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Physical Therapist Assistants Performing Joint Manipulations: A Moving Debate.

Recently there has been considerable attention given to the issue of whether joint mobilizations should be performed by PTAs. This attention was sparked by a recent statement by CAPTE on 11/6/12 stating that they will now recognize and allow PTAs to perform joint mobilization. Many objected to this statement saying that joint mobilizations must only be performed by clinicians with higher degrees of knowledge and skill sufficient enough to carry out these procedures. CAPTEs stance for this statement was later clarified on 12/4/12 by stating that because many PTs were delegating manual therapy to PTAs in the clinical setting, they justified including only Grade 1-2  joint mobilization of the extremities into the national PTA licensure examination, furthermore, they clarified that they will no longer deem PTA programs that choose to teach joint mobilizations in their curricula out of compliance with CAPTE evaluative criteria. However, these PTA programs that choose to include joint mobilizations into their curricula will have to show evidence that they are teaching appropriate levels and are in accordance with certain standards for administering joint mobs.

There is much to consider regarding this issue. From an academic standpoint, joint mobilizations in the Grade 1-2 range are not difficult to perform and do not require a greater degree of psychomotor understanding or skill. From experience, a joint mobilization that is performed very early in the joint range of motion, can really be performed even by patients themselves, (ie: small amplitude, rhythmic oscillations, at beginning of range while not reaching limit of available movement). Realistically these movements are not specific and are required just to maintain the patient’s current level of ROM and does not stress the tissues to any appreciable degree to attain greater desired ranges of motion and likely would not lead to complications . Many PTs are accustomed to delegating these mobilizations to PTAs in their POC as they feel there is no appreciable risk for doing so, even though it may be technically illegal to do so (ie: in New York State, joint mobilizations previously could not be included into the PTA curriculum).

Many would argue that allowing PTAs to perform joint mobilizations, despite the benign level of risk of Grade 1-2 mobilizations, would be ‘dummying’ down the skill.  Dr. Stanley Paris, a world-renowned physical and manual therapist openly expressed his disdain of the CAPTE for approving first year PT students to practice “thrust” techniques in his article “Past Present and Future of Joint Manipulation”. He opined that mobilizations as defined by APTA:  “skilled passive movement of and related soft tissues” should not be performed by student PTs before they are “educationally and skill-wise prepared to learn appropriate segmental manipulation”. In fact, he strongly urges that manipulation treatments should be provided by only those skilled PTs that have undergone the necessary formal and sound instructional technique. Therefore PTAs may not be as adequately trained to perform even lower level joint mobilizations after graduating their program(s) and may require further formal training. Clearly an educational gap exists but does this truly affect the ability of a PTA to perform lower level joint mobilizations? What are your thoughts?

Of course, another important point is whether the joint mobilization treatment will be reimbursed if performed by a PTA. With recent changes in reimbursement, ultimately it remains to be seen if joint mobilizations performed by PTAs will be paid sufficiently or even paid at all. Only the demand for PTA in the future can determine this need which continues to remain promising as we see a prevalent growing trends of baby boomer populations in the United States currently and in the foreseeable future needing physical therapy treatment.

Tell us your thoughts!

- Sanjoy Roy, PT, CSCS, Cert. MDT