Chiropractors, therapists keep battling.

LITTLE ROCK PHYSICAL THERapist Michael Teston has found himself in the middle of the latest war between chiropractors and physical therapists.

In December, the Arkansas State Board of Chiropractic Examiners brought Teston up on charges that he was acting as a chiropractor when he treated patients, including one patient who was an under-cover private investigator hired by the board.

Teston had been cleared of the same charges in October by the Arkansas State Board of Physical Therapy, who said what he did was clearly physical therapy.

The chiropractic examiners, though, thought otherwise. They fined Teston $10,000 for practicing chiropractic without a license.

Teston appealed the Chiropractic Board's ruling to the Pulaski County Circuit Court, where the case is pending.

While physical therapists and chiropractors have been snapping at each other for years, Teston's case marked the first time in Arkansas' that a physical therapist had been fined by the Chiropractic Board over his technique.

Physical therapists think the launch of the attack is a way to acquire more market share among patients who have bad backs.

The Chiropractic Board's order "takes away from all physical therapists, not just Mr. Teston, the right to perform spinal 'mobilizations' on their patients, notwithstanding the fact that physical therapists are specifically authorized to perform 'mobilizations' under the Physical Therapy Act," Teston's attorneys, John Gill and Derrick Davidson of Gill Elrod Ragon Owen & Sherman P.A. of Little Rock, said in court filings. "This case involves critical issues that have broad implications in a turf war that persists between chiropractors and physical therapists."

Back to Basics

Working with patients' backs is a large part of a physical therapist's practice, said Sam Denton, Arkansas Physical Therapy Association president.

Denton didn't know how much revenue the bad-back treatments generate, but if the ruling is upheld, "it could crunch some people," he said.

To help the legal fight, the National Physical Therapy Association and Arkansas Physical Therapy Association are assisting with Teston's legal bills, Denton said.

The Arkansas Chiropractic Association is also watching the lawsuit.

"That is [an] important battleground, and if it becomes necessary for the profession to support the legal battle there, we must be ready to do so," according to the association's Web site.

While the Arkansas State Board of Chiropractic Examiners declined to comment, the Arkansas Chiropractic Association said physical therapists can still work with the back.

"They are not to manipulate any bones of the body," said Dr. Scott Schuck, president of the Arkansas Chiropractic Association. "We felt that with the information that the chiropractic examiners had that it was obvious that (Teston) was doing something that was out of his scope of practice."

Schuck said while some chiropractors may view the case as a battle for market share of bad back injuries, he sees it as a question of training.

Case Develops

When Katherine Fryar's car slid off an icy road and hit a tree in January 2001, the Southwest Airlines reservations agent reported suffering from neck and back pain.

Fryar scheduled an appointment with her doctor, who, after examining her, referred her to Teston, who has 20 years of physical therapy experience.

At Teston's Touchstone Physical Therapy in Little Rock, Fryar said she received back treatments included "popping my cervical, thoracic and lumbar regions of the spine."

But after three months of treatments, Fryar stopped seeing Teston in April 2001, as her condition worsened.

"I reached the point that I was unable to work," she said in a handwritten one-page letter to the Chiropractic Board dated May 13, 2002, more than a year after receiving treatment.

"I am concerned not only for the treatment I received but also for that of other patients," she wrote. "The exam rooms are separated by drapes and I was aware of several occasions that other patients were having their spine manipulated."

When the Chiropractic Board received the letter on May 21, 2002, it dived into an investigation. The Chiropractic Board hired private investigator Dennis Hendrix to go to the clinic, pose as a patient with back pain and report what happened.

Hendrix said in his report to the board that Teston turned his upper torso "creating a snapping or popping sensation emanating from my spine." Teston told him that the popping and snapping sensation was "joint mobilization."

The case against Teston would hinge on the definitions of mobilization and manipulation.

Physical therapists can administer mobilizations, which are passive movements, but are prohibited from performing manipulations, which involve a more forceful movement.

"The terms, however, are not defined and distinguished in any meaningful way in the Chiropractic Act," said Teston's attorneys, Gill and Davidson, in court filings. "As a result, when it comes to these treatments, Mr. Teston and other physical therapists cannot determine what treatments they are permitted and prohibited from performing."

Teston's attorney at the time, Mark Hodge of Little Rock, said his client didn't practice chiropractic.

"At worst for my client is that you have a law that's too vague and nobody can tell what they're allowed to do," Hodge said.

The chiropractic examiners investigated the allegations, as did the Arkansas State Board of Physical Therapy.

The physicaltherapy board found the treatments Teston used were within the scope of the practice of physical therapy.

"The physical therapy treatments included soft tissue mobilization, cold packs, hot packs, therapeutic exercise and neuromuscular re-education," the physical therapy board's order dated Oct. 17 said.

Still, the chiropractic examiners moved ahead with a hearing.

During the hearing, Fryar testified that Teston put her in "kind of like a wrestling hold" and put pressure on the spine and the joint popped.

"He would feel my vertebrae and determine where he felt was the problem, put his hand there," Fryar testified. "I would cross my hands over my chest and lay down over his hand and would feel--hear a popping sound, feel the movement of the vertebrae."

A witness for the Chiropractic Board, Edward Brian Ashton of Maryland who is a licensed physical therapist and holds a doctor of chiropractic degree, said when a person hears a pop or a crack in his back, it is considered a spinal manipulation. But he added that he didn't read the Arkansas Chiropractic Act.

After 20 minutes of deliberations, the board ruled Teston's treatments for both Fryar and Hendrix were chiropractic.

"The board finds that the maneuvers described by (Fryar) were spinal manipulations which can only be performed by licensed Chiropractors in the state of Arkansas," the chiropractor's order said.

Teston's attorneys have asked a Pulaski County Circuit Court judge to throw the order out.

"The order violates the Chiropractic [Practices] Act that grants physical therapists, like Mr. Teston, an exemption from the definition of the practice of chiropractic," Gill and Davidson said in court papers. They also said the act is unconstitutional because it is vague, ambiguous and overly broad.

Reaction

The ruling sent shock waves through the physical therapy profession.

Teston was doing what he was trained to do, said Jim Farris, interim director for the physical therapy program at Arkansas State University at Jonesboro.

"Our graduates are fully qualified to treat any ailment of the spine," he said.

As a result of the ruling, the Arkansas Physical Therapy Association pushed for--and received--new state legislation limiting the investigative authority of state regulatory boards. The legislation now calls for a health care worker only to be investigated by the board that issues the worker's license.

The Arkansas Chiropractic Legislative Council blasted the move.

"This very well may be chiropractic's worst defeat in several years," an undated Arkansas Chiropractic Legislative Council newsletter said. "This act makes it more difficult for our board to police and protect our profession concerning scope of practice from licensees of other health care boards."

But the Arkansas Chiropractic Association supported the bill.

"This bill is not chiropractic specific and affects all health care licensing boards in the same fashion," the association's Web site said.

Still, chiropractors and physical therapists have had a ongoing feud over who can do what.

For years, people thought chiropractors only cracked backs and their practice was quackery, said Dr. Jerome F. McAndrews, spokesman for the American Chiropractic Association.

But that perception has been changing during the past 20 years.

More doctors are referring patients to chiropractors when they were sending them to physical therapists, he said.

Schuck, president of the Arkansas Chiropractic Association, said chiropractors go through extensive studies on the anatomy of the spine and how to properly manipulate the spine.

And other states allow physical therapists to do what chiropractors do, he said.

"But their training doesn't allow them to do it as well and get the results," Schuck said. "And in the end that's what's important to the patients, getting better."