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Physiotherapy and spinal manipulation.

I recall many years ago, what seemed then to me an intriguing question posed by a physiology lecturer--what is the largest system in the human body? The class was divided between the vascular system and the nervous system. Then one student, not me I hasten to add, suggested the two aforementioned systems combined would make, along with bone and muscle, the musculo-skeletal system. It, in fact, comprises some seventy percent of the human body.

The musculo-skeletal system is the major component of study in physiotherapy, and in our undergraduate years we struggle to comprehend the integration of its components: vascular, muscular, skeletal and neurological, that combine to create the system we study and treat all our professional careers.

The initial massage sessions, so often scorned, introduce the student to the handling of soft tissue--its shape, texture, and tone. Add to this a surface projection of the anatomy lesson and these soft tissue elements begin to reveal their functions. Since the late 1980's undergraduate manual skills training has progressed to a point to be on a par with postgraduate skills of the 1970's and early 1980's.

Movement, without which no human lives, brings another state of understanding of the musculoskeletal system by teaching the sensation transmitted by tissues as they go about their respective natural functions. Because these lessons are taught early in one's undergraduate days, what may seem obscure and remote in time is reflected by understanding and delight as knowledge expands with time and ensuing teaching.

The intellectual cognitive skills taught as part of taking a patient history and sifting the possible hypothesis to match the complaint, is a marvellous balance to the physical skills mentioned above. These skills again reflect the advances in physiotherapy training. Patient history, physical examination and diagnosis were not part of undergraduate training prior to the late 1980's. By matching these two processes the physiotherapist arrives at a picture of the way the patient has lived and how their tissues have responded to this living process.

The examination of the musculo-skeletal system by a sound, systematic approach, will elicit whether or not treatment of a physical nature is needed, that is, patient selection is the key to safe and effective management of any case. Manipulation, in the context of physiotherapy is but one treatment option used to complement other therapeutic measures. Used as a stand alone therapy, it has limited value.

An article was published recently in the Australian Journal of Physiotherapy (Refshauge et al 2002), that discussed the relevance of cervical spine manipulation to physiotherapy--was this method of treatment justified on the basis of safety and effectiveness, and if so, who should use such treatment? The paper alludes to ethical and safety issues, supported by the supposed lack of clinical evidence. It isolates manipulation, the definition of which is presumably HVT (high velocity thrust), as not being an appropriate technique at this time in our professional development. And were it to be so by weight of evidence then only a select few, based on superior training, should perform such acts. Manipulation, in the orthopaedic sense, is the taking of a joint into a range not achievable by active means--no more than that. To appreciate the barriers at which to manipulate is part of the training process of joint and soft tissue active and passive movement. It is inherent in all our treatment; it is a fundamental part of undergraduate teaching; it is a corner stone of modern physiotherapy.

In a recent Master Class article (Hing et al, 2003) the New Zealand approach to teaching manipulation, in particular cervical manipulation was detailed. It especially highlighted the problems found among students who use the Maitland approach to the cervical spine. Hing and his colleagues outlined how safety-engendered the New Zealand approach to manipulation is because of the training that precedes its use, and that manipulation, and cervical manipulation specifically, is used sparingly within physiotherapy. This suggests that manipulation is used selectively and, based on ACC incident data, very safely.

Each graduate develops skills at a different rate, some will seek further training in manipulation, and others will direct their attention to the vast scope of physiotherapy outside manipulation. But each will have the grounding in the science and art of soft tissue and joint management. New Zealand has, for many years, had diverse options available to further postgraduate study, both part and full time. These have always been well supported and add greatly to the on-going education we all enjoy and find a challenge.

Spinal manipulation skills, along with many other approaches to treating the musculo-skeletal system are an integral part of physiotherapy; they are enhanced by further learning and instruction--but then, what subject isn't?


Refshauge KM, Parry S, Shirley D, Larsen D, Rivett DA and Boland R (2002): Professional responsibility in relation to cervical spine manipulation, Australian Journal of Physiotherapy 48: 171-179.

Reid DA, Hing WA, and Monaghan M (2003): Masterclass, Manipulation of the cervical spine, Manual Therapy 8 (1), 2-9.

Michael Monaghan Nelson
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Author:Monaghan, Michael
Publication:New Zealand Journal of Physiotherapy
Geographic Code:8NEWZ
Date:Jul 1, 2003
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