Thoughts on the partial delegation of joint manipulation

The recent position on Physical Therapy Assistant (PTA) Education and Joint Mobilization put forth by the Commission on Accreditation of Physical Therapy Education (CAPTE) has raised a great deal of controversy and healthy debate within our profession. While I support change, I don’t believe that the current stream of events is justifiable. Here are my concerns about CAPTE’s position.

1.	This decision is in direct conflict with APTA’s position: HOD PO6 00-30-36.
2.	A failure to recognize the evaluative component of manipulation and the associated arthrokinematic principles.
3.	The inadequate representation of PTA’s in the Federation of State Boards of Physical Therapy (FSBPT) Survey.
4.	It reflects a backwards decision-making process; essentially, ‘the tail wagging the dog’.
5.	Oversimplification of Grades I & II manipulation as ‘not necessarily requiring the level of expertise of a physical therapist’.
6.	Use of a questionable example of peripheral joint mobilization in their position statement; i.e., the patellofemoral joint.

Situation as it Currently Stands

In their position statement, CAPTE noted that, ‘… the Commission believes that it is not inappropriate to train PTAs to perform soft tissue mobilization or to manually assist the physical therapist (PT) in the delivery of peripheral joint mobilization procedures (i.e., assist with patient positioning, stabilization, or grade I & II movements).’1

The rationale for this position is that the FSBPT and other entities (not named) identified joint mobilization as a component of current PTA practice.2 Therefore, CAPTE supports the addition of ‘grade I and II peripheral joint mobilization techniques’ to the PTA curriculum through accreditation evaluative criteria. CAPTE provides rationale to support this position by offering that PTA’s should be adequately prepared to monitor patient responses to these interventions. In addition, CAPTE’s position is that ‘grade I and II peripheral joint mobilization techniques do not necessarily require the level of expertise of a physical therapist because these techniques do not require the application of manual force at the end range of tissue restriction that may produce an adverse patient response’.1 Furthermore, CAPTE states that these types of peripheral joint mobilization techniques are often included in a patient's home program, which the PTA may be asked to teach or monitor. Thus, CAPTE does not object to the inclusion of course objectives or learning experiences in the PTA curriculum that are intended to teach these psychomotor skills to PTA students, nor does CAPTE object to testing PTA student competence when performing these (grades I and II) skills. However, CAPTE does not endorse the inclusion of PTA curricular objectives or learning experiences related to the delivery of more complex (i.e., grade III and above) peripheral or spinal joint mobilization techniques that require the skill level of a physical therapist and on-going assessment of the patient's response.1 Interestingly, the example selected by FSBPT and CAPTE to support their position was patellofemoral joint mobilization. This was considered representative of all peripheral joint mobilizations.

1) This decision is in direct conflict with APTA’s position: HOD PO6 00-30-36

I would like to address CAPTE’s position from my experiences as a clinician and teacher. It is important that DPT students understand and respect the role of the PTA and the differences in DPT vs. PTA practice. Here is the position of APTA on this matter, entitled ‘Procedural Interventions Exclusively Performed by Physical Therapists’ (HOD P06-00-30-36):3

‘The physical therapist's scope of practice as defined by the American Physical Therapy Association Guide to Physical Therapist Practice includes interventions performed by physical therapists. These interventions include procedures performed exclusively by physical therapists and selected interventions that can be performed by the physical therapist assistant under the direction and supervision of the physical therapist. Interventions that require immediate and continuous examination and evaluation throughout the intervention are performed exclusively by the physical therapist. Such procedural interventions within the scope of physical therapist practice that are performed exclusively by the physical therapist include, but are not limited to, spinal and peripheral joint mobilization/manipulation, which are components of manual therapy, and sharp selective debridement, which is a component of wound management.’3

Therein, if our profession allows PTAs to perform any manipulation (based on arthrokinematic principles), as opposed to range of motion (based on osteokinematic principles), we are promoting examination and evaluation, in addition to medical screening, as PTA competencies. Manipulation requires all of these elements, as well as recognition of indications and contraindications for those interventions. Are PTA’s prepared to do this and can patients or payers recognize when PTA’s cannot? While some have concluded that those who are in opposition to the CAPTE statement are self-serving and preserving a skill for a select group (i.e. PT’s), it seems that ‘allowing’ Grade I or II manipulation to be performed by PTA’s is only a small part of the issue; the much larger concern is that of delegating interventions that require constant assessment and re-assessment.

Reevaluation of a patient is in order EVERY time a patient returns to the clinic. The therapist must determine if the patient’s response to the previous interventions, including the home exercise program, was appropriate. Physical Therapists’ practice has drastically changed in the outpatient environment since the supportive role of the PTA was developed. We no longer have the ‘luxury’ (and I embrace this evolution of practice) to spend three visits per week performing a rote treatment protocol. Patient visits are limited. If ongoing examination and evaluation aren’t part of every treatment session, then we are doing our patients a disservice. In consideration of patient safety, it is imperative that CAPTE and FSBPT only allow manipulative skills to be taught to physical therapists that have been taught the requisite examination, evaluation and medical screening skills.

2) The lack of evidence to support CAPTE’s position and recognition of the evaluative component of manipulation and associated arthrokinematic principles.

Where is the evidence that supports the position that grade I & II peripheral joint manipulation techniques don’t require the level of expertise of a physical therapist? CAPTE’s rationale for downplaying the expertise required to perform these mobilization techniques is that they don’t require forces to end range of tissue restriction, nor do they require ongoing examination and evaluation during the procedure. How could a PTA trained only from a curriculum designed to provide selected, supportive interventions, fully understand the grades or amplitudes of pressure required to avoid end range unless he/she has evaluated the full extent of that restriction in joint mobility? In order to perform a grade I or II mobilization, one needs to evaluate the patient’s full range of passive accessory mobility. Variations in joint structure, congruency and mobility are considered in relation to body types. In addition, peripheral joint restrictions vary according to the primary and potentially secondary pathologies.4 Each of these factors may subtly or wholly influence the joint play available. For example, a patient with limited post-surgical knee extension may have that limitation resulting from joint effusion whereas a patient with a post-amputation knee flexion contracture will have a far different limiting mechanism. As a physical therapist, I have been prepared to recognize the difference in the low amplitude, or grade I & II manipulation, that each patient requires. In each situation, the force production varies. These variations would require that these topics be covered in the PTA curriculum. From an educational perspective, the variations of force or amplitude would be difficult to include in the time constraints of the PTA curriculum. From an ethical practice perspective, physical therapists need to consider the implications of instructing PTA’s in interventions that are not adequately presented in PTA curricula.

Notably absent from CAPTE’s position statement was mention of the rate of force application. Mintken and colleagues5 described the need to standardize terminology related to the term, ‘manipulation.’ They recommended describing the rate of force application, location in range of available movement, direction of force, target of force, relative structural movement, and patient position. The omission of the rate, direction, and velocity of force application in the CAPTE position statement is a significant omission suggesting that CAPTE considers grade I & II manipulation as little more than ‘wiggling joints’.

When teaching manipulation across the continuum of velocity, force and amplitude, it is imperative that students understand the differences in arthrokinematic and osteokinematic motion, both in theory and in practice. Arthrokinematic motions are not under voluntary control of the patient, therefore, motion introduced specifically to a joint must constantly be monitored throughout the treatment session; this defines a need for immediate and continuous examination and evaluation throughout the intervention. It is imperative to examine the reactivity and response of the joint, as well as the patient, during and immediately after the intervention. If a therapist doesn’t know how to evaluate specific joint motion or have the ability to examine for adverse reactions, then he/she is putting the patient’s safety at risk by performing joint manipulation. Within this scheme, students are taught to use the information from ongoing clinical interventions and assessments to confirm or reject a diagnosis. If our profession is to support CAPTE’s position and truly is concerned about the well-being of our patients, then we must mandate that PTA’s learn the principles of medical screening, which definitively includes differential diagnosis. This is outside the acceptable scope of interventions to be delegated to a PTA.

3) The inadequate representation of PTA’s in the FSBPT Survey.

Also from an educator’s perspective, when critically analyzing the FSBPT report, there was very little evidence to support the recommendations from the FSBPT PTA survey.2 This survey represented less than 1% of US PTAs. In the Work Activity analysis for joint mobilization, PTAs in the cohort that met the FSBPT threshold reported performance of joint mobilization at a rate of ‘once per month or less.’ Does this really represent enough utilization of this practice to warrant mandating changes in PTA practice, as well as PTA program curricula?

4) Is the ‘tail wagging the dog’?

The quality assurance process that was used by FSBPT is inverted. First, FSBPT identifies an intervention that is being performed by PTAs, and then CAPTE recommends that the intervention be part of PTA curricula. This led the profession to ask whether or not the best interest of our patients is being served.6 This is a classic example of the ‘tail wagging the dog’. Best practice (and history) would suggest that PT’s would call for this action, if/when there was a determination that ‘handing off’ this component of practice was in order. Discussion would ensue at the APTA’s House of Delegates and, if adopted, CAPTE and FSBPT would work with APTA to adopt and implement the appropriate academic standards and competency assessments. The implications of adopting the CAPTE and FSBPT position on manipulation is that we open a door that would allow practice policies and standards to be determined by multiple bodies.

5) The oversimplification of Grades I & II manipulation as ‘not necessarily requiring the level of expertise of a physical therapist’

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6) Using the patellofemoral joint as an example for peripheral joint manipulation.

As a PT educator teaching manipulation and anatomy, I find it disconcerting that manipulation of the peripheral joints is considered less complex than manipulation of the spine. How did all of the risk end up being associated with spinal manipulation? Moreover, from an anatomical and arthrokinematic perspective, the patellofemoral joint (given in the CAPTE rationale) isn’t a representative example of the principles of peripheral joint mobilization. Patellar gliding is a frequent exercise given as part of a home program to patients, but application of this procedure cannot be extrapolated to, e.g., manipulation of the subtalar joint or the temporomandibular joint. ‘Manipulation is the skilled passive movement of a joint/segment’ that frequently isn’t under the voluntary control of the patient.7 In order to ensure patient safety, it should be reiterated that a thorough understanding of joint anatomy and arthrokinematics, as well as the ability to evaluate the effectiveness of the technique during and after a treatment session, are essential for practitioners of manual therapy. The requisite didactic preparation, as well as the skills of assessment and reassessment, is not part of PTA program curricula.

Manipulation is a complex psychomotor skill and appropriate and effective instruction methods are being established. The premise that ‘Grades I & II’ manipulation require lower level skills is unfounded. Current research indicates that measurement of the following parameters indicate successful delivery or expertise in manipulation. These include: pre-load, speed of delivery, peak force, time to peak force, force duration, line of action and coordination.8^–10 While many of these studies have been published on spinal manipulation, the principles and application are the same for peripheral joint manipulation.11

Clinically, ‘grade I and II mobilization’ (recently described as ‘low amplitude’ manipulation with oscillatory motions) is used to treat the most irritable or reactive joints or conditions.5 These preparatory techniques are used to introduce movements in patients with significant pain. In many cases, these patients are too acute and/or reactive to tolerate any other intervention. The logic behind ‘handing off’ these interventions is questionable. These are the most acute scenarios oftentimes and require ongoing assessment of the patient.

The use of postsurgical patellar manipulation as an example of peripheral joint mobilization, as seen in CAPTE’s position statement, reflects a distorted perception of the clinical skill necessary for effective application of extremity mobilization. Such a global extrapolation of uniquely dissimilar techniques demonstrates a lack of understanding of the skill set required for examination, evaluation and provision of mobilization. It erroneously reduces the complexity of the skill level required to deliver these interventions, as well as the complexity of the patients who need them.

Beyond the scope of this paper, but certainly relevant, we must also appreciate that, in today’s healthcare environment, outcomes are being closely scrutinized for their value. The partial delegation of manipulation proposed by CAPTE should be fully considered by all physical therapists not only as it relates to safety, outcomes and efficacy, but also for the potential impact that that decision may have on the public’s perception of the value of the services provided by physical therapists.

In summary, the logic supporting CAPTE’s position is contradictory and weakly founded. It appears that a few PTs taught limited joint mobilization techniques to a limited number of PTAs. This prompted FSBPT to call for inclusion of manipulation questions in the PTA exam. CAPTE responded by adding manipulation to PTA curricular objectives. Now, PTA’s are being asked to treat beyond their level of training, since they are not thoroughly prepared to examine and evaluate patients. This partial delegation of manipulation is a much greater issue than dividing the mobilization workload; it is in direct opposition to our professional values, state practice acts, and responsibilities to patient safety.