Arch Phys Med Rehabil. 2018 (Jan); 99 (1): 72–81 ~ FULL TEXT
Daniel Rhon, DSc, Tina Greenlee, PhD, Julie Fritz, PhD
Department of Physical Medicine & Rehabilitation,
Madigan Army Medical Center,
Joint Base Lewis McChord,
OBJECTIVE: To describe the use of manipulative treatment for shoulder and spine conditions among various provider types.
DESIGN: Retrospective observational cohort.
SETTING: Single military hospital.
PARTICIPANTS: Consecutive sample of patients (N=7,566) seeking care for an initial spine or shoulder condition from January 1 to December 31, 2009.
INTERVENTIONS: Manipulative treatment (eg, manual therapy, spinal and joint manipulation).
MAIN OUTCOME MEASURE: Manipulation treatment was identified with procedure billing codes in the medical records. Spine and shoulder conditions were identified by using the International Classification of Diseases, 9th Revision codes. All data were abstracted from the Department of Defense Military Health System Management and Analysis Tool.
RESULTS: Of 7,566 total patients seeking care, 2014 (26.6%) received manipulative treatment at least once, and 1870 of those received this treatment in a military facility (24.7%). Manipulative treatment was used most often for thoracic conditions and least often for shoulder conditions (50.8% and 24.2% of all patients). There was a total of 6,706 unique medical visits with a manipulative treatment procedure (average of 3.3 manipulative treatment procedure visits per patient).
CONCLUSIONS: Manipulative treatment utilization rates for shoulder and spine conditions ranged from 26.6% to 50.2%. Chiropractors used manipulation the most and physical therapists the least.
KEYWORDS: Chiropractic; Hospitals; Manipulation, spinal; Military personnel; Musculoskeletal manipulations; Physical therapist; Physicians; Rehabilitation; Shoulder; Spine
From the FULL TEXT Article:
Manipulative treatment, a manual “hands-on” intervention, is recommended for the management of musculoskeletal disorders in several interdisciplinary clinical practice guidelines. [1–3] It is most often utilized to treat spinal pain,  but also recommended for the management of shoulder disorders. [5, 6] In fact, surveys indicated that manual therapy are core treatments for physical therapists and chiropractors. 
While the terminology can vary between disciplines, the premise is similar: manipulative treatment uses primarily the hands as a manner to evaluate and treat patients, through movement of joints and soft tissue. In the Military Health System, several medical disciplines are credentialed to provide manipulative treatment.
These include chiropractors (DC), osteopathic physicians (DO), and physical therapists (PT). The treatment can be delivered in both primary and secondary care settings. While some state practice acts may limit manipulative treatment to certain specialties, healthcare providers practicing in a federal facility fall under federal regulations, which currently allow delivery of the treatment by all three professions.
While manipulative treatment is recommended in various systematic reviews and clinical practice guidelines for shoulder and spine disorders, [1, 5, 6] few studies have looked at how often it is actually utilized in clinical practice. The existence of clinical practice guidelines does not mean they will be utilized,  and in fact compliance is often poor.  Both patient and environmental characteristics can influence the feasibility of implementing recommended care.  It is currently unknown to what extent manipulative treatment is utilized by healthcare providers with the Military Health System. Self-reported use in surveys indicates that manual therapy utilization is high amongst physical therapists and chiropractors,  but actual practice may not reflect findings reported in surveys.
The purpose of this study was to identify and report the utilization rates of manipulative treatment by various provider disciplines in the management of shoulder and spine conditions.
This was retrospective observational cohort of patients in the Military Health System seeking medical care for a spine or shoulder diagnoses at Madigan Army Medical Center between 1 January and 31 December 2009. This setting was chosen because all three disciplines of interest provide care here. There are no copay or insurance limitations for TRICARE beneficiaries within the Department of Defense. The project was approved by the Army Western Regional Medical Command Institutional Review Board.
Selection of subjects
Patients that presented to the primary care clinic for an initial consultation related to a spine or shoulder condition from 1 January to 31 December 2009 were included. Data was abstracted retrospectively from the Military Health System Management Analysis and Reporting Tool (M2), which is a healthcare utilization database managed by the Defense Health Agency (DHA). This database was queried for any new encounters associated with a spine or shoulder diagnosis (Appendix A). A new encounter was defined as a visit for that diagnosis at a primary care clinic, without a qualifying diagnosis present in the 12 months prior. All healthcare visits in the 12 months after the initial diagnosis were queried for presence of a Current Procedural Terminology (CPT) code reflecting manipulative treatment. and then any visits occurring in the civilian network were excluded. All healthcare utilization for the final cohort was abstracted from the M2 database for an entire 12–month period after the date of diagnosis. (Figure 1), and provided at the single-person level.
Data Access and Cleaning Methods
The DHA utilizes a robust method for addressing errors in data. Data are transmitted from the electronic medical record to the global M2 database daily, and M2 processes the data weekly. The data at this point is raw and goes through validation. The master data file is updated monthly, and at this point both new processed data, and updates to previously added data are added to the master file. This process is explained in detail via documentation publically available online.  The data was pulled and aggregated by a senior healthcare analyst at Madigan Army Medical Center with access to M2. A de-identified copy was provided to the research team as list of single-person visits within the healthcare system for every patient that met the criteria, and during the full period of surveillance.
We followed the REporting of studies Conducted using Observational Routinely-collected Data (RECORD)  extension of the Strengthening of Reporting of OBservational studies in Epidemiology (STROBE) to improve our reporting during our restructuring of the data from the M2. The RECORD statement has utility when determining the use of codes and algorithms to identify populations, exposures, and outcomes, and the use of routinely collected healthcare data. 
Description of providers delivering manipulative treatment Typical providers of manipulation in the MHS include osteopathic physicians (DO), chiropractors (DC), and physical therapists (DPT). The DOs reside mostly in primary re clinics, such as the Family Medicine Department, but also work in specialty care as
physiatrists in the Department of Physical Medicine & Rehabilitation (PMR). The DCs and PTs in this particular hospital, can also fall under this department (PMR) as a specialty care service. At Madigan Army Medical Center, all 3 worked together in the Department of PMR. To capture all manipulation events, we included visits to these 3 specialty care clinics in addition to the Family Medicine clinic within this hospital.
Definition of manipulative treatment
Manipulative treatment involves primary use of the hands to assess and treat a patient, and is used most often as an intervention for musculoskeletal disorders. The terminology varies between disciplines and even within disciplines, but includes the labels of manual therapy, mobilization, manual stretching, contract-relax, and manipulation techniques. The American Osteopathic Association defines osteopathic manipulative
treatment as “involving the use of hands to diagnose, treat, and prevent illness or injury” (osteopathic.org). The American Physical Therapy Association uses the term manipulation and mobilization interchangeably, and defines it as “comprising a continuum of skilled passive movements to the joints and/or related soft tissue that are applied at varying speeds and amplitudes, including a small-amplitude/ high- velocity
therapeutic movement” (apta.org). We identified Current Procedural 187 Terminology (CPT) codes that represent these treatments within all three disciplines: 97140, 98925 to 98929, and 98940 to 98943. We abstracted any encounters that included a manipulative treatment code during the 1–year period following initial diagnosis. These manipulation codes are not clinician-specific. The chiropractic codes are used exclusively
by the DCs, however the Osteopathic Manipulation Therapy (OMT) codes are used and found in encounters by both DOs and PTs.
Manipulative treatment codes occurring with a spine or a shoulder diagnosis, were recorded as frequency counts for each patient, and overall utilization rates were calculated as the percentage of total patients seeking care that received at least one manipulation intervention during the 12 months after initial diagnosis in primary care. Rates were compared between provider type and by body region (lumbar, thoracic, cervical, and shoulder). Overlap of diagnoses were also reported, as many individuals had a qualifying diagnosis in more than one region. Demographic and medication use was also reported descriptively. Medications included non-steroidal anti-inflammatory (NSAID) and opiate-based pain medication using the ACSF therapeutic class codes
280802 and 280808/280812 respectively. We also looked at cases that received manipulative treatment from more than one provider type. Finally, we looked at the occurrence of any serious adverse events based on ICD9 codes that occurred after a manipulative treatment visit (Table 1).
The project was approved by the Army Western Regional Medical Command Institutional Review Board.
Out of a total of 7,566 patients presenting to primary care for initial assessment of a shoulder or spine condition during this 1–year period, 2,014 (26.6%) unique patients received manipulative treatment in any location, and 1883 received it in a military clinic. (Figure 1). Most of the patients were active duty service members (N = 1277, 67.8%).). Demographic information is outlined in Table 2. Thoracic spine diagnoses had the highest rate of manipulative treatment utilization (50.2%) while the shoulder had the least
20.7% (Table 2).
While the slight majority of patients in this cohort had only 1 body region involved (56.9%), almost half had multiple body region involvement (Figure 2). The lumbar spine was the most common singly-involved region (N = 663; 35.2%) and the thoracic spine was the least common singly-involved (N = 80; 4.2%).
Manipulative Treatment Coding
There was a total of 5,817 unique medical visits with a manipulative treatment procedure code. Most procedure codes utilized were osteopathic, followed by chiropractic (Figure 3). The overlap in codes likely reflects the patients that saw multiple providers for manipulative treatment, but also reflects a variation in coding patterns as 1,122 visits (19.3%) included both a chiropractic and osteopathic manipulation procedure code (Figure 3). This means some providers were using multiple codes, 233 and for 262 visits
234 (4.5%), all three different codes were used on the same visit.
Medical Provider Type
Of the total 5,817 unique medical visits with a manipulative treatment procedure, the majority were with a chiropractor (N = 3,172; 54.5%). Figure 4 reflects the overlap between patients receiving manipulative treatment from multiple providers. For example, 14.4% of patients received manipulative treatment from both physicians and chiropractors, 7.7% from both chiropractors and physical therapists,
and 3.4% of patients received manipulative treatment from all 3 providers (Figure 4).
As shown previously, many patients were receiving care for disorders in multiple body regions (Figure 2), but the type of provider seen also varied depending on the body region. For patients with a lumbar spine disorder, the majority saw a physician (46.4% compared to, but for patients with shoulder disorders, the majority saw a physical therapist (Figure 5).
No diagnosis codes representing the adverse events in Table 1 were identified within 30 days of a manipulative treatment visit.
Manipulative treatment for shoulder and spine disorders appears to be utilized frequently
by various providers within this large MHS hospital. There are very few reports of utilization in other settings, making it difficult to make comparisons. While survey findings have indicated high rates of manual therapy by physical therapists and chiropractors,  this is also the first report comparing actual utilization between different provider types in the same setting.
Current clinical practice guidelines and recent systematic reviews recommend the use of manipulative treatment for spine and shoulder disorders. [4, 5, 13] Multiple trials and systematic reviews have also demonstrated the value of manipulative treatment for managing shoulder pain, both to shoulder joints (glenohumeral, acromioclavicular, scapulothoracic, and sternoclavicular) as well as to the thoracic spine. [5, 6, 14] Over a dozen countries, including the United States, have published national clinical practice guidelines and the majority include spinal manipulation as a recommended or optional treatment for low back pain.  The Department of Defense (DoD) and Veterans Administration (VA) endorses the clinical practice guidelines modified from the ACP and APA.  These recommend the use of spinal manipulation for the treatment of low back pain. Interestingly, while the large majority of the evidence to support manipulative treatment is with respect to the lumbar spine, a higher percentage of patients with cervical and thoracic spine disorders received manipulative treatment compared to those with lumbar spine diagnoses. While these findings demonstrate that 27.8% of all patient with lumbar disorders received manipulative treatment during this 1 year, and that 46.4% of these patients received their manipulative treatment from a physician, it is difficult to determine compliance with practice guidelines. This may reflect training, comfort of provider with techniques, patient preference, or provider beliefs on efficacy compared to competing treatments. Clinical practice guidelines also attempt to place recommendations for spinal manipulation into context with other treatments, and weigh the evidence for acute versus chronic conditions. These are variables beyond the scope of extraction from the M2 healthcare utilization database.
Provider utilization of manipulative treatment varied by body region. The use of this treatment may seem more intuitive for the spine, reflecting why physicians and chiropractors utilized the treatment the most in that body region. Physicians may also have had the highest rate of utilization because they also see most patients. Not every patient would be referred to a chiropractor or physical therapist, likely making the rate of utilization based on number of actual patients seen by chiropractors and physical therapists much higher. However, for the shoulder, physical therapists delivered a large majority (49.1%) of the manipulative treatment for shoulder conditions. This was by far the largest discrepancy between providers for all body regions, and may be due to the high propensity of literature for its use in the shoulder conducted by physical therapists (Figure 3). [15, 16]
It is unknown if manual therapy utilization is changing for these conditions. There has recently been a concern with the decline of manipulative treatment in osteopathic medicine. [17, 18] Frazer and colleagues were able to track changes in the use of manual therapy for treatment of plantar fasciitis using a large claims database.  They were able to show a year-to-year increase over a 5 year period. However, these analyses were not found for other body regions, and these types of comparison are not possible without baseline data. There is a dearth of literature providing utilization rates for manual therapy in the management of musculoskeletal disorders. A better understanding of the implementation of guideline-based treatment is needed, but begins with identifying utilization rates. In theory, utilization trends should align with current recommendations.
There were more patients in this cohort with multiple body region involvement than single-region involvement (Figure 2), and it was not possible to tell if the manipulative treatment was directed at a single or multiple body regions. However, treatment of one region can positively affect adjacent regions, [20–22] and therefore it may not be appropriate to try and compartmentalize the exact location of treatment. Multiple body region involvement may also reflect the complexity of patients receiving manipulative treatment. Potentially patients with broader region pain conditions represent more chronic and complex conditions. [23–25] These may be conditions where manipulative treatment is considered and incorporated further downstream in the overall clinical pathway, after other treatments have failed. The chronicity is evidenced by the pain medication prescription patterns in this cohort. Opiates are usually not recommended as the initial medication management approach for most musculoskeletal disorders. However, the use of opiate medication ranged from 60.1% of thoracic spine to 83.1% of the shoulder patients (Table 2). Duration of symptoms, and therefore chronicity, was unknown for this cohort.
Most patients did not receive manipulative treatment as the initial treatment strategy, as the median day to the first manipulative treatment ranged from 32 days or the thoracic spine to 78 days for the shoulder. Timing of care can be an important variable that influences prognosis and recovery. Specifically for low back pain, early treatment within 14 days of initial primary care visit, to include manual therapy, has been shown to improve downstream healthcare utilization and costs at 18 months.  Spinal manipulation when delivered within 14 days of initial onset of symptoms also increases the likelihood of improved outcomes. [27, 28] An understanding of current timing of care within hospital settings can be helpful in determining whether standards of care can be improved and whether outcomes change based on timing.
Now that incidence rates have been described within this setting, further research is needed to determine if these rates are representative of practice patterns across the MHS. Prospective studies with clinically meaningful outcomes are also needed to understand outcomes related to timing of manipulative treatment, comparison with pain medication to include opiates, and barriers to utilization between various disciplines.
There are several limitations to this study. First, all data of this nature is subject to the accuracy of how it was entered into the electronic medical records. It is also not possible to identify the exact anatomical region for manipulation procedure delivery. For example, if a manipulation procedure code and a cervical diagnosis code were entered into the documentation for the same visit, it was not possible to confirm that the manipulation occurred in the cervical spine versus the thoracic spine. Both areas can be treated for neck
disorders. However, as discussed earlier, treatment in one area can positively affect an adjacent area.  Finally, these findings represent 1 military hospital, and may not
necessarily reflect patterns of care in other military, VA, or civilian hospitals.
Manipulative treatment is used often in management of spine and shoulder disorders within the MHS by physicians, physical therapists, and chiropractors alike. Initial manipulative treatment usually does not occur until at least 30 days after initial consultation, and most patients that receive this treatment have multi-site involvement of symptoms. Future research is needed to evaluate this process on a larger cohort with
broader demographics, and evaluate downstream healthcare utilization and patient reported outcomes in those that receive manipulative treatment compared to those that do not.
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