprehensive argument that such a lengthy repose is simply unnecessary. It was refreshing to see such an argument solidified on paper and backed by numerous literary references, moving what is a common colloquial conversation around the Physical Therapy water cooler to the status of a documented issue. In writing Chiropractic Legal Challenges to the Physical Therapy Scope of Practice: Anybody Else Taking the Ethical High Ground, Huijbregts has issued a real challenge to the chiropractic profession. The question now is: Are they listening?

State chapter meetings of the APTA are often boring and even more often bleak. Perhaps this is due to the repetitive nature of the business relating to legislative affairs. The Physical Therapy profession is seemingly perpetually forced to devote enormous resources to the defense of our scope of practice in response to the constant attacks upon it from chiropractors and physicians. In some cases, these debates are truly that: a legal debate taking place in the appropriate venue to answer questions about safety, qualifications, and ethics that serve to protect society from potential harm. In other cases, the question of manipulation perhaps foremost among them, these debates are disguised attempts to hoodwink legislators into ruling on behalf of one profession or another without regard to any societal benefit. This is the ethical low road that Huijbregts is arguing against in his challenge. So many times we hear about medical professions acting to protect their piece of the economic health care pie. I have to ask: Is acting simply to preserve an economic position ever considered the ethical high ground? The medical industry is one of the fastest growing segments of our economic world. It seems out of place to argue over the relative size of each profession's proverbial slice of pie at the same time that every health care provider's pie is growing so substantially.

This is a dangerous time for our health care system in the United States as reform moves once again to the forefront of the political agenda. Even while a war is being waged, headlines about health care prevail when one of the many presidential hopefuls announces their plan to fix our nation's health system. It is in times like these when the power and threat of semantic arguments and tactics of obfuscation become more real. When fast decisions are made for popular gain, all sides might not be given a chance to clarify the difference between two points of view. For example, evidence exists that is not fully supportive of Physical Therapy interventions for low back pain¹. However, when such evidence is further scrutinized, it becomes clear that a watered-down version of Physical Therapy was utilized in the research, devoid of much manual therapy and rigorous patient classification. A legislator untrained in the medical arts may miss this important distinction and, in turn, make crucial decisions without recognizing the subtleties hidden within a carefully worded bill. Frankly, arguments relying on semantics such as where mobilization ends and manipulation begins seem ridiculous. Until chiropractors can better define the conceptual basis of subluxation or define the “paraphysiologic motion”, logic supports the APTA definition of manual therapy that does not distinguish between mobilization and manipulation². Who has not, clinically, caused a cavitation of a thoracic spine while performing even the lightest of mobilizations? If such techniques were so fundamentally different as to require an entirely different doctoral level education, then I surely should not be able to perform the maneuver in question without intent!

As we are reminded, the ultimate goal of scientific pursuit is to increase our society's knowledge base. The creation of such knowledge does not imply ownership. We must hold ourselves true to this ideal when defending the many chiropractic challenges to our scope of practice. Physical Therapy has contributed greatly to the development of manual therapy concepts, including manipulation. But, we do not own these concepts. We should never argue our ability and right to perform manipulation based on our assistance in developing the concepts of manipulation, however great that contribution might be. However, if through that development of knowledge, we have created a documented record of Physical Therapists safely and effectively performing spinal manipulation with positive clinical outcomes^3–7, then these facts should be proclaimed far and wide.

Human behavior changes when there is an incentive to do so. What will be the incentive for the chiropractic group to cease their perpetual attempts to limit our scope of practice? Perhaps hoping for a journey to an ethical high ground is a case of hoping beyond hope. Instead, let Physical Therapists move forward in avenues of marketing our services to the public, the government, and businesses. Physical Therapists should progressively provide lawmakers with incentive to protect our scope of practice based on a continued pattern of excellent scientific research in the field of manual therapy. In the meantime, however, let's also be prepared with skilled lobbyists and healthy legislative budgets.