Joint Mobilization And The PTA: Much Ado Over Nothing?

It has become a hot topic in the world of physical therapy: the role of the physical therapist assistant (PTA) in joint mobilization. It appears to be a growing point of contention and divisiveness within the profession. Surprised? Not I.

Physical therapists will claim that joint mobilization requires advanced training and clinical skills that are not, nor should be, a part of PTA practice or education. I find this whole issue, and the roots to it, annoying at best. The profession once again finds itself facing an issue that drains energy from the unity and clarity of vision that our profession both needs and deserves.

Let me give you some real-world examples of why this debate has become mildly ridiculous – and how the voice of reason can return some sanity to the equation.

Joint mobilization is the process of taking a joint to various points in its range of motion passively. It typically employs gliding motions of the joint surfaces up to the end range of the joint itself. At that point, a mobilization becomes a manipulation, which then utilizes a high velocity, low amplitude thrust. Keep in mind that nobody is debating the issue of manipulation. Training in manipulation is purely within the scope of physical therapist education. But that isn’t of question, nor is it something that PTAs are taking issue with whatsoever. The problem: should a PTA be performing a joint mobilization - or not?

Let’s examine the issue from a slightly different, yet highly relevant, perspective.

Does a patient have the capacity to take their own joint (or joints) to end range passively? Are they capable of monitoring symptomatic and mechanical responses to repeated end range movements? The answer: absolutely. We ask them to do so on a daily basis, and have no apprehension in doing so. We really don’t even think twice about it.

So if a patient is capable of doing so – and doing so in a highly effective and independent fashion – then why is a PTA incapable of doing so? A PTA has more training, even at baseline, than the average patient. If there was still a concern, could a PTA complete sufficient training to do so? Absolutely.

PTAs are taught to monitor changes in signs and symptoms with exercise and other treatment interventions. This feedback is then provided to the supervising PT. What makes joint mobilization any different?

Listen, off in the distance – the hue and cry is beginning. Here are but a few samples of the rationale that you will certainly hear:

“PTAs don’t have the knowledge of biomechanics and kinematics required”. Well, sadly, the issue of joint kinematics is inundated with hypothetical constructs of slide, glide and spin that may – or may not – even be relevant or consistent – PT, PTA, biomechanist, or otherwise.

“PTAs aren’t as safe in performing joint mobilizations”. Well, you seem to be pretty comfortable allowing PTAs to work in an acute care setting with lines, monitors, and potentially life-threatening issues – just don’t ask them to passively move a joint to end range and monitor symptom response. Seriously?

“PTAs don’t have the training in specific mobilization techniques”. Interestingly enough, we are now finding that generalized mobilizations do as well clinically as specific techniques, and that mobilization may in fact provide the same (or better) response than manipulation! If we can teach patients to do it – and do so effectively – then what makes it such an audacious activity for a PTA?

I suspect this is all much ado over nothing in the big scheme of things, especially when we consider the significant issues that face our profession in the health care world these days. So where does the solution lie? A true understanding of the meaning of professional autonomy. More on that in an upcoming post.

Photo credits: GabrielaP93