Spinal Manipulation.

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(p 3-9)]

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.[1]

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 Services[5] 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 AHCPR[5] and RAND[6] documents and the 27 cited reports of clinical trials,[7-33] 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 doctor, 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 AHCPR[5] and RAND[6] 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 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 RAND[6] Documents or by Both Documents(a)

                             Spinal         Other
  Primary Author             Manipulation   Intervention

Cited by both AHCPR[5]
 and RAND[6] (n=B):
  Bergquist-Ullman[7]        PT             PT
  Coxhead[8]                 PT             PT
  Farrell[9]                 PT             PT
  Gibson[10]                 OS             PT
  Glover[11]                 MD             PT
  Godfrey[12]                DC or MD       PT
  Hadler[13]                 MD             MD (thrust excluded)
  Mathews[14]                PT             MD, PT

Cited by either AHCPR[5]
 or RAND[6] (n= 15):
  Arkuszewski[15],(b)        MD             MD
  Brodin[16]                 MD             MD
  Doran[17]                  MD or OS       MD, PT
  Evans[18]                  MD             MD
  Hoehler[19]                MD             MD
  MacDonald[20]              OS             OS
  Mathews[21],(c)            PT             PT
  Meade[22]                  DC             PT (manipulation
                                             allowed)
  Meade[23]                  DC             PT (manipulation
                                             allowed)
  Ongley[24]                 MD             MD (torsion excluded)
  Postacchini[25]            DC             MD, PT
  Sims-Williams[26]          PT             PT
  Waagen[27]                 DC             DC (sham "adjustment")
  Waterworth[28]             PT             MD, PT
  Zylbergold[29]             PT             PT

Cited by RAND[6] but did
not meet AHCPR[5] criteria
(n=4):
  Coyer[30],(b)              PT             MD
  Edwards[31],(b)            PT             PT
  Nwuga[32],(b)              PT             PT
  Rasmussen[33]              MD or PT       PT

(a) Reprinted by permission of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). This table first appeared in Articulations. 2000;6(2). DC=chiropractor, MD=medical doctor, OS=osteopath, PT=physiotherapist/physical therapist, AHCPR=Agency for Health Care Policy and Research.

(b) Controlled trial that did not use random allocation to treatment groups.

(c) Limited report of the same controlled trial reported by Mathews.[14]

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.

Table 2. Counts of Cited Reports of Clinical Trials of Spinal Manipulation, Listed by Profession That Provided Spinal Manipulation or Other Intervention(a)

                                          Spinal         Other
                                       Manipulation   Intervention

Reports cited by both AHCPR[5]
and RAND[6] (n=8):
  Chiropractor                               1              0
  Medical doctor                             3              2
  Osteopath                                  1              0
  Physiotherapist/physical therapist         4              7

Reports cited by either AHCPR[5]
or RAND[6] (n=15):
  Chiropractor                               4              1
  Medical doctor                             6              8
  Osteopath                                  2              1
  Physiotherapist/physical therapist         4              8

Reports cited by RAND[6] that did
not meet AHCPR[5] criteria (n=4):
  Chiropractor                               0              0
  Medical doctor                             1              1
  Osteopath                                  0              0
  Physiotherapist/physical therapist         4              3

Totals for all reports cited by
either AHCPR[5] or RAND[6] or by
both (n=27):
  Chiropractor                               5              1
  Medical doctor                            10             11
  Osteopath                                  3              1
  Physiotherapist/physical therapist        12             18

(a) Reprinted by permission of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). This table first appeared in Articulations. 2000;6(2). AHCPR=Agency for Health Care Policy and Research.

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 insuficient (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.

Dave Johnson, PT, PhD, FAAOMPT Assistant Professor of Physical Therapy and of Biostatistics & Epidemiology Health Sciences Center The University of Oklahoma Oklahoma City, OK 73190 ([e-mail])

Mike Rogers, PT, OCS, OMPT, FAAOMPT Private Practitioner Rogers Orthopaedic Physical Therapy D'Iberville, MS 39532 ([e-mail])

References

[1] Wynn-Gilliam K. APTA mobilizes on manipulation. PT Magazine. 2000;8(2): 34-39.

[2] Moore J. Manipulation: still hot in the statehouse. PT Magazine. 2000;8(5):24-29.

[3] Guide to Physical Therapist Practice. Rev ed. Alexandria, Va: American Physical Therapy Association; 1999.

[4] Orthopaedic Manual Physical Therapy: A Description of Advanced Clinical Practice. Biloxi, Miss: American Academy of Orthopaedic Manual Physical Therapists; 1998.

[5] Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; December 1994. AHCPR Publication No. 95-0642.

[6] Shekelle PG, Adams AH, Chassin MR, et al. The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Santa Monica, Calif: RAND; 1991. RAND publication R-4025/1-CCR/FCER.

[7] Bergquist-Ullman M, Larsson U. Acute low back pain in industry: a controlled prospective study with special reference to therapy and confounding factors. Acta Orthop Scand. 1977;170:1-117.

[8] Coxhead CE, Inskip H, Meade TW, et al. Multicentre trial of physiotherapy in the management of sciatic symptoms. Lancet. 1981;1(8229): 1065-1068.

[9] Farrell JP, Twomey LT. Acute low back pain: comparison of two conservative treatment approaches. Med J Aust. 1982; 1:160-164.

[10] Gibson T, Grahame R, Harkness J, et al. Controlled comparison of short-wave diathermy treatment with osteopathic treatment in non-specific low back pain. Lancet. 1985; 1(8440): 1258-1261.

[11] Glover JR, Morris JG, Khosla T. Back pain: a randomized clinical trial of rotational manipulation of the trunk. Br J Ind Med. 1974;31:59-64.

[12] Godfrey CM, Morgan PP, Schatzker J. A randomized trial of manipulation for low-back pain in a medical setting. Spine. 1984;9:301-304.

[13] Hadler NM, Curtis P, Gillings DB, et al. A benefit of spinal manipulation as adjunctive therapy for acute low-back pain: a stratified controlled trial. Spine. 1987; 12:702-706.

[14] Mathews JA, Mills SB, Jenkins VM, et al. Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections. Br. J Rheumatol. 1987;26: 416-423.

[15] Arkuszewski Z. The efficacy of manual treatment in low back pain: a clinical trial. Manual Medicine. 1986;2:68-71.

[16] Brodin H. Inhibition-facilitation technique for lumbar pain treatment, Int J Rehab Res. 1984;7:328-329.

[17] Doran D, Newell DJ. Manipulation in the treatment of low back pain: a multicentre study. BMJ. 1975;2:161-164.

[18] Evans DP, Burke MS, Lloyd KN, et al. Lumbar spinal manipulation on trial, part 1: clinical assessment. Rheumatol Rehabil. 1978; 17:46-53.

[19] Hoehler FK, Tobis JS, Buerger AA. Spinal manipulation for low back pain, JAMA. 1981;245:1835-1838.

[20] MacDonald RS, Bell CMJ. An open controlled assessment of osteopathic manipulation in nonspecific low-back pain [published erratum appears in Spine. 1991;16:104]. Spine. 1990; 15:364-370.

[21] Mathews W, Morkel M, Mathews J. Manipulation and traction for lumbago and sciatica: physiotherapeutic techniques used in two controlled trials. Physiotherapy Practice. 1988;4:201-206.

[22] Meade TW, Browne W, Mellows S, et al. Comparison of chiropractic and hospital outpatient management of low back pain: a feasibility study. J Epi Comm Health. 1986;40: 12-17.

[23] Meade TW, Dyer S, Browne W, et al. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ. 1990;300: 1431-1437.

[24] Ongley MJ, Klein RG, Dorman TA, et al. A new approach to the treatment of chronic low back pain. Lancet. 1987;2(8551): 143-146.

[25] Postacchini F, Facchini M, Palieri P. Efficacy of various forms of conservative treatment in low back pain: a comparative study. Neuro-orthopaedics. 1988;6(1):28-35.

[26] Sims-Williams H, Jayson MIV, Young SMS, et al. Controlled trial of mobilisation and manipulation for patients with low back pain in general practice. BMJ. 1978; 2(6148): 1338-1340.

[27] Waagen GN, Haldeman S, Cook G, et al. Short term trial of chiropractic adjustments for the relief of chronic low back pain. Manual Medicine. 1986;2:63-67.

[28] Waterworth RF, Hunter IA. An open study of diflunisal, conservative and manipulative therapy in the management of acute mechanical low back pain. NZ Med J. 1985;98:372-375.

[29] Zylbergold RS, Piper MC. Lumbar disc disease: comparative analysis of physical therapy treatments. Arch Phys Med Rehabil. 1981;62:176-179.

[30] Coyer AB, Curwen IHM. Low back pain treated by manipulation: a controlled series. BMJ. 1955; 1:705-707.

[31] Edwards BC. Low back pain and pain resulting from lumbar spine conditions. Australian Journal of Physiotherapy. 1969; 15:104-110.

[32] Nwuga VCB. Relative therapeutic efficacy of vertebral manipulation and conventional treatment in back pain management. Am J Phys Med. 1982;61:273-278.

[33] Rasmussen GG. Manipulation in the treatment of low back pain: a randomized clinical trial. Manuelle Medizin. 1979; 1:8-10.

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