To the Editor:

We are writing to discuss a matter of importance to the physical therapy profession, namely, the practice of spinal manipulation by physical therapists. We are concerned by the attempts of other disciplines to introduce legislation that would exclude spinal manipulation from physical therapy state practice acts.1,2 Having reviewed 2 often-cited publications concerning spinal manipulation, we have found strong support for spinal manipulation being part of the professional practice of chiropractors, medical doctors, osteopaths, and physical therapists, rather than being the exclusive domain of any one of these professions.

The American Physical Therapy Association's Guide to Physical Therapist Practice includes this description of manual physical therapy: Manual therapy techniques consist of a broad group of skilled hand movements, including but not limited to mobilization and manipulation, used by the physical therapist to mobilize or manipulate soft tissues and joints for the purpose of modulating pain; increasing joint range of motion (ROM); reducing or eliminating soft tissue swelling, inflammation, or restriction; inducing relaxation; improving contractile and noncontractile tissue extensibility; and improving pulmonary function. These interventions involve a variety of techniques, such as the application of graded forces.3(p3-9)

This statement describes a generally accepted, broadly defined element of physical therapist practice and is inclusive of a more specific element of physical therapist practice: spinal manipulation. The American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) recognizes a nearly identical definition of manual therapy.4

The spinal manipulation literature includes 2 landmark publications: Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14,5 and The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review.6 These documents together cite 27 reports of clinical trials of spinal manipulation. The Agency for Health Care Policy and Research (AHCPR), which produced the former publication, was an agency of the US Department of Health and Human Services5 and today is known as the Agency for Healthcare Research and Quality (AHRQ). RAND, a nonprofit research institution, produced the latter publication with support from the National Institutes of Health, the Consortium for Chiropractic Research, and the Foundation for Chiropractic Education and Research.6

In reviewing the AHCPR5 and RAND6 documents and the 27 cited reports of clinical trials,733 we noted that a variety of health care professionals served on the expert panels that evaluated clinical trials of spinal manipulation. We believe that the multidisciplinary composition of the panels was used in an effort to protect against bias in the selection and interpretation of these clinical trials. The expert panels in the RAND and AHCPR publications adopted nearly identical definitions of spinal manipulation, and each panel used a systematic article selection process. Therefore, we considered all of the 27 reports cited. We identified the profession of those who provided spinal manipulation and control interventions for each clinical trial. Various combinations of 4 health professions (chiropractors, medical doctors, osteopaths, and physical therapists) provided the interventions for the trials, but physical therapists provided both spinal manipulation and other interventions in more clinical trials than did any other profession. For these reasons, we conclude that the AHCPR and RAND publications support spinal manipulation as being part of the professional practice of chiropractors, medical doctors, osteopaths, and physical therapists, rather than being the exclusive domain of any one of these professions.

The AHCPR review panel included physicians, nurses, chiropractors, experts in spine research, physical therapists, a psychologist, an occupational therapist, and a consumer representative.5 Two expert panels contributed to the RAND study: a multidisciplinary panel that included orthopedics, osteopathy, chiropractic, internal medicine, neurology, and family practice and an all-chiropractic panel that represented 5 chiropractic colleges and included 4 chiropractors in private practice.6

In both the AHCPR and RAND studies, systematic processes were used to review literature related to spinal manipulation, and the definitions of spinal manipulation were nearly identical. In the AHCPR clinical practice guideline, the definition was as follows: Spinal manipulation includes many different techniques. For this guideline, manipulation is defined as manual therapy in which loads are applied to the spine using short or long lever methods. The selected joint is moved to its end range of voluntary motion, followed by application of an impulse loading.5(pp34–35)

In the RAND overview, the definition stated: Manipulation encompasses many different techniques. The two most commonly used methods are nonspecific long-lever manipulations and specific short-lever, high-velocity spinal adjustments.6(p3)

The AHCPR panel received the assistance of librarians of the National Library of Medicine in applying selection criteria to a pool of 112 articles concerning spinal manipulation.5(p35) This process resulted in a final set of 13 articles reporting 12 clinical trials. The RAND expert panels identified a pool of 67 articles for possible analysis and applied selection criteria to arrive at a set of 22 reports of controlled trials of spinal manipulation.6(p3)

Together the AHCPR5 and RAND6 documents refer to 27 reports of clinical trials. Of these reports, 8 met both the AHCPR and RAND criteria for review, 15 met either the AHCPR criteria or the RAND criteria, and 4 met the RAND criteria but did not meet the AHCPR criteria. Table 1 groups the 27 reports in this manner and indicates the professions that provided the interventions for the treatment groups. The treatment groups are categorized as “spinal manipulation” and as a single “other intervention” group to represent the various control interventions included in each clinical trial. If more than one profession provided spinal manipulation in a clinical trial, each profession is listed. If a trial involved more than one control treatment group, the profession that provided each control intervention is listed. If a report did not indicate the profession of those who provided interventions, we inferred a provider's profession from the authors' professional designation or institutional affiliation, or from those of clinicians acknowledged to have participated in the trial.

Table 2 presents counts of clinical trials involving a profession's participation as provider of either “spinal manipulation” or “other intervention.” Physical therapists were the leading providers for both treatment categories. Physical therapists provided spinal manipulation in more reports of clinical trials than did medical doctors, in more than twice the number than did chiropractors, and in 4 times the number than did osteopaths. Regarding the “other intervention” treatment category, physical therapists participated as provider more often than the other 3 professions combined.

The AHCPR and RAND systematic reviews of clinical trials each led to findings and recommendations regarding spinal manipulation. In its spinal manipulation summary, the AHCPR guideline concludes:

  • Manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms.

  • When findings suggest progressive or severe neurologic deficits, an appropriate diagnostic assessment to rule out serious neurologic conditions is indicated before beginning manipulation therapy.

  • There is insufficient evidence to recommend manipulation for patients with radiculopathy.

  • A trial of manipulation in patients without radiculopathy and with symptoms lasting longer than a month is probably safe, but efficacy is unproven.

  • If manipulation has not resulted in symptom improvement that allows increased function after 1 month of treatment, manipulation therapy should be stopped and the patient reevaluated.5(p34)

Regarding the efficacy of spinal manipulation, the RAND publication states: The literature on the efficacy of spinal manipulation is of uneven quality. While many studies are randomized controlled trials, there is a great diversity in the initial selection and evaluation of patients for study, assignment of those patients to spinal manipulation or a control treatment, the type of spinal manipulation given, the type of control treatment given, and the method of assessing a response. Given that caveat, support is consistent for the use of spinal manipulation as a treatment for patients with acute low-back pain and an absence of other signs or symptoms of lower limb nerve-root involvement. Support is less clear for other indications, with the evidence for some insufficient (acute and subacute low-back pain with sciatica, acute and subacute low-back pain with minor lower limb neurologic findings, most types of chronic low back pain), while the evidence for others is conflicting (acute low-back pain with sciatica and minor lower limb neurological findings, subacute low-back pain without sciatica, and chronic low-back pain without sciatica).6(pv)

In summary, clinical trials of spinal manipulation performed by physical therapists provide the major source of evidence supporting the AHCPR and RAND findings and recommendations. However, three other professions also contributed to that evidence. The multidisciplinary expert panels that produced the AHCPR and RAND documents recognized spinal manipulation to include many different techniques, including both long-lever and short-lever, high-velocity methods. Most importantly, these landmark publications support spinal manipulation as being part of the professional practice of chiropractors, medical doctors, osteopaths, and physical therapists, rather than being the exclusive domain of any of these professions.

Table 1.

Profession of Those Who Provided Spinal Manipulation or Other Intervention in Reports of Clinical Trials Cited by Agency for Health Care Policy and Research (AHCPR)5 or RAND6 Documents or by Both Documentsa

Table 2.

Counts of Cited Reports of Clinical Trials of Spinal Manipulation, Listed by Profession That Provided Spinal Manipulation or Other Intervention.a


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