Manual Therapy: Critical Assessment Role the

Profession of physical Therapy

Interest in manual therapy appears to continue to grow among physical therapy Joseph P Farrell
clinician$and educators throughout the world even though the underlying con- Qall M Jensen
cepts and techniques have not been justiJied by a knowledge base. The purposes of
this article are to critically asress the role of manual therapy within the physical
therapy p@eson and to provide an intduction to the other articles in this
special issue, Eisner's model of explicit, implicit, and null curricula is used as a
framework for our analysis and our discussion of manual therapy. The explicit
area of manual therapy includes discusions of the deJinition and the role of
manual therapy, the scientiJic rationalefor manual therapy, and manual therapy
in education and a comparison of manual therapy evaluativeframeworks. The
implicit area deals with the role of clinical decision making and critical thinking
in manual therapy in education and rehabilitation. In the null (unaddressed)
area of tnunual therapy, we suggest directionsfor future development and re-
search. [FarrellJP,J m e n GM. Manual therapy: a critical assement of role in the
profession of physical therapy. Phys Ther. 1992;72:843-852.I

Key Words: Joint mobilization,Manual therapy, Orthopedics.

Mennell stated, fession. Manual therapists provide the world.7l8 Clinical interest and
Beyond all doubt the use of the human nonsurgical management of spinal application in the manual therapy
hand, as a method of reducing human and extremity dysfunction related to arena often exceed the current under-
suffering,is the oldest remedy known the neuromusculoskeletal system.3-5 standing of the scientific rationale and
to man; historically no date can be We believe the role of the manual basis for this form of treatment. The
given for its adoption.l@3) therapist in the rehabilitation process purposes of this article are to present
is to assess pain and function, detect a critical assessment of the role of
The human hand continues to be an movement abnormalities, test anatom- manual therapy in the profession and
essential tool for physical therapists. ical tissue structures, and design a to provide an introduction to the
Since the inception of physical ther- treatment program that is related to other articles in this special issue.
apy, manual treatment has been part realistic goals. The treatment should
of the identified knowledge base.2 be continually reassessed and altered We will use a framework from the
How manual treatment (eg, massage, to optimize recovely to full function.6 literature, Eisner's model9 of explicit,
corrective exercise, muscle training): implicit, and null curricula, as a gen-
or the laying on of hands, has been Interest in manual therapy appears to eral framework for our analysis and
used continues to evolve. Today, man- continue to grow among physical discussion. In Eisner's framework, the
ual therapy is seen by many as an therapists and educators throughout explicit dimension refers to knowl-
area of specialization within the pro- edge and ideas that are public, easily
identified, and part of common prac-
tice. Analysis of the explicit dimension
JP Farrell, PT,is Senior Clinical Faculty, Kaiser-Hayward Physical Therapy Residency Program in of manual therapy will include discus-
Advanced Onhopedic Manual Therapy, Kaiser Permanente Medical Center, 27400 Hesperian Blvd, sions of the definition and the role of
Hayward, CA 94541, and Private Practitioner, Redwood Onhopaedic Physical Therapy Inc, 20211
Patio Dr, Ste 205, Castro Valley, CA 94546 (USA). Address correspondence to Mr Farrell at the sec- manual therapy, the scientific ratio-
ond address. nale for manual therapy, the role of
manual therapy in education, and a
GM Jensen, PhD, PT,is Associate Professor and Research Coordinator, Department of Physical
Therapy, Samuel Merritt College, 370 Hawthorne Ave, Oakland, CA 94703. comparison of evaluative approaches

Physical Therapy/Volume 72, Number 12December 1992 843/ 11

 in manual therapy. The implicit di- nation, endurance, flexibility;stabiliza- There are multiple definitions of the
mension, often labeled as the most tion and education; and specific man- terms "manipulation" and "mobiliza-
powerful dimension of the frame- ual therapy procedures.6.lo-13 tion." For example, Cyriaxlo defines
work, includes the values and behav- manipulation as the use of hands to
iors that underlie that which we do In our view, manual therapy is not a passively move a joint for a therapeu-
explicitly (eg, the explicit focus is specialty utilizing only passive move- tic purpose. Paris4 describes manipu-
frequently on doing the evaluation, ment techniques. Many manual thera- lation as the skillful application of a
yet the clinician's analysis and inter- pists appear to agree that manual passive movement to a joint. Grieve
pretation of the clinical data are im- techniques include massage and mus- defines manipulation as
perative for a successful outcome). In cle stretching of soft tissues, distrac- . . . an accurately localized, single,
the implicit dimension, our discussion tion and traction techniques, specific quick and decisive movement of small
will focus on the role of critical analy- (ie, specific to one vertebral motion amplitude, following careful position-
sis in manual therapy (eg, systematic segment such as L4-5) or general (ie, ing of the patient. It is not necessarily
evaluation, critical thinking, clinical specific to a region of the spine such energetic and is completed before the
decision making). Our consideration as L1-S1) high-velocity manipulation patient can stop it. The manipulation
of the null dimension, that which is and joint mobilization, and what is may have a regional or more localized
unattended or forgotten, will include called "adverse neural tissue mobiliza- effect, depending upon the technique
discussion of areas in need of further ti0n."3,5,~.15Butler defines adverse or position of the patient.5@534)
exploration and development. neural tissue mobilization as
The Orthopaedics Section of the
. . . abnormal physiological and me- APTA17 defines mobilization as the act
Expllclt Dlmenslon chanical responses produced from of imparting movement, actively o r
nervous system structures when their
Defnltlon and Role normal range of movement and stretch passively, to a joint o r soft tissue.
capabilities are tested.l5@55) Maitland6 defines mobilization as the
The practice of manual therapy has passive movement performed with a
evolved from numerous clini- Manual techniques are one compo- rhythm and grade ;o that the patient
cians.MJo-13 The contributions of nent part of nonsurgical management is able to prevent the technique from
these clinicians has led to an eclectic of the patient and are used to assist in being performed. Paris18 suggests that
set of evaluation and treatment proce- elimination of pain and improve func- the terms "mobilization" and "manip-
dures for musculoskeletal dysfunction. tion. A thorough examination per- ulation" are identical in meaning and
I We believe that some experienced, formed by a skilled manual therapist thus can be used interchangeably.
skillful clinicians consider muscu- should, however, govern the use of
loskeletal conditions as complex as passive movement procedures as part Among some physical therapists in
spinal dysfunction, as being multifac- of the treatment for the presenting the United States, "mobilization" has
torial and multistructural in effect.3 clinical signs and symptoms. probably evolved as a common term
Consideration of these multiple fac- for two reasons: (1) Therapists may
tors and structures is seen in the The Practice Mairs Committee of the want to avoid the term "manipula-
indications and procedures for man- Orthopaedics Section of the American tion" because of its strong association
ual therapy. Indications for manual Physical Therapy Association (APTA), with the chiropractic profession, and
treatment frequently evolve from offered the following position: (2) "mobilization" is an accepted term
clinical criteria rather than from de- in some physical therapy state prac-
Manipulative techniques by licensed
scriptions of pathology (eg, asymme- physical therapists in evaluation and tice acts. Researchers have argued that
try of position, altered joint range of treatment of individuals with muscu- there is recognition and acceptance
motion, functional limitation, soft loskeletal dysfunction has [sic]always for use of the term "manipulation" by
tissue texture abnormalities).6J4As- been an integral component within the physical therapists with training in this
sessment of soft tissue texture abnor- scope of practice . . . . 1.Manipulation ~pecialty.'3-*~ Manipulation, in a gen-
malities refers to the clinician's palpa- in all forms is within the scope of eral sense, means any manual proce-
practice of the licensed physical thera- dure in which the hands or fingers
tion of the soft tissues (eg, skin, pist. 2. The force, amplitude, direction,
muscle, connective tissue structures), are used to move a vertebral motion
duration, and frequency of manipula- segment (ie, two adjacent vertebra
feeling for thickness, swelling, or tive treatment movements is a discre-
tightnes6 A variety of physical ther- and their interconnecting tissues),22
tiona~ydecision made by the physical
apy procedures frequently are re- soft tissue structure, o r a peripheral
therapist on the basis of education and
quired to assist the patient in restor- clinical experience and on the patient's joint. We believe that the suitability of
ing function. These procedures may clinical profile. 3. Manipulation implies manipulation is dependent on precise
include soft tissue massage; various a variety of manual techniques which is clinical assessment and the patient's
forms of traction; proprioceptive neu- not exclusive to any specific response to treatrt1ent.~J5Various
romuscular facilitation; electrothera- profe~sion.l6@~~) medical, chiropractic, osteopathic, and
peutic modalities, ergonomic analysis; physical therapy clinicians use manip-
exercise to improve strength, coordi- ulative procedures and have many

Physical Therapy /Volume 72, Number 12December 1992

different terms to describe the manual therapy often revolve around tion of the normal anatomical and
techniques. criteria based on clinical findings physiological relationships of the
rather than knowledge of the muscu- synovial joints and skilled, passive
In summary, we believe manual ther- loskeletal pathology (eg, similar diag- movements delivered to the relaxed
apy is more than the passive move- noses can present different clinical joint within the normal joint ranges of
ment of joints. Manual therapy is not findings); (3) musculoskeletal condi- voluntary and involuntary movement.
exclusive to any profession, and dif- tions often improve with time; and
ferent professionals use a variety of (4) the clinical application of manual In 1988, a similar survey was done
manual techniques. The practitioner therapy demands interaction of hu- by Ben-Sorek and Davis,7 who inves-
should decide on the force, ampli- man beings, and there is the effect of tigated the presence of joint mobili-
tude, direction, duration, and fre- human beha~ior.6~14~16~27 The medical zation in physical therapy curricula
quency of manual therapy techniques and physical therapy professions have and compared their results with
based on his or her educational back- examined the efficacy of manipulation those of the 1970 survey by
ground and clinical experience to- in the treatment of patients who have S t e ~ h e n s . 3No
~ operational defini-
gether with the patient's clinical low back ~ain.~%30 Some positive tion of joint mobilization was used
profile.16 short-term effects have been found in the survey. Only 50 physical ther-
with application of manipulation o r apy education programs were sur-
Sclentlflc Ratlonale m0bilization.28~3~ The majority of re- veyed, and 38 (76%) of those pro-
search in manual therapy pertains to grams responded. Thirty-eight
Professional interest in the application spinal conditions, particularly the percent of the programs reported
of manual therapy evaluation and lumbar In this issue, Di that mobilization was taught as a
treatment techniques appear to con- Fabio's article addresses the issue of separate course, and 60% had mobi-
tinue to flourish,7,8,23despite contin- efficacyin manual therapy. lization as a subunit in another
ued slow development of a substan- course. These data demonstrated
tial, scientific rationale for manual Role of Manuai Therapy significant increases in course offer-
therapy"23824In addition, there appear in Education ings and content from the data gath-
to be no active investigative agendas ered by Stephens in 1970. The most
among researchers and clinical ex- There is evidence that manual therapy prevalent manual techniques used by
perts. In 1985, in the foreword of the has had an expanding role in physical programs were those of Paris,4 Mait-
second edition of Aspects of Manipu- therapy curricula. For example, in land,6 Cyriax,loand Kaltenborn."
lative Therapy, Maitland observed 1970, Stephens32 surveyed all physical
None of us can aford to neglect the therapy programs in the United States In January 1992, the Evaluative Crite-
anatomical and physiological compo- (N= 51) regarding the inclusion of ria for Accreditation of Education
nenw: of manipulative therapy, and it is manipulative therapy in entry-level Programs for the Preparation of Physi-
essential that the clinician should try to curricula. In this survey, she used the cal Therapists went into effect.33 These
bridge the gap between the practice term "manipulative therapy," not criteria now include mobilization as
and theory of how, when and why "manual therapy," and defined it as a one of the specific skills of the gradu-
treatment should be administered and system of manual therapeutic tech- ate.33 The previous Standards and
why it is su~cessful.~ niques for the restoration of the integ- Criteria for Accreditation of Physical
rity of joints, including spinal articula- Therapy Educational Pr0grarns3~had
Biomechanics, anatomy, and neuro- tions, by use of normal involuntary referred to the ability of the physical
physiology are frequently the disci- ranges of passive movement. Among therapist to be able to perform defini-
plines used to provide rationales or the 40 programs (78%) that re- tive physical therapy testing of the
theories for the use of manual thera- sponded to her survey, no programs musculoskeletal system with no spe-
py,8,24-'6although there are few stud- offered separate courses in manipula- cific mention of mobilization skills.
ies that have specifically examined tive therapy, but 17% offered some Physical therapy education has
whether and how these theoretical instruction in manipulative therapy, evolved considerably since 1970,
arguments provide a basis for prac- with class time ranging from 3 to when just a few programs included
tice. In this issue, articles by Riddle, 20 hours. Thirty schools (59%) were content and skills in "manipulative
Di Fabio, Twomey, Threlkeld, and not teaching manipulative techniques, therapy." Currently, all entry-level
Walker critically assess what we know and the most frequently cited reason education programs must have some
as well as what we need to know to was insufficient time because of cur- content on mobilization. Tracking this
provide a scientific basis for practice. riculum priorities. Her initial defini- process of curricular change for phys-
tion of manipulative therapy may have ical therapy programs raises questions
Research in manual therapy is compli- been somewhat restrictive, and she such as these for the profession: What
cated by the following factors: (1) proposed an expanded definition of elements are essential in our "opera-
Various clinicians and researchers manipulative therapy at the comple- tional definitions" of certain clinical
disagree over the etiology of muscu- tion of her study. This expanded defi- procedures (eg, mobilization, manual
loskeletal pain; (2) indications for nition included reference to restora- therapy)? and What forces drive deci-

Physical Therapy/Volume 72, Number

sion making for content in entry-level pears to be a critical factor in under- therapist (Tab. 2). The evaluation
physical therapy cumcula? standing how the evaluation will be frameworks for all three approaches
structured and how the clinical find- (ie, Maitland,6 Kaltenborn," and
Comparlson of Evaluatlve ings will be interpreted. Table 1 pro- McKenzieI2 approaches) have many
Approaches in Manual Therapy vides an overview of evaluation ap- elements similar to Cyriax'sl0
proaches used in manual therapy that screening criteria. Each approach
The philosophical approach to eval- have been physician-generated (ie, also includes examination proce-
uation and treatment has been and Cyriax,lo Mennell,l3 and osteopath- dures specific to the approach. For
continues to be the strongest point i~39~40approaches). Cyriax'slo contri- example, Maitland6 emphasizes the
of identification and argument re- bution in devising a logical method importance of continual assessment
garding differences among the vari- for clinical examination of "soft tissue in developing working hypotheses
ous approaches to manual therapy structures" or musculoskeletal prob- based on evaluation. Kaltenborn"
(Tabs. 1, 2). Our use of a "philo- lems has been a component of many includes elements that represent his
sophical approach o r basis" rather of the other evaluative frameworks in background as an osteopath (eg,
than a theoretical rationale for the manual therapy.3 Common elements reference to somatic dysfunction) as
manual therapy approach is purpose- in these three approaches include well as biomechanical assessments
ful. We believe that the basis for gathering of patient data through of joint motion. McKenzieIZ uses
these manual therapy approaches is taking of a history; active movement evaluation of repeated active move-
better described by using the term testing; palpation; and mobilization, ments and patient self-treatments as
"philosophy" (ie, the general beliefs, manipulation, and patient education key elements in his assessment.
concepts, and attitudes35 shared by as treatment interventions. Again, the Similarities among these three ap-
those who practice) than by the term major differences appear in the philo- proaches include the use of palpa-
"theory." Our definition of theory is sophical basis for the approach, which tion; testing of joint movements; and
consistent with that of Kerlinger: in turn leads to a difference in inter- mobilization/manipulation, exercise,
(A theory is] a set of interrelated con- preting musculoskeletal signs and and patient education as treatment
structs (concepts),definitions, and symptoms. For example, Cyriaxlo strategies.
propositions that present a systematic subscribes to an assessment system
view of phenomena by specifying rela- closely linked with his interpretation As practitioners become more eclectic
tions among variables, with the pur- of applied anatomy (eg, differentiating in their evaluation and management
pose of explaining and predicting the contractile and noncontractile struc- of patients, the lines between evalua-
phen0rncna.3~@9) tures). Mennell'sl3 primary focus is tive approaches are likely to continue
examination of synovial joints and to blur over time. A challenge for
In 1979, Cookson and KenP7 and treatment of joint dysfunction with manual therapists will be to search
Cookson38 published review articles joint-play techniques. Central to the for and identify the underlying theo-
emphasizing the similarities and dif- osteopathic approach is the belief that retical arguments for manual therapy
ferences among the various ap- the body is an integrated unit o r total evaluation and treatment procedures
proaches commonly used in orthope- system; that is, the neuromusculoskel- that cross the various "philosophical
dic manual therapy. These articles eta1 system is connected with other approaches" so that propositions can
provide an overview of the four major systems of the body, and disease pro- be derived from the theories and
approaches in manual therapy as cesses are frequently visible in the tested.
espoused by Maitland: Cyriax,IoKal- musculoskeletal system. A second
tenborn,ll and MennelL13A compari- belief is that structure governs func- Implicit Dlmenslon
son of the four evaluation approaches tion and an abnormality in structure
used in manual therapy, as reviewed can lead to abnormal function. So- Musculoskeletal Evaluatlon:
by Cookson and Kent37 and Cook- matic dysfunction is the impaired or The Role of Critical Analysis
son,38 as well as two other approaches altered function of the somatic system
frequently used by physical therapists (skeletal, arthrodial, and myofascial Even though we see that, explicitly,
(ie, McKenzie's approach to the structures and related vascular, lym- manual therapy approaches are based
spinel2 and the osteopathic approach phatic, and neural elemer1ts).39,~~ on somewhat different philosophies,
to musculoskeletal dysfunction39~~) is they d o share a common dimen-
presented in Tables 1 and 2. The The physical therapist-generated sion-there is always some form of
selection of these six approaches is evaluative frameworks, like the systematic evaluation and treatment of
not meant to be exhaustive or com- physician-generated evaluative patients with musculoskeletal dysfunc-
prehensive, but it is representative of frameworks, subscribe to a philo- tion. The implicit dimension, that is,
major approaches integrated into sophical basis. This philosophical the values and behaviors that are
physical therapy practices today. basis often includes integration of central to the work of the manual
other approaches, but with applica- therapist, includes perhaps the most
The philosophical basis presented for tion of evaluation and treatment important contribution to the profes-
these evaluative approaches also ap- techniques done by the physical sion made by manual therapy. This

Physical Therapy /Volume 72, Number 12December 1992

-
Table 1. Comparisons of Physician-Generated Evaluative Approaches Used in Manual i'%erapy

Manual Therapy Approach

Cyrlaxlo (Orthopedic
Medlclne) Contentlons Mennelll3 Contentlons OsteopathlcN.4o Contentlons

Philosophical basis 1. All pain has an 1 . Dysfunction is a sign of a serious 1. The body is a total unit, and the
anatomical source pathological process or joint neuromusculoskeletalsystem is
2. All treatment must disease connected with other systems;
reach that anatomical 2. Loss of normal joint movement or therefore, disease processes can be
source joint play can lead to dysfunction visible in the musculoskeletal system
3. If the diagnosis is 3. Joint manipulation can restore 2. The structure of the body governs
correct, all treatment normal joint-play movements function; an abnormality in structure
will benefit the source can lead to abnormal function
3. Somatic dysfunction is the impaired
function of related components of
the somatic system (eg, skeletal,
arthroidal, and myofascial structures
and related vascular, lymphatic, and
neural elements)
4. Manipulative therapy can restore
and maintain normal structure and
function relationships

Key concepts Diagnosis of soft tissue Assessment of joint play Diagnosis of somatic dysfunction
lesions a Clinical examination focuses on the
Categorization of presence of asymmetry, restriction of
referred pain movement, and palpation of soft
Differentiation of tissue texture changes (ie, palpation
contractile and of skin, muscle, and other connective
noncontractile lesions tissue for feeling of thickness,
swelling, tightness, or temperature
change)

Evaluation framework
History Observation, history Present complaint History
Age and occupation Onset Knowledge of physical trauma, past
Symptoms (site and Nature of pain visceral and soft tissue problems
spread, onset and Localization of pain Present complaint
duration, behavior) Loss of movement a Establish relationship behveen
Medical considerations Past history adaptation, decornpensation, trauma.
Inspection Family history and time from patient's history
Medical systems review

Physical Physical examination Physical examination Physical examination

Active movements Inspection Postural analysis
Passive movements Palpation Regional screening functional units
Resisted movements Examination of voluntary a Pelvic girdle
Neurological movements Foot
examination Muscle examination Vertebral column
Palpation Special tests (eg. Shoulder girdle
roentgenography) Hand
a Examination of joint-play Detailed evaluation of regions in
movements dysfunction

Interpretation of evaluation Identification of anatomical Joint dysfunction Positional fault

structure associated with Restriction fault
lesion Segmental or multisegmental

Treatment strategies Friction massage Manipulation Manipulation

Injection Mobilization Mobilization
Manipulation Physical therapy (eg, exercise, Muscle energy
Mobilization modalities) Myofascial techniques
Physical therapy (eg, Patient education Counterstrain
exercise, modalities) Exercise therapy
Patient education Patient education

Physical Therapy /Volume 72, Number 12December 1992

-
Table 2. Comparisons of P L y d c a l ~ a p ~ - G e n e r a t Evaluative

Manual Therapy Approach

Maltland8 (Australian) Contentlons
ed Approaches Used in Manual Therapy

Kaltenbornll (Norwegian) Contentlons McKerulelz Contentions

Philosophical basis 1. Personal commitment to 1. Biomechanical assessment of joint 1. Predisposing factors of sitting
understand the patient movements posture, loss of extension range, and
2. Think about and apply theoretical 2. Pain, joint dysfunction, and soft tissue frequency of flexion contribute to
thinking (eg, pathology, anatomy) changes are found in combination spinal pain
and clinical thinking (eg, signs and 2. Patients should be involved in
symptoms) self-treatment
3. Continual assessment and
reassessment of data
Key concepts Examination,technique, and Somatic dysfunction During movements of the spine, a
assessment are interrelated and Application of principles from positional change to the nucleus
interdependent arthrokinematics (eg, concave-convex pulposus takes place
Grades of movement (I-V) rule, close- and loose-packed Flexed lifestyle leads to a more
Testing accessory and positions) posterior position of nucleus
physiological joint movements Grades of movement (1-111) Intervertebraldisk is a common
Differential assessment to prove or source of back pain
disprove clinical working
hypotheses
Evaluation framework Subjective examination (as defined by History ("five-five scheme") History
Maitlands) 1. Immediate case history (eg, assess Interrogation (eg, Where did pain
Establish kind of disorder symptoms for localization, time, begin, how, constant or intermittent,
Area of symptoms character, and so on) what makes it better or worse,
Behavior of symptoms 2. Previous history (eg, assess for kind previous episodes, further
Irritability of treatment, relief of symptoms, questions?)
Nature presence of similar symptoms or Physical examination
Special questions related symptoms) Posture (sitting, standing)
History 3. Social background Examination of movement (flexion,
Planning the objective examination 4. Medical history extension, side gliding)
(as defined by Maitlands) 5. Family history Movements in relation to pain
Physical examination Patient's assessment of cause of Repeated movements
Observation complaint Test movements
Functional tests Physical examination Other tests (eg, neurological, other
Active movements Inspection joints)
Isometric tests Function (active and passive
Other structures in plan movements; testing with traction,
Passive movements (eg, special compression, and gliding; resisted
tests, physiological and accessory tests)
joint movements, relevant adverse Palpation
neural tissue tension tests) Neurological tests
Palpation Additional tests
Neurological examination
Highlight main findings
Interpretation of Initial assessment-relate examination Biornechanical assessment (ie, Postural syndrome
evaluation findings to restriction of joint mobility) and Dysfunctionalsyndrome
Behavior of patient's symptoms assessment of soft tissue changes Derangement syndrome
The diagnosis
Stage of disorder
Stability of disorder
Irritability of disorder
Treatment strategies Based on continual assessment Mobilization Patient self-treatment using repeated
Mobilization Exercise (emphasis on proprioceptive movements
Manipulation neurornuscular facilitation) Exercise
Adverse neural tissue mobilizationa Tractionldistraction Mobilization or manipulation (if needed)
Traction Soft tissue mobilization Patient education
Exercise Manipulation
Patient education Patient education

aAbnormal physiological and mechanical responses produced from nervous system structures when their normal range of movement and stretch capa-
bilities are tested.'5

16 / 848 Physical Therapy /Volume 72, Number 12/December 1992

contribution is an emphasis on sys- The importance of developing thera- the interview data collected, which, in
tematic evaluation as well as analysis pists' thinking and analytical skills, as essence, is a clinical judgment or
and interpretation of the clinical data. well as their technical skills, raises decision based on the experience,
important questions. Do entry-level training, and skills of the clinician. A
We have seen increased integration of degree programs promote critical "working hypothesis" is formulated
manual therapy in practice and educa- analysis of technique and allow time with the intent of identifying the po-
ti0n.7~23~32.33
Along with this growth for thoughtful analysis and reflection? tential musculoskeletal structures
has been an increased emphasis on Are these programs focused on cover- involved in the presenting pathology.
the evaluative process as well as the ing a given amount of material, con- The clinician uses his or her assess-
thinking and reasoning behind clini- sistent with trends in clinical prac- ment skills and knowledge to rank
cal decision making. For example, tice?54 Do we see in continuing the importance of each component of
Cookson and KenP7 argue that al- education programs an equal empha- the working hypothesis according to
though therapeutic techniques ap- sis on critical analysis of scientific the SINS algorithm. (S=severity,
plied for a certain musculoskeletal rationales or underlying theories as I= irritability, N =nature of the com-
condition may vary across the differ- well as application and mastery of plaint, and S=stage of pathology).49.9
ent philosophical approaches, evalua- clinical techniques?
tion of the patient to determine Severity is the term used to describe
whether to treat or not to treat is The Maitland, or Australian, approach the clinician's assessment of the inten-
essential. Over the last few years, includes an evaluative framework that sity of the patient's symptoms as they
several musculoskeletal texts have is based on a conceptual model o r relate to a functional activity. For
been written, not by physicians, but framework.49jw We believe that the example, if the patient has ceased
by physical therapists.5.6.41-'5 These Australian evaluation framework is an using his o r her arm to dress and is
texts focus on orthopedic assessment, example of how a clinician can facili- unable to find a position to ease pain,
including evaluation and treatment. tate his or her clinical-reasoning pro- then the symptoms are considered
The value of clinical reasoning and cess. What follows in this next section severe. Nonsevere symptoms are
decision making in practice and edu- is an example of how the manual represented by the patient who is
cation also is a theme in recent pro- therapist uses the evaluation frame- able to dress with arm o r shoulder
fessional w r i t i n g ~ . ~ 6 9 work for organizing and interpreting pain, yet the pain is not intense
clinical data. enough to stop the functional activity
In our view, this process of not only even though pain is experienced.
using a systematic evaluation scheme, The Australian Approach: Irritability is the term used to de-
but investigating the clinical reasoning An Example of a Framework scribe the clinician's assessment based
and decision making that underlie the for Critical Analysis on (1) the amount of activity needed
evaluation and the understanding and to bring on the patient's symptoms
interpretation of findings is an ex- In the Australian approach, the evalua- and (2) the amount of time before
tremely important goal for the profes- tion process should begin when a the patient's symptoms subside (dura-
sion. Professional expertise is de- patient walks into the treatment room. tion). For example, a shoulder pain
scribed by many educators in the An interview process occurs in which that begins when the patient lifts an
professions as not only the possession the manual therapist guides the pa- arm and that lasts for 4 hours means
of technical skills, but also the use of tient's description of his or her symp- that the patient's condition is ex-
analytical skills for critical analysis and toms by defining the location and tremely irritable (little activity causes
deliberate action.sl-53 This critical behavior of those symptoms, obtain- considerable pain that lasts for a long
analysis requires that the professional ing the patient history, and determin- period of time). Conversely, a shoul-
education process assist students in ing any precautions that may preclude der pain that is aggravated when the
becoming critical analysts. This pro- treatment. The interview (defined by patient lifts his or her arm, but eases
cess must occur in the "context of Maitland6 as the subjective examina- when the patient returns the arm to
action" or practice. For example, the tion) is vital as the first step in deter- his or her side, would be considered
practitioner must first make sense of a mining the source of the patient's a nonirritable condition.
situation by imposing a structure or complaint. Maitland uses the term
framework for analysis. This frame- "subjective" here to represent the The nature of the complaint is the
work is used to help define a prob- interactive portion of the examination, term that represents the clinician's
lem and judge the potential conse- that is, the therapist's interview with assessment of the patient's pain toler-
quences of action. Students and the patient in which the therapist ance, including consideration of cul-
practitioners must think about what begins to interpret the patient's per- tural differences, stability of the condi-
they will do and why and then take ceptions of his o r her symptoms. The tion, type of pathology, and the
action. The initial emphasis for stu- term "subjective" is not used in a physical therapist's hypothesis of the
dents should be on the thoughtful scientific manner to represent a sub- structures responsible for producing
analysis of an experience rather than jective measure o r test.55 The clinician the pain complaint. The stage of the
finding the correct procedure.52-5* makes an assessment o r appraisal of pathology is a term used to describe

Physical Therapy/Volume 72, Number 12December 1992

the clinician's assessment of what the e r ~ 5 ~ ~have
5 7 suggested that the use of (authority figures) and that knowl-
progression of symptoms is for the established clinical classification sys- edge, like knowledge from tradition,
patient. For example, if the patient tems may assist physical therapists in has not been validated or verified
reports that he or she had low back this classification process. As the phys- through research.5B For example, the
pain 2 days ago and now has lower- ical therapy profession moves toward philosophical bases of the different
extremity pain radiating to the ankle, more systematic observation and approaches to manual therapy are
the clinician may suspect that the classification of clinical phenomenon, generally well-known and central
pathological condition is deteriorat- the manual therapist could serve a aspects of the written materials, yet
ing. The hypothesis would then be critical role assisting with the develop there has been little focus on devel-
reranked accordingly.6~45 ment of this process. In this special oping and discussing application of
issue, the article by Jones provides theory to practice o r generating test-
Clinical decisions that relate to inter- further dialogue about the role of able questions from identified key
vention also revolve around assessing clinical reasoning in manual therapy. theories.
data during and at the conclusion of
the physical examination, during the Null Dlmenslon We cannot ignore that clinical prac-
application of treatment techniques, tice combines the elements of art
and at the conclusion of the initial We believe that there are other as- and science. Clinical observation
treatment.6150From this form of analy- pects of manual therapy that are part and manual technique are central
sis, treatment goals are established of the null dimension, that is, aspects components of the artistry of prac-
and a treatment strategy is formulated. that are often ignored. Grieve de- tice in manual therapy. Feinstein59
scribes the present state of manual suggests that clinical practice is nei-
Throughout the course of treatment, therapy well: ther art nor science, but the most
the therapist continues to assess the We continue to sound as though we scientific art and the most humanis-
effect of treatment on the patient's know so much, when we know com- tic science. Several articles in the
hnctional limitations that relate to his paratively little. It might be a good July 1989 issue of Physical Therapy
o r her lifestyle and work environment thing to admit this. We make much of on clinical decision making focused
and the active, passive, o r functional clinical science, enthusiastically refer- on discussion and improvement of
movement signs and symptoms that ring to this or that part of the massive clinical mea~ures.47.55~60~61 Delitto60
relate to the clinical working hypothe- mountain of literature which best suggests consideration of Feinstein's
sis. Through continual assessment of serves our particular interest . . . . Much principles of clinimetric~6~ (eg, de-
of what we do is simply what has been
each technique, exercise, or modality, velopment of clinimetric indexes
proven on the clinical shop floor to be
the clinician progresses treatment and effective in getting our patients bet- that address face validity and content
hypothesizes which structures or ter-we do not always know ~ h y . ~ 3 ( p ~ ) validation and that have a formal
body regions most likely contribute to expression of the index) as a way of
the patient's problem. For example, if One aspect of manual therapy that is expanding the scientific basis of
a patient's active or passive movement frequently ignored is consistent dis- clinical practice. Many of these prin-
signs, symptoms, and functional status cussion and analysis of the identified ciples have application for investiga-
are not changing at what the clinician theory o r body of general principles tions in manual therapy.
believes is an appropriate rate, the underlying the knowledge base. We
clinician needs to reassess (ie, rerank, have noted that biomechanics, anat- For example, palpation plays a central
reject, or reformulate) the working omy, and neurophysiology are often role in application of sevelal manual
hypothesis and alter the treatment discussed as providing an underlying therapy techniques. Palpation is a
accordingly.49 rationale for manual therapy and are practical skill that apparently requires
enthusiastically referred to as the many hours of training and practice
The clinician has a central role to play elements that fit our applications.24 to maste1-.~3 Many manual therapists
in collecting and interpreting clinical We need to ask ourselves, What are believe that palpation of the spine
data for individual patients. We pro- the sources of knowledge cited for and associated areas that contribute to
pose that the clinician also has a cen- manual therapy in either entry-level the presenting symptoms may be the
tral role to play in the generation of o r continuing professional education? most informative aspect of the physi-
classification systems that identify Is the knowledge base in manual cal examination." Sophisticated imag-
commonalities and differences across therapy built on a model of tradition ing techniques continue to serve as
patient cases. In 1989, Rose47 argued o r authority or the scientific meth- major tools in the diagnosis of muscu-
that therapists need to identify and od?58A model of tradition refers to loskeletal problems, with less reliance
characterize the relationships between knowledge obtained from "truths" or on palpation. The challenge for physi-
clinical entities and specific treatments beliefs that were accepted in the past cal therapists will be to integrate
and management strategies. He ar- and that continue to influence prac- technology and manual skills so that
gued that clinicians need to use a tice. A model of authority is when both components can enhance thera-
process of rational practice and criti- knowledge is gained from experts pists' understanding of musculoskele-
cal thinking to achieve this goal. 0th- tal problems. For example, Jull et a165

Physical Therapy / Volume 72, Number 12December 1992

studied 20 patients, all of whom had underlying musculoskeletal evaluation Therapy. Ncw York, NY:Churchill Livingstone
complained of chronic neck o r head- and treatment (eg, anatomic, biome- Inc; 1986:605421.
4 Paris SV. Mobilization of the spine. Phys
ache for at least 1year, who under- chanical, neurophysiologic), but gives Tbm 1979:59:98%995.
went manual examination of the cer- more purposeful consideration to 5 Grieve GP. Common VertebralJoint Ptoh-
vical zygapophyseal joints and aspects of human behavior. For exam- l a . 2nd ed. New York, NY: Churchill Living-
radiographic assessment. In one ple, theories regarding patient- stone Inc; 1989:303-349, 534.
6 Maitland GD. Vertebral Manipulation. 5th
group of patients (n = 11), the pres- provider interactions, health behavior, ed. Boston, Mass: Butterwonh; 1986:l-13.
ence o r absence of symptoms associ- and cultural aspects of illness6- may 7 Ben-Sorek S, Davis CM. Joint mobilization
ated with a joint was established by also help clinicians develop a fuller education and clinical use in the United States.
radiographically controlled diagnostic understanding of the context of clini- Phys Ther. 1988;68:1000-1004.
nerve blocks. The manual therapist cal practice. 8 Glasgow E, Twomey LT, ed. Aspects of Ma-
nipulatic~eTherapy. 2nd ed. New York, NY:
was unaware of the diagnosis and Churchill Livingstone Inc; 1985.
examined the patients 1 to 4 weeks 9 Eisner E. The Educational Imagination: On
after the nerve block. The order of Design and Evaluation of Educational Pro-
events was reversed in the second This assessment of manual therapy grams. New York, I W MacMillan Publishing
Co; 1979:74-92.
group of patients (n=9); that is, the has provided an introduction to the 1 0 Cyriax JH. Textbook of Onhopaedic Medi-
manual examination was first, fol- current role of manual therapy in the cine. Volume I: Diagnosis of Soj Tissue Le-
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dall; 1982.
Of the 20 patients studied, the manual therapy represents more than just the
11 Kaltenborn FM. Mobilization of the Ex-
therapist identified all 15 patients who application of passive movements, and tremity Joints. 3rd ed. Oslo, Norway: Olaf Nor-
had symptomatic zygapophyseal joints the field continues to evolve as a lis Bokhandel Universitetsgaten; 1980.
and also identified the 5 patients who subspecialty in physical therapy. The 12 McKenzie RA. The Lumbar Spine: Mechani-
did not have joint involvement. This knowledge base and practice of man- cal Diagnosis and Therapy. Waikanae, New
Zealand: Spinal Publications; 1981.
study is an example of systematic ual therapy have strong ties to the 1 3 Mennell JM. Back Pain: Diagnosis and
investigation of the "an" of palpation philosophical approaches advocated Treatment Using Manipulative Techniques
and represents an initial step toward by several clinicians. The scientific Boston, Mass: Little, Brown & Co Inc; 1960.
investigation of the validity of palpa- base of manual therapy is frequently 14 Haldeman S. Spinal manipulative therapy: a
status repon. Clin Orthop. 1983;179:62-70.
tion techniques. tied to knowledge from other disci- 15 Butler D. Mobilization of the Nervous Sys-
plines (eg, anatomy, biomechanics, tem. New York, NY: Churchill Livingstone Inc;
Another area of manual therapy that is neurophysiology), with few o r no 1991.
often ignored are investigations re- investigations to substantiate the con- 16 Nicholson G. Practice ABairs Committee
repon: position statement on manipulation,
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of manual therapy. Several investiga- and practice, o r the efficacy of prac- paedics Section. American Physical Therapy
tions have examined the use of man- tice. Systematic and continual assess- Association. 1991;3(2):22-23.
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o m . La Crosse, Wis: Onhopaedics Section Inc.
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2 0 Godfrey CM, Morgan PP, Schatzker J. A ran-
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21 Meade TW, Dyer S, Browne W, et al. Low
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ments? Such investigations, ultimately, comparison of chiropractic and hospital outpa-
Gielen66 identifies two major ele- should be helpful in developing theo- tient treatment. BMJ. 1990:300:1431-1437.
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Physical Therapy /Volume 72, Number 12December 1992