Manipulation has been a component of physical therapy practice since the inception of the profession.1 The level of research evidence to support the use of manipulation is greater than most other interventions that physical therapists (PTs) use, especially for treatment of acute low back pain (LBP). Unfortunately, having research evidence available to support an intervention does not always result in its implementation. Reports of practice patterns both in the United States and abroad suggest that spinal manipulation is underutilized by PTs.2,3 

In an effort to implement evidence-based clinical practice guidelines for the use of manipulation, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) has collaborated with the American Physical Therapy Association (APTA) to develop resources to enhance the level of instruction of manipulation in physical therapy professional education.4 The purpose of this article is to provide a sample of the research on manipulation, to explain why manipulation must be included in professional physical therapy education, and to describe the measures taken by the AAOMPT and the APTA to enhance the level of instruction of manipulation within physical therapy education.

Evidence for the Effectiveness of Manipulation

The strongest research support for the safe and effective use of manipulation is in the treatment of patients with acute LBP. Numerous independent agencies have conducted systematic reviews of the literature to develop clinical-practice guidelines based on the strength of the evidence and have concluded that spinal manipulation is a safe, effective intervention for the management of acute LBP.5-8 In fact, spinal manipulation received the highest level of evidence awarded any intervention for the treatment of LBP in the 1994 Agency for Health Care Policy and Research Guidelines, which was the first clinical practice guideline to recommend the use of manipulation in the care of acute LBP.6

The level of research evidence to support the use of manipulation by PTs for the treatment of acute LBP has recently been further strengthened by the publication of an article by Childs et al9 in the Annals of Internal Medicine. The article regarded a randomized control trial that validated the clinical-prediction rule for use of manipulation for acute LBP. The clinical prediction rule, first developed by Flynn et al,10 is a set of five criteria that were determined to predict successful outcome from a lumbopelvic manipulation when at least four of the five criteria were met in the patient-examination findings.

In Child’s study, 131 patients with acute LBP, 18 to 60 years of age, who were referred to a PT, were examined. Patients were randomly assigned to receive physical therapy that included two sessions of high-velocity thrust spinal manipulation plus an exercise program (manipulation + exercise group), or an exercise program without spinal manipulation (exercise-only group).9 During the first two sessions, patients in the manipulation + exercise group received high-velocity thrust manipulation and range-of-motion exercise. Patients in the exercise-only group were treated with a low-stress aerobic and lumbar spine-strengthening program. Patients in both groups underwent physical therapy twice during the first week and then once per week for the next 3 weeks, for a total of five sessions.

The patients who were positive for the clinical-prediction rule for manipulation and received the manipulation intervention (manipulation + exercise group) had dramatic improvements in pain and disability after 1 week, after 4 weeks, and at 6 months.9 The statistical analysis revealed that patients who were positive for the clinical-prediction rule and received the thrust spinal manipulation had a 92% chance of achieving a successful outcome at the end of 1 week.9 At the 6-month follow-up, patients who did not receive spinal manipulation demonstrated significantly greater use of medication, health care utilization, and lost time from work due to LBP than did the manipulation group.9 

Evidence is also mounting for the use of manipulation in the management of patients with pain in other spinal regions and for extremity conditions11-13; however, the strength of the evidence is not quite as strong as the evidence for acute LBP at this time. The research evidence for the management of cervical spine disorders recommends a multimodular approach that combines the use of manual therapy procedures and specific exercises.14,15 The use of nonthrust-manipulation techniques seems to have as great a level of support in the literature for treating cervical spine disorders as the use of thrust-manipulation techniques.14,15 This is contrary to the lumbar and lumbopelvic region, where the majority of the evidence is for the use of thrust manipulation.

Epidemiological research demonstrates that individuals with lumbo/pelvic, cervical, shoulder, and knee sprains/strains/conditions represent the largest patient population seeking outpatient physical therapy services.16-19 Research supports the use of manipulation for each of these diagnostic conditions. Since a large number of physical therapy graduates expect to work in outpatient settings, the inclusion of manipulation in the didactic and clinical education experiences of physical therapy students is highly recommended, especially if the profession is to embrace evidence-based practice.

Professional Consensus Documents

The Guide to Physical Therapist Practice makes it clear that manipulation is within the scope of physical therapy practice.20 Mobilization/manipulation is defined in the Guide to Physical Therapist Practice as, “A manual therapy technique 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.”20

Since the terms “manipulation” and “mobilization” are used interchangeably, the term “manipulation” is used in APTA and AAOMPT documents to refer to both thrust and nonthrust techniques. Thrust manipulation has recently been defined as “High-velocity, low-amplitude therapeutic movement within or at end range of motion.”4

 The Normative Model of Physical Therapist Professional Education: Version 200021 includes manipulation as an intervention that should be taught in professional physical therapy education. In addition, manipulation is a component of several evaluative criteria used by the Commission on Accreditation for Physical Therapist Education (CAPTE) for the accreditation of physical therapy education programs.22 In October 2004, the CAPTE adopted new evaluative criteria that will go into effect January 1, 2006, which states (Under CC-5.39: Patient/Client Management Expectation) that both thrust- and nonthrust-manipulation techniques must be included in the curriculum of physical therapy professional education programs.

While survey data show that manipulation in some form has been included in professional physical therapy curricula since at least the 1970s and has steadily increased,23 a 2002 survey suggested that more than 50% of the professional physical therapy education programs did not teach thrust-manipulation techniques.24

Collaboration for Manipulation Education

In early 2003, the APTA and the AAOMPT teamed up to form the Manipulation Education Committee. Its purpose was to develop and initiate strategies to support and facilitate manipulation instruction in professional physical therapy education programs and to heighten awareness among academic faculty of legislative and regulatory issues associated with manipulation instruction in professional physical therapy programs.4 The committee, chaired by Trish King, included PTs with extensive experience in manual physical therapy research, practice, and education. Members were supported by and represented the following organizations: the AAOMPT, the APTA Orthopaedic Section, and the APTA Education Section. They included: Trish King (chair), Richard Erhard, Timothy Flynn, Catherine Patla, Stanley Paris, Robert Rowe, Barbara Sanders, Phil Sizer, Marcie Swift, Robert Wainner, Melissa Wolff-Burke, Bill Boissonnault, and myself. Justin Elliott, associate director-state relations of APTA’s department of state governmental affairs, was the APTA staff member who helped coordinate the committee’s activities; the APTA education department also provided input.

The committee’s view is that the curriculum of professional physical therapy education programs must embrace the entire continuum of manipulative procedures, including thrust manipulation for the spine and extremities. There are several reasons for this view, which include: evidence for the safety and effectiveness of manipulation, consistency and compliance with current physical therapy education program standards, the preparation of graduates to practice in accordance with The Guide to Physical Therapist Practice,20 and legislative/regulatory defense of PTs’ scope of practice.

The committee developed, distributed, and educated the physical therapy community about the Manipulation Education Manual (MEM).4 The MEM includes chapters on the background of legislative and regulatory issues related to manipulation, educational and practice standards, and evidence supporting manipulation.4 Additional chapters include curriculum resources that provide sample instructional materials such as course syllabi objectives, sample practical examinations and evaluative materials, and sample illustrations of thrust-manipulation techniques that are commonly taught in professional physical therapy education programs.4 The MEM does not make recommendations on which techniques should be taught, but rather offers manipulation techniques as sample instructional materials. An instructional resource list and instructor qualifications for teaching manipulation are included, as well as educational opportunities and professional resources available for instructors to enhance their level of knowledge and skill in manipulation. A copy of the MEM can be obtained by contacting the APTA department of state governmental affairs.

The MEM was published by the APTA and sent to all CAPTE-accredited physical therapy education programs in summer 2004. Committee members conducted educational programming on this topic at multiple APTA and AAOMPT conferences throughout 2003, 2004, and 2005. A course on teaching manipulation and using the MEM was also developed for PT educators and clinical instructors, and it continues to be offered and coordinated by the AAOMPT.

The MEM has had an impact, as noted in the follow-up online survey of academic faculty who teach the musculoskeletal curriculum in the more than 200 physical therapy education programs in the United States. The survey, conducted in late 2004, found that faculty from 18 of the 45 programs who responded reported that their time spent on thrust manipulation in the curriculum as a result of the MEM increased.25 Faculty from an additional 22 programs reported that they already were including thrust manipulation in their curriculum.25 Therefore, following the work of this committee, 89% of the programs who responded now include thrust manipulation in their curriculum.

In conclusion, a growing body of research evidence supports the inclusion of the entire continuum of manipulation procedures in the scope of practice and education of PTs. For PTs to practice evidence-based physical therapy to manage musculoskeletal disorders, they must continue to strive to refine the practice, education, and regulatory protection of manual physical therapy–including thrust manipulation. The AAOMPT and the APTA have taken the lead in enhancing the level of manipulation instruction in physical therapy education, and the development of the Manipulation Education Manual has been a useful resource for the physical therapy clinical and education community.

Kenneth A. Olson, PT, DHSc, OCS, FAAOMPT, is currently the president of the American Academy of Orthopaedic Manual Physical Therapists. He is also the president and managing partner of Northern Rehabilitation and Sports Medicine Associates in DeKalb, Ill, a private physical therapy practice. In addition, he serves as a mentor in the University of St Augustine, St Augustine, Fla, Manual Physical Therapy Fellowship program, and is a part-time faculty member at Northern Illinois University, DeKalb, Ill, and Marquette University, Milwaukee, where he teaches courses on spinal and extremity manipulation.

References

1. Paris S. A history of manipulative therapy through the ages and up to the current controversy in the United States. J Man Manip Ther. 2000;8:66­–77.

2. Gracey JH, McDonough SM, Baxter GD. Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. Spine. 2002;27:406–411.

3. Jette AM, Delitto A. Physical therapy treatment choices for musculoskeletal impairments. Phys Ther. 1997;77:145–154.

4. American Physical Therapy Association, American Academy of Orthopaedic Manual Physical Therapists. Manipulation Education Manual. Alexandria, Va: APTA. 2004.

5. DoD/VA, ed. DoD/VA Low Back Pain Guidelines. 1999. Available at: http://www.qmo.amedd.army.mil/lbpfr.htm. Accessed June 1, 2004.

6. Bigos S, Bowyer R, Braen GR, et al. Acute Low Back Problems in Adults. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1994.

7. Wellington, NZ, ACC, and National Health Committee, ed. New Zealand Acute Low Back Pain Guide. 1997. Available at: http: //www.nzgg.org.nz/library/gl_complete/backpain1/index.cfm#contents. Accessed June 1, 2004.

8. Waddell G, Feder G, McIntosh A. Low Back Pain Evidence Review. London: Royal College of General Practitioners; 1999. Available at: http: //www.rcgp.org.uk/rcgp/clinspec/guidelines/backpain/backpain5.asp#Guideline. Accessed June 1, 2004.

9. Childs J, Fritz J, Flynn T, et al. A clinical prediction rule to identify patients with low back pain most likely to respond to spinal manipulation: A validation study. Ann Intern Med. 2004;141:922–928.

10. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843.

11. Hoving JL, Koes BW, de Vet HC, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Ann Int Med. 2002;136:713–722.

12. Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation along a randomized controlled trial. BMJ. 2003;326:911.

13. Wainner RS, Flynn TW, Whitman JW. Spinal and Extremity Manipulation: The Basic Skill Set for Physical Therapists; Integrating Technical Application with the Current Best Evidence. Fort Collins, CO: Manipulations, Inc; 2001. Available at: http: //hstat.nlm.nih.gov/hq/ Hquest/screen/BySubject/s/59946. Accessed June 1, 2004.

14. Jull G, Potter H, Niere K, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27:1835–1843.

15. Aker P, Bronfort G, Goldsmith CH, et al. A cochrane review of manipulation and mobilization for mechanical neck disorders. Spine. 2004;29:1541–1548.

16. Boissonnault WG. Prevalence of comorbid conditions, surgeries, and medication use in a physical therapy outpatient population: a multicentered study. J Orthop Sports Phys Ther. 1999;29: 506–519.

17. Di Fabio RP, Boissonnault W. Physical therapy and health-related outcomes for patients with common orthopaedic diagnoses. J Orthop Sports Phys Ther. 1998;27:219–230.

18. Jette AM, Davis KD. A comparison of hospital-based and private outpatient physical therapy practices. Phys Ther. 1991;71: 366–375.

19. Davis KD, Haley SM, Jette AM. Physical therapy episodes of care for patients with low back pain. Phys Ther. 1994;74: 101–110.

20. American Physical Therapy Association. Guide to physical therapist practice. Phys Ther. 2001;81:9–746.

21. American Physical Therapy Association Division AE, ed. A Normative Model of Physical Therapist Professional Education. Alexandria, Va: American Physical Therapy Association; 2000.

22. Commission on Accreditation in Physical Therapy Education (CAPTE), ed. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, Va: American Physical Therapy Association; 1998.

23. Bryan JM; Finstuen K, McClune LD. Spinal mobilization curricula in professional physical therapy education programs. JOPTE. 1997;11:11–15.

24. Boissonnault WG, Bryan JM, Fox K. Joint manipulation curricula in first professional physical therapist education programs. J Orthop Sports Phys Ther. 2004;34:171–181.

25. Olson KA. Message from the American Academy of Orthopaedic Manual Physical Therapists President: Accomplishments and Appreciation. Articulations. September/October 2004.