Alabama Courts Uphold Practice of
Spinal Manipulation by Physical Therapists

Stephen Barrett, M.D.

Chiropractic organizations would like to stop physical therapists from including spinal manipulation within their practice. Their efforts appear to be financially motivated [1]. The American Chiropractic Association has tried (unsuccessfully) to stop Medicare from paying for manipulation performed by physical therapists [2,3]. In a few states, chiropractic organizations have have obtained laws that make the practice of spinal manipulation by physical therapists either difficult or illegal. In two states—Arkansas and Alabama—the chiropractic board has sued an individual physical therapist with the hope that a successful outcome would affect all physical therapists. This article reports on these two lawsuits.

The Arkansas Lawsuit

The Arkansas case involved Michael Teston, P.T., who included spinal manipulation in his practice as a physical therapist in Little Rock, Arkansas. In 2002, the Arkansas State Board of Chiropractic Examiners received a complaint from a patient, conducted an undercover investigation, held a hearing, and issued an order fining Teston $10,000 for "practicing chiropractic without a license." The board's action was based on the claim that Teston had manipulated a patient's spine. The Arkansas State Board of Physical Therapists had ruled that Teston's treatment was mobilization, not manipulation, and was therefore within the lawful scope of physical therapy. However, the chiropractic board concluded that because his procedures produced an audible "popping" sound, they were manipulation, which the board claimed was reserved for licensed chiropractors and physicians. Teston appealed the ruling to the Pulaski County Circuit Court, which sided with the chiropractors [4]. Teston then appealed to the Arkansas Supreme Court. The Arkansas State Board of Physical Therapy, the American Physical Therapy Association, and the Federation of State Boards of Physical Therapy each filed an amicus curae brief on his behalf, and the American Chiropractic Association and the International Chiropractors Association filed briefs supporting the chiropractic board [5-9]. In 2005, the Arkansas Supreme Court upheld the chiropractic board ruling [10] and the U.S. Supreme Court declined to review the case. During the 2003 legislative session, the Arkansas Physical Therapy Association campaigned for a law that would include manipulation within their scope of practice, but they were not successful.

The Alabama Lawsuit

The Alabama case involved James Dunning, D.P.T., who practices physical therapy in Montgomery, Alabama. He is also president of the Spinal Manipulation Institute, which is described on its Web site as "the worldwide leader in spinal manipulation education." The site also indicates that in addition to obtaining a doctoral degree in physical therapy in the United States, Dunning obtained a master of science degree in advanced manipulative physiotherapy from the University of Birmingham, England and completed advanced training in osteopathic spinal manipulation through the London School of Osteopathy [11].

In February 2008, the Alabama State Board of Chiropractic Examiners sent the Institute a cease-and-desist letter about a seminar Dunning was scheduled to teach titled "High-Velocity Low-Amplitude Thrust Manipulation of the Cervical, Thoracic, Lumbar and SI Joints." The Alabama State Board of Physical Therapy had already approved the seminar for continuing education credit for Alabama-licensed physical therapists, but the letter claimed that the techniques were chiropractic and not within the scope of a physical therapist. The letter warned that if the board did not receive a satisfactory response within seven days, it would initiate a lawsuit [12]. Dunning responded that if the Chiropractic Board believed that he was acting outside the scope of his authority as a physical therapist, they had a legal right to complain to the Physical Therapy Board.

The Chiropractic Board did not respond to Dunning's letter, and the seminar was taught as planned. But rather than pursuing his teachings, it decided to target his professional practice. In September 2008, the Chiropractic Board complained to the Physical Therapy Board about an advertisement that Dunning's clinic was running in a local magazine. The Chiropractic Board stated that it was "troubled" by the assertion that he was able to perform "spinal manipulation" and by his use of the title "Dr." which, it alleged, could mislead consumers to believe his office involved the practice of medicine [13]. The Physical Therapy Board found nothing wrong with the ad. The Chiropractic Board then requested a formal advisory opinion from the Alabama Attorney General about Dunning's use of spinal manipulation and whether he was practicing chiropractic without a license by performing manipulative procedures. However, before an opinion was issued, they withdrew this request.

In May 2009, the Chiropractic Board filed a lawsuit which claimed that "by advertising or performing spinal manipulations for the relief of pain . . . Dunning is either holding himself out as and/or is practicing chiropractic without a license." The suit asked the court to (a) declare that "spinal manipulations can only be performed by individuals licensed to practice chiropractic in this state" and (b) issue a permanent injunction barring Dunning from advertising or performing spinal manipulations [14].

In response, Dunning denied that he was practicing chiropractic and asked the court to summarily dismiss the suit [15,16]. At the trial court's hearing on the summary judgment motion:

In September 2009, the judge dismissed the case [18]. The Chiropractic Board then appealed to Supreme Court of Alabama. In his opposing brief, Dunning argued that Alabama law empowered the Physical Therapy Board to interpret the Physical Therapy Act under which he practices, and that instead of attempting to resolve the scope-of-practice issue through ordinary administrative channels, it had asked the court to bind the Physical Therapy Board unilaterally. Dunning also noted that neither the Chiropractic Practice Act nor the Physical Therapy Act mentioned the term "spinal manipulation." In January 2012, after a 27-month wait, the Supreme Court of Alabama affirmed the trial court's ruling in favor of Dr. Dunning by a 9-0 vote without issuing a written opinion. Dunning was represented by Richard A. Bearden with the law firm of Massey, Stotser & Nichols, P.C., in Birmingham, Alabama.

Vigilance is Needed

Spinal manipulation is appropriately taught in physical therapy schools and postgraduate courses. There is no logical reason why anyone who is properly trained and licensed to perform spinal manipulation should not be able to do it. In fact, if anyone deserves to be restricted, it is the large proportion of chiropractors who misuse manipulation to "correct" nonexistent "vertebral subluxations." [19]

Michael Teston lost his case because the courts interpreted Arkansas law against him—a situation physical therapists could change through passage of legislation that is less restrictive. Alabama's laws are worded more favorably. It is time to stop the chiropractic bullying. Physical therapists should work hard to seek or maintain laws that keep spinal manipulation within their scope.

References

  1. Huijbregts PA. Chiropractic legal challenges to the physical therapy scope of practice: anybody else taking the ethical high ground? Journal of Manual & Manipulative Therapy 15:69-80, 2007.
  2. Manipulation: A covered physical therapist service. American Physical Therapy Association Web site, archived Nov 3, 2002.
  3. Penn JG. Memorandum opinion. American Chiropractic Association v. Tommy G. Thompson, Secretary of Health and Human Services. U.S. District Court for the District of Columbia, Civil Action No. 98-2762, Oct 14, 2004. On Dec 13, 2005, the U.S. Court of Appeals (Case No. No. 04-5411) upheld the District Judge's opinion that Medicare could cover manipulation done by other professionals beside chiropractors.
  4. Fox TD. Order. Michael Teston vs. Arkansas State Board of Chiropractic Examiners. Pulaski County Circuit Court, Sixth Division, Case No. CV03-0502, Sept 9, 2003.
  5. Brief of amicus curiae. Federation of State Boards of Physical Therapy, July 13, 2004.
  6. Brief of amicus curiae. Arkansas State Board of Physical Therapy, July 15, 2004.
  7. Brief of amicus curiae. American Physical Therapy Association, July 14, 2004.
  8. Brief of amicus curiae. American Chiropractic Association, Sept 14, 2004.
  9. Brief of amicus curiae. International Chiropractors Association, Sept 14, 2004.
  10. Glaze T. Opinion. Teston vs. Arkansas State Board of Chiropractic Examiners. Supreme Court of Arkansas, Case No. 04-420, April 7, 2005.
  11. Institute faculty. Spinal Manipulation Institute Web site, accessed March 20, 2015.
  12. Ward JS. Letter to Spinal Manipulation Institute. Feb 5, 2008.
  13. Bolton S. Letter to Alabama Board of Physical Therapy, Sept 9, 2008.
  14. Complaint. Alabama State Board of Chiropractic Examiners v. James Dunning. Montgomery County Circuit Court, Civil Action No.: CV-2009-900640, May 27, 2009.
  15. Dunning's motion for summary judgment, July 1, 2009.
  16. Dunning's reply to objections to motion for summary judgment, Aug 21, 2009.
  17. Transcript of summary judgment motion hearing, Aug 25, 2009.
  18. Price C. Ruling on summary judgment motion, Sept 9, 2009.
  19. Bellamy J. A cure for chiropractic. Science-Based Medicine blog, Feb 20, 2014.

This article was revised on March 23, 2015..

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