Background:

Physical Therapists.

Licensed physical therapists may perform a variety of services, including:

examining, evaluating, and testing individuals with mechanical, physiological, and developmental impairments, functional limitations in movement, and disability or other health and movement-related conditions;
alleviating impairments and functional limitations in movement;
training for, and the evaluation of, the function of a patient wearing an orthosis or prosthesis;
performing wound care services;
reducing the risk of injury, impairment, functional limitation, and disability related to movement; and
engaging in administration, consultation, education, and research.

To be licensed as a physical therapist, an applicant must:

have a baccalaureate degree in physical therapy from an institution of higher education or a baccalaureate degree from an institution of higher education and a certificate or advanced degree from an approved school of physical therapy;
be of good moral character; and
pass an examination.

A licensed physical therapist may not use spinal manipulation or manipulative mobilization of the spine and its immediate articulations. A physical therapist may not advertise that he or she performs spinal manipulation or manipulative mobilization of the spine.

Chiropractors.

Chiropractic is a health care practice involving the diagnosis, analysis, care, and treatment of the vertebral subluxation complex and its effects, articular dysfunction, and musculoskeletal disorders, all for the restoration and maintenance of health and recognizing the recuperative powers of the body. To be licensed as a chiropractor, an applicant must:

graduate from an accredited chiropractic college;
show satisfactory evidence of a resident course of study of at least 4,000 hours of instruction;
be of good moral character; and

pass an examination.

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Summary of Substitute Bill:

A physical therapist with at least one year of full-time (at least 36 hours a week), post-graduate, orthopedic practice experience that consists of direct patient care may perform spinal manipulation, spinal manipulative therapy, high velocity thrust maneuvers, and grade five mobilization of the spine and its immediate articulations (spinal manipulation) if he or she completes the following additional requirements:

100 hours of training in differential diagnosis;
250 hours of didactic and practical training related to the delivery of spinal manipulative procedures;
150 hours of training in spinal diagnostic imaging; and
300 hours of supervised clinical practical experience in spinal manipulative procedures, which must be:
- supervised by a clinical supervisor who is: (1) a physical therapist authorized to perform spinal manipulation; (2) a licensed chiropractor; (3) a licensed osteopathic physician and surgeon; or (4) a person who holds an endorsement or advanced certification, the training requirements for which are commensurate with the training requirements for physical therapists authorized to perform spinal manipulation (the ability of this last type of person to supervise a physical therapist expires on July 1, 2020);
- under the close supervision (the supervisor has personally diagnosed the condition to be treated, has personally authorized the procedures to be performed, and is physically present in the operatory) of the clinical supervisor for at least the first 150 hours of the clinical practical experience, after which the supervised clinical experience must be under direct supervision (the supervisor is continually on-site and present in the facility, is immediately available to assist the person being supervised, and maintains continued involvement in appropriate aspects of each treatment session); and
- completed within 18 months of completing the educational requirements, unless the educational requirements were completed prior to July 1, 2015, in which case they must be completed by January 1, 2017.

A physical therapist authorized to perform spinal manipulation must consult with another health care practitioner authorized to perform spinal manipulation if spinal manipulative procedures are required beyond six treatments. A physical therapist authorized to perform spinal manipulation may not:

have a practice in which spinal manipulation constitutes the majority of the services provided;
practice or utilize any form of chiropractic manipulative therapy in any form;
delegate spinal manipulation;
advertise that he or she performs chiropractic adjustment, spinal adjustment, maintenance or wellness manipulation, or chiropractic care of any kind; or
bill a health carrier for spinal manipulation separately, or in addition to, other physical therapy procedures.

A physical therapist authorized to perform spinal manipulation must complete at least 10 hours continuing education directly related to spinal manipulation per reporting period. At least five hours of the training must be related to procedural technique and application of spinal manipulation.

If a physical therapist intends to perform spinal manipulation on a patient the physical therapist knows is being treated by a chiropractor, the physical therapist must make reasonable efforts to coordinate patient care with the chiropractor in order to avoid conflict or duplication of services.

By November 15, 2019, the Board of Physical Therapy must report to the Legislature any disciplinary actions taken against physical therapists whose performance of spinal manipulation resulted in physical harm to a patient. Prior to finalizing the report, the Board of Physical Therapy must consult with the Chiropractic Quality Assurance Commission.

Substitute Bill Compared to Original Bill:

The substitute bill:

requires the one year of orthopedic practice experience necessary for a physical therapist to perform spinal manipulation to be full-time (at least 36 hours a week), to be post graduate, and to consist of direct patient care;
expands the definition of spinal manipulation to include spinal manipulative therapy and high velocity thrust maneuvers and limits mobilization of the spine and its immediate articulations to grade five mobilization;
removes two ways in which a physical therapist may become authorized to perform spinal manipulation: certification as an Orthopedic Certified Specialist and completion of a residency or fellowship;
increases the number of hours of education necessary for a physical therapist to perform spinal manipulation from 150 hours plus a year of supervised practice to 800 hours;
specifies that the 800 hours must be divided as follows:
- 100 hours of training in differential diagnosis;
- 250 hours of didactic and practical training related to the delivery of spinal manipulative procedures;
- 150 hours of spinal diagnostic imaging; and
- 300 hours of supervised clinical practical experience in spinal manipulative procedures;
requires the clinical experience to be:
- supervised by a clinical supervisor who is a physical therapist authorized to perform spinal manipulation, a licensed chiropractor, a licensed osteopathic physician, or a person who holds an endorsement or advanced certification, the training requirements for which are commensurate with the training requirements for physical therapists authorized to perform spinal manipulation (the ability of this last type of person to provide the supervision expires on July 1, 2020);
- under the close supervision of the clinical supervisor (during which the supervisor must be in the operatory) for at least the first 150 hours, after which the clinical experience must be under direct supervision; and
- completed within 18 months of completing the educational requirements, unless the educational requirements were completed prior to July 1, 2015, in which case they must be completed by January 1, 2017;
removes the requirement that a physical therapist performing spinal manipulation develop a treatment plan;
requires a physical therapist to consult with another practitioner, other than a physical therapist, authorized to perform spinal manipulation if spinal manipulative procedures are required beyond six treatments;
prohibits a physical therapist from billing a health carrier for spinal manipulation separately, or in addition to, other physical therapy procedures;
removes the requirement that a physical therapist consult with other providers the physical therapist knows are also treating the patient; instead, requires a physical therapist who intends to perform spinal manipulation to coordinate care with a chiropractor the physical therapist knows is also treating the patient to prevent conflict or duplication of services;
removes the requirement that the continuing education be approved by the Board of Physical Therapy; and
delays the ability for physical therapists to perform spinal manipulation until July 1, 2015.

Staff Summary of Public Testimony:

(In support) The stakeholders have done good work over the past year trying to work this bill out. Passing this bill will ensure the best possible care for patients by allowing physical therapists to use evidence-based treatments that they are trained to perform. Washington is one of two states that prohibits physical therapists from performing spinal manipulation. Physical therapists who provide care for members of the military are authorized to perform spinal manipulation. Without this bill, physical therapy patients will have to seek out another provider if spinal manipulation is indicated, which wastes time and money. All schools of physical therapy teach these skills, which students must master before graduating. Physical therapy training is skills-based, not hours-based. Physical therapists are taught that spinal manipulation is not required for every patient, which is consistent with best practices. Physical therapy students are reluctant to attend Washington schools because they know they will be learning skills that are illegal to practice in the state. This bill can also adversely affect research, because researchers are forced to go to other states to perform spinal manipulation. The parameters in this bill will make Washington the strictest state in the nation with respect to spinal manipulation.

(Opposed) This is not a chiropractors versus physical therapists issue. Spinal manipulation is a safe and effective technique, but only with appropriate training; spinal manipulation is a complex skill and must be adaptive and context-specific. These are highly refined skills that take years to acquire. There has been no evidence presented that physical therapy education is adequate; physical therapy training is too narrow and is buried within broader training. Chiropractors learn multiple techniques to give appropriate care. There are at least six other states with some sort of prohibition against physical therapists performing spinal manipulation; some states are silent on the issue. Over half the injuries from spinal manipulation are caused by providers who are not chiropractors. Members of the military get spinal manipulation only from physical therapists; the bias continues. Other states and many organizations, including the World Health Organization, recommend significantly more training to perform spinal manipulation than is required by this bill. Physical therapists currently do not refer to chiropractors. Under this bill, a physical therapist may be able to start clinical training without ever laying hands on a patient.