Chiropractic Spinal Adjustment / Manipulation Adjustment vs. Manual Therapy: DC vs. DO vs. PT
Part 2 of 2 (Continued from January 2020)
FEATURE
By
Matt Erickson
DC, FSBT &
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
In part one of this two-part series, it was explained that the primary service performed by the doctor of chiropractic (DC) is a specific chiropractic spinal adjustment (CSA). From an insurance coding and billing perspective, a CSA is also regarded as a chiropractic manipulative treatment (CMT). Using current procedure terminology (CPT) codes, CMT is coded as 98940, 98941, or 98942. A CSA is also generically referred to as spinal manipulation.
Doctors of osteopathy (DOs) also have their own nonspecific form of spinal manipulation called osteopathic manipulative treatment (OMT). OMTs are coded using CPT codes 98925, 98926, and 98927. Conversely, since medical doctors (MDs) perform very little spinal manipulation, a CPT code has not been created for them.
To add to this, nonspecific spinal manipulation can also be regarded as a type of manual therapy, which not only can be performed by DCs, DOs, and MDs but also by physical therapists (PTs). Further, manual therapy-based spinal manipulation is coded using CPT code 97140. Thus, given the different types of spinal manipulation, this can lead to confusion because the application, intention, or result is not synonymous amongst provider types.
As stated, nonspecific spinal manipulation is regarded as a form of manual therapy that can also be performed by PTs. Further, PTs also have their own unique nonspecific form of spinal manipulation called �thrust joint manipulation� (TJM). According to Puentedura, Slaughter, Reilly, Venturan, and Young (2017), �Thrust joint manipulation (TJM) is defined as a high-velocity low-amplitude thrust technique, which can be distinguished from other joint mobilization techniques that do not utilize a final thrust maneuver� (p. 74).
Manual Therapy Defined
A 2015 publication by the American Chiropractic Association (ACA) stated, �Manual therapy techniques consist of, but are not limited to, connective tissue massage, joint mobilization and manipulation, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. As the code descriptor states, �manual� providers use their hands to administer these techniques. Therefore, procedure code 97140 describes �hands-on� therapy techniques. This confirms spinal manipulation can be defined specifically as a chiropractic spinal adjustment or CMT or nonspecifically as a type of manual therapy� (http: //www. acatoday. org/LinkClick. aspx?fileticket=mwNx3rFnBWo%3D&portalid=60).
Nonspecific spinal manipulation as a form of manual therapy can be performed by a DC and complement a specific CSA. However, it is not synonymous with a specific CSA, nor is it a replacement for it. Regarding the practice of chiropractic, the World Federation of Chiropractic (2001) explained chiropractic is, �A health profession concerned with the diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments, including spinal adjustment and other joint and soft-tissue manipulation� (https://www.wfc.org/ website/index.php?option=com_content&view=article&id=90&Itemid=l 10).
As explained, physical therapists (PTs) can also perform manual therapy in the form of nonspecific spinal manipulation (and spinal mobilization), but not a specific CSA or nonspecific OMT. Paris (2000) wrote, �In practice, however, especially within American physical therapy, the term mobilization is frequently used to refer to nonthrust techniques and the word manipulation to thrust techniques� (p. 67).
Regarding manual therapy, Paris (2000) also reported, �A clinical approach utilizing skilled, specific hands-on techniques, including but not limited to manipulation/mobilization, used by physical therapists to diagnose and treat soft tissue and joint structures for the purpose of modulating pain, increasing range of motion, reducing or eliminating soft tissue inflammation, inducing relaxation, improving contractile and noncontractile tissue repair, extensibility and or stability, facilitating movement, and improving function� (p. 67).
Spinal Manipulation by Provider Type
In a United States-based review (which derived from an analysis of 67 articles and nine books or textbooks) by Shekelle, Adams, Chassin, Hurwitz, Phillips, and Brook (1991, p. 3), the authors stated, �A recent analysis of a community-based sample of patients showed that chiropractors delivered 94% of all the manipulative care for which reimbursement was sought, with osteopaths delivering 4%, and general practitioners and orthopedic surgeons accounting for the remainder� (https://www.rand.org/pubs/reports/R4025zl.html).
In other words, DCs perform 94% of all spinal manipulations (as a specific CSA) in the United States while DOs perform 4% (as a nonspecific OMT) and subsequently, the remaining 2% are performed by PTs (as nonspecific TJM) and medical doctors (MDs).
It is also important to recognize that nonspecific spinal manipulation is a form of manual therapy, and there is no CPT code that differentiates nonspecific spinal manipulation from spinal mobilization as provided by PTs. Therefore, while PTs perform more manual therapy than MDs, in reality, PTs perform far less nonspecific spinal manipulation than 2%.
As explained earlier, spinal manipulation among DCs (specific CSA or CMT), DOs (nonspecific OMT), and PTs (nonspecific TJM) has its own descriptive form. However, one unique feature of spinal manipulation provided is that a specific CSA (CMT) and nonspecific OMT are physician-only services, while spinal manipulation by PTs (TJM) is categorized as a form of manual therapy. In part one of this series, we discussed in detail the mechanics of spinal manipulation versus mobilization, how it is different among DCs, DOs, and PTs, and the historical confusion regarding manipulation and mobilization by PTs.
Regarding spinal manipulation by PTs, Paris (2000) wrote, �It is not possible to speak of manipulation in physical therapy without speaking of manipulation in medicine since medicine created physical therapy to aid rehabilitation. Physicians trained these aides who later became physical therapists. Hence the history, philosophy, and practice of medicine vis-a-vis physical rehabilitation, including manipulation and all areas of manual therapy, evolved into physical therapy (physiotherapy)� (p. 69-70). In other words, although PT came out of medicine, spinal manipulation performed by PTs is regarded as a form of manual therapy and not a physician-based HVLA spinal manipulation.
Therefore, while PTs report a history of performing nonspecific spinal manipulation, that statement is more of a political argument to allow the entire profession to legally perform spinal manipulations and perhaps one day be granted physician class status in the US. Their position to legally perform nonspecific spinal manipulation makes sense given the trend in the literature demonstrating positive pain-modulating effects with spinal manipulation, in general, that is not observed with spinal mobilization.
Spinal Manipulation Not Mobilization Modulates Pain
In a study by Coronado, Bialosky, Carnaby, Bishop, and George (2012), the authors concluded, �Spinal manipulative therapy (SMT) appears to modulate pain through both central and peripheral pathways. Studies have investigated the effect of SMT using variable experimental pain modalities, including chemical, electrical, mechanical, and thermal stimuli. SMT demonstrated a favorable effect over other interventions [spinal mobilization] on pressure pain thresholds (PPT). Additionally, subgroup analysis showed a significant effect of SMT on remote sites of pressure stimulus application, further supporting a potential influence on higher levels within the central nervous system� (p. 765).
Specific Adjustment versus Nonspecific Spinal Manipulation
Palmer College of Chiropractic (2019, para. 3) stated, �A chiropractic adjustment is a very safe, specific, controlled force applied to a joint to restore proper function and mobility. Accidents, falls, stress, or overexertion can negatively impact your spine or other joints. These changes impact tissues, the nervous system, and other areas of the body. Left unresolved, this could make you more susceptible to chronic problems. Chiropractic adjustments reduce pain, increase movement, and improve performance� (http: //www. palmer, edu/about-us/ what-is-chiropractic/).
The International Chiropractic Association (ICA) (n.d.) also wrote, �The ICA holds that the chiropractic spinal adjustment is unique and singular to the chiropractic profession. The chiropractic adjustment shall be defined as a specific directional thrust that sets a vertebra into motion with the intent to improve or correct vertebral malposition or to improve its juxtaposition segmentally in relationship to its articular mates, thus reducing or correcting the neuroforaminal/neural canal encroachment factors inherent in the chiropractic vertebral subluxation complex (a.k.a. neurobiomechanical pathology or NBP). The adjustment is characterized by a specific thrust applied to the vertebra utilizing parts of the vertebra and contiguous structures as levers to directionally correct articular malposition� (p. 6).
That said, although it has been determined that neurological irritation/interference does not occur at the root level, it is, however, centered in the nociceptors in the facets and the Pacinian corpuscles, Ruffini corpuscles, and nociceptors in the supporting ligaments. Thus, the previous description of the chiropractic spinal adjustment, in part, supports the literature-based as described by Evans (2002).
The Application of a Specific CSA
Regarding the application of a specific chiropractic spinal adjustment, Mootz and Shekelle (1997, p. 72) reported, �Both mobilization and manipulation are used to facilitate joint motion. When applied in manual medicine and physical therapy, assessment, and manipulative treatment tend to focus exclusively on joint pain and restriction. However, even though the execution of high-velocity manipulative thrusts by chiropractors and nonchiropractors may appear similar, chiropractic techniques focus on a more global clinical picture to characterize and apply adjustments� (https://www.chiroweb.com/archives/ ahcpr/uschiros.PDF). Thus, the clinical application of a specific CSA versus nonspecific manual therapy or OMT is different.
Mootz and Shekelle (1997) also reported, �Chiropractors typically consider the nature and mode of condition onset, muscle spasm, pain radiation patterns, static and dynamic postures, and/or gaits as well as joint pain in determining whether or not a mechanical intervention should be applied (Mootz, 1995a). For example, the spinal areas manipulated using typical manual medicine and physical therapy assessment approaches are often based on which joints or regions have restricted motion� (p. 72). This further explains that the clinical application of a specific CSA is more than just manipulating joints to increase motion.
Mootz and Shekelle (1997) continued, �In contrast, the decision as to which area to manipulate using various chiropractic techniques may be based upon pain radiation patterns, which paraspinal muscle regions are taut and how they are innervated, the biomechanical function of affected joints compared to that of adjacent areas, and the mechanics involved in initial onset (Grice, 1992; Gitelman, 1992). Therefore, the regions manipulated (adjusted) by chiropractic may not directly correspond to the symptomatic region or to the area that a nonchiropractor may feel is the site of the manipulate lesion� (p. 72-73). This demonstrates how the specific application of a CSA is not synonymous with nonspecific spinal manipulation.
The previous statement by Mootz and Shekelle (1997) has been verified in recent literature as identifying central modulation of pain. As reported by Reed, Pickar, Sozio and Long (2014), �Forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease sensitivity) in both symptomatic and asymptomatic subjects. Cervical spinal manipulation (chiropractic HVLA) has been shown to result in unilateral as well as bilateral mechanical hypoalgesia. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, LI, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing, including activation of descending pain inhibitory systems. Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated� (p. 277).
The Intention of a Specific CSA
Another concept that differentiates the intention behind spinal manipulation as a specific CSA from nonspecific TJM and OMT is that the origin of chiropractic follows a salutogenic model (what keeps one healthy or well). Conversely, traditional medicine (which includes both osteopathy and physical therapy) subscribes to what is known as the pathogenic model (what causes disease or makes one ill).
Lindstrom and Eriksson (2005) reported, �Salutogenesis, the origin of health, is a stress resource-orientated concept, which focuses on resources, maintains and improves the movement toward health. It gives the answer for why people, despite stressful situations and hardships, stay well. The theory can be applied at an individual, a group, and a societal level. It is the opposite of the pathogenic concept where the focus is on the obstacles and deficits� (p. 440).
Thus, spinal manipulation as a specific CSA is a specific HVLA thrust maneuver designed to correct spinal patho-neuro-biomechanics [remove nerve irritation/interference, restore biomechanical balance], increase important proteins such as substance P (Evans 2002) and as a result increases the body�s ability to maintain homeostasis. Conversely, a nonspecific spinal manipulation as manual therapy (TJM) or OMT is a generalized HVLA thrust maneuver of joints and connective tissue to improve motion, decrease pain, and decrease muscle tension.
The intent of nonspecific TJM or OMT, therefore, is in treating pain and dysfunction. That is not to say a nonspecific spinal manipulation will not help a patient. However, when it is not performed as a specific chiropractic based neurobiomechanical corrective adjustment or from a salutogenic health management perspective, its intent is something else entirely.
Conclusion
Mechanically, spinal manipulation is regarded as the use of a high-velocity, low-amplitude (HVLA) force where spinal mobilization is regarded as a low-velocity, low-amplitude force (LVLA). There is also a clear distinction between spinal manipulation performed by a DC, DO, or PT. Further, 94% of all spinal manipulation is performed by DCs, while 4% is performed by DOs, and less that 2% is performed by PTs.
As explained, manual therapy as a nonspecific spinal manipulation or spinal mobilization can complement the specific CSA, but not replace it. Additionally, despite the political arguments about PTs performing nonspecific spinal manipulation, the literature supports that nonspecific spinal manipulation beyond improving joint function, increasing range of motion, and reducing pain is different when applied as a specific CSA versus a nonspecific TJM or OMT.
PTs and DOs also follow a pathogenic model and perform nonspecific spinal manipulation called TJM or OMT, respectfully. Conversely, DCs follow a salutogenic model and perform a specific CSA. Thus, the intention of CSA is also not synonymous with TJM or OMT. As stated earlier, in part one of this series, we discussed in detail the mechanics of spinal manipulation versus mobilization, how it is different among DCs, DOs, and PTs, and the historical confusion regarding manipulation and mobilization by PTs.
Finally, as explained, unlike doctors of chiropractic, PTs do not have physician class status in the United States, which is required in order to fully manage patients with spinal-related disorders. Conversely, since DCs are trained physicians and have physician class status, they can fully manage patients with spinal-related disorders and, as such, are positioned to take over a much-needed role in our healthcare delivery system as a primary spine care provider. Moreover, regardless of whether PTs are able to provide nonspecific spinal manipulation, they are not trained or licensed as physicians and, therefore, are not qualified to take on a role as a primary spine care provider.
References
1. Puentedura Emilio Slaughter Rebecca, Reilly Sean, Ventura Erwin, and Young Daniel. (2017). Thrust joint manipulation utilization by U.S. physical therapists. Journal of Manual & Manipulative Therapy, 25(2), 74-82.
2. American Chiropractic Association. (2015). CPT® Position on the Proper Use of Procedure Code 97140 [PDFfile] http: www.acatoday.org LinkClick.aspx?fileticket mwNx3rFnB Wo %3D&portalid=60.
3. World Federation of Chiropractic. (2001). Definition of Chiropractic. Retrieved from https://www. wfc.org/website index.php?opti on = c om c ontent &vi ew = arti -cle&id=90&Itemid=ll 0
4. Paris Stanley V, PhD, PT. (2000). A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States. The Journal of Manual & Manipulative Therapy 8(2), 66-77.
5. Shekelle Paul G., Adams Alan H., Chassin Mark R, Hurwitz Eric L., Phillips Reed B., and Brook Robert H. (1991). The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Santa Monica, CA: RAND Corporation. Retrieved from https ://www. rand, org pubs reports R4025zl.html.
6. Coronado, R. A., Gay, C. W., Bialosky, J. 17, Carnaby, G. D., Bishop, M. I)., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic reviewv and meta-analysis. Journal of Electromyography Kinesiology, 22(5), 752-767.
7. Palmer College of Chiropractic. (2019). What is Chiropractic? Retrieved from http://www.palmer.edu/ about-us/what-is-chiropractic/.
8. International Chiropractic Association, (n.d.). International Chiropractors Association Statements of Official Policy 1-21 [PDF file]. Retrieved from http://www.chiropractic.org/ wp-contentuploads, 2018 01/ALL-STATEMENTS-OF-OFFICIAL-ICA-POLICY-combined-policies-for-review.pdf
9. Evans, I). W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal ofManipidative and Physiological Therapeutics, 25(4), 251-262.
10. Mootz Robert and Shekelle Paid. (1997 Dec). Chiropractic in the United States: Training, Practice [PDF file]. Retrieved from https ://www. chi row eb. com archives ahcpr uschiros.PDF.
11. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons. Journal of Manipulative and Physiological Therapeutics, 37, 141-148.
12. Lindstrom Bengt and Eriksson Monica, (2005). Salutogenesis. Journal of Epidemilogy Community Health, 59, 440442.
13. Sinnott, R. J. (2016). Sinnott�s textbook of human adaptability: A quest to optimize the trajectory of life.
Dr. Matt Erickson is the President of Body Right Chiropractic in Clearwater, Florida. He graduated from Hope College 'n 1994 w4h 9 BA in Chemistry (Biochemisemphasis) and a Physical Education minor. Dr. Erickson graduated from Palmer College of Chiropractic in 1998 earning the President's List Award for clinical excellence. Through the Academy of Chiropractic he is Trauma Qualified, Primary Spine Care Qualified and Interprofessional Hospital Qualified. In 2018, Dr. Erickson completed a 2-year Fellowship in Spinal Biomechanics and Trauma. You can reach Dr. Erickson at [email protected] or (727) 498-5208.
Dr. Mark Studin is the founder of the Academy of Chiropractic and the Doctors PI Program (www.DoctorsPIProgram.com). He also teaches in both chiropractic and medical at various levels on MRI spine interpretation, spinal biomechanical engineering, spinal trauma pathology, triaging the injured and other spinal and trauma-related topics. Dr. Studin consults and creates strategic business strategies for chiropractors, medical doctors, hospitals and lawyers nationally. He can be reached at 631-786-4253 or [email protected]
