Manual Therapy: A Critical Assessment of Role in the

Profession of Physical Therapy

Joseph P Farrell and Gail M Jensen
PHYS THER. 1992; 72:843-852.

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Manual Therapy: Critical Assessment

Profession of physical Therapy

Role

the

Joseph P Farrell
Qall M Jensen

Interest in manual therapy appears to continue to grow among physical therapy

clinician$and educators throughout the world even though the underlying concepts 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 research. [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,
Beyond all doubt the use of the human
hand, as a method of reducing human
suffering,is the oldest remedy known
to man; historically no date can be
given for its adoption.l@3)
The human hand continues to be an
essential tool for physical therapists.
Since the inception of physical therapy, manual treatment has been part
of the identified knowledge base.2
How manual treatment (eg, massage,
corrective exercise, muscle training):
or the laying on of hands, has been
used continues to evolve. Today, manual therapy is seen by many as an
area of specialization within the pro-

fession. Manual therapists provide

nonsurgical management of spinal
and extremity dysfunction related to
the neuromusculoskeletal system.3-5
We believe the role of the manual
therapist in the rehabilitation process
is to assess pain and function, detect
movement abnormalities, test anatomical tissue structures, and design a
treatment program that is related to
realistic goals. The treatment should
be continually reassessed and altered
to optimize recovely to full function.6
Interest in manual therapy appears to
continue to grow among physical
therapists and educators throughout

JP Farrell, PT,is Senior Clinical Faculty, Kaiser-Hayward Physical Therapy Residency Program in
Advanced Onhopedic Manual Therapy, Kaiser Permanente Medical Center, 27400 Hesperian Blvd,
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 second address.
GM Jensen, PhD, PT,is Associate Professor and Research Coordinator, Department of Physical
Therapy, Samuel Merritt College, 370 Hawthorne Ave, Oakland, CA 94703.

the world.7l8 Clinical interest and

application in the manual therapy
arena often exceed the current understanding of the scientific rationale and
basis for this form of treatment. The
purposes of this article are to present
a critical assessment of the role of
manual therapy in the profession and
to provide an introduction to the
other articles in this special issue.
We will use a framework from the
literature, Eisner's model9 of explicit,
implicit, and null curricula, as a general framework for our analysis and
discussion. In Eisner's framework, the
explicit dimension refers to knowledge and ideas that are public, easily
identified, and part of common practice. Analysis of the explicit dimension
of manual therapy will include discussions of the definition and the role of
manual therapy, the scientific rationale for manual therapy, the role of
manual therapy in education, and a
comparison of evaluative approaches

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843/ 11

in manual therapy. The implicit dimension, often labeled as the most

powerful dimension of the framework, includes the values and behaviors that underlie that which we do
explicitly (eg, the explicit focus is
frequently on doing the evaluation,
yet the clinician's analysis and interpretation of the clinical data are imperative for a successful outcome). In
the implicit dimension, our discussion
will focus on the role of critical analysis in manual therapy (eg, systematic
evaluation, critical thinking, clinical
decision making). Our consideration
of the null dimension, that which is
unattended or forgotten, will include
discussion of areas in need of further
exploration and development.

Expllclt Dlmenslon

Defnltlon and Role

The practice of manual therapy has

evolved from numerous clinicians.MJo-13 The contributions of
these clinicians has led to an eclectic
set of evaluation and treatment procedures for musculoskeletal dysfunction.
We believe that some experienced,
skillful clinicians consider musculoskeletal conditions as complex as
spinal dysfunction, as being multifactorial and multistructural in effect.3
Consideration of these multiple factors and structures is seen in the
indications and procedures for manual therapy. Indications for manual
treatment frequently evolve from
clinical criteria rather than from descriptions of pathology (eg, asymmetry of position, altered joint range of
motion, functional limitation, soft
tissue texture abnormalities).6J4Assessment of soft tissue texture abnormalities refers to the clinician's palpation of the soft tissues (eg, skin,
muscle, connective tissue structures),
feeling for thickness, swelling, or
tightnes6 A variety of physical therapy procedures frequently are required to assist the patient in restoring function. These procedures may
include soft tissue massage; various
forms of traction; proprioceptive neuromuscular facilitation; electrotherapeutic modalities, ergonomic analysis;
exercise to improve strength, coordi-

nation, endurance, flexibility;stabilization and education; and specific manual therapy procedures.6.lo-13
In our view, manual therapy is not a
specialty utilizing only passive movement techniques. Many manual therapists appear to agree that manual
techniques include massage and muscle stretching of soft tissues, distraction and traction techniques, specific
(ie, specific to one vertebral motion
segment such as L4-5) or general (ie,
specific to a region of the spine such
as L1-S1) high-velocity manipulation
and joint mobilization, and what is
called "adverse neural tissue mobilizati0n."3,5,~.15
Butler defines adverse
neural tissue mobilization as
. . . abnormal physiological and mechanical responses produced from
nervous system structures when their
normal range of movement and stretch
capabilities are tested.l5@55)
Manual techniques are one component part of nonsurgical management
of the patient and are used to assist in
elimination of pain and improve function. A thorough examination performed by a skilled manual therapist
should, however, govern the use of
passive movement procedures as part
of the treatment for the presenting
clinical signs and symptoms.
The Practice Mairs Committee of the
Orthopaedics Section of the American
Physical Therapy Association (APTA),
offered the following position:
Manipulative techniques by licensed
physical therapists in evaluation and
treatment of individuals with musculoskeletal dysfunction has [sic]always
been an integral component within the
scope of practice . . . . 1.Manipulation
in all forms is within the scope of
practice of the licensed physical therapist. 2. The force, amplitude, direction,
duration, and frequency of manipulative treatment movements is a discretiona~ydecision made by the physical
therapist on the basis of education and
clinical experience and on the patient's
clinical profile. 3. Manipulation implies
a variety of manual techniques which is
not exclusive to any specific
profe~sion.l6@~~)

There are multiple definitions of the

terms "manipulation" and "mobilization." For example, Cyriaxlo defines
manipulation as the use of hands to
passively move a joint for a therapeutic purpose. Paris4 describes manipulation as the skillful application of a
passive movement to a joint. Grieve
defines manipulation as
. . . an accurately localized, single,
quick and decisive movement of small
amplitude, following careful positioning of the patient. It is not necessarily
energetic and is completed before the
patient can stop it. The manipulation
may have a regional or more localized
effect, depending upon the technique
or position of the patient.5@534)
The Orthopaedics Section of the
APTA17 defines mobilization as the act
of imparting movement, actively o r
passively, to a joint o r soft tissue.
Maitland6 defines mobilization as the
passive movement performed with a
rhythm and grade ;o that the patient
is able to prevent the technique from
being performed. Paris18 suggests that
the terms "mobilization" and "manipulation" are identical in meaning and
thus can be used interchangeably.
Among some physical therapists in
the United States, "mobilization" has
probably evolved as a common term
for two reasons: (1) Therapists may
want to avoid the term "manipulation" because of its strong association
with the chiropractic profession, and
(2) "mobilization" is an accepted term
in some physical therapy state practice acts. Researchers have argued that
there is recognition and acceptance
for use of the term "manipulation" by
physical therapists with training in this
~pecialty.'3-*~
Manipulation, in a general sense, means any manual procedure in which the hands or fingers
are used to move a vertebral motion
segment (ie, two adjacent vertebra
and their interconnecting tissues),22
soft tissue structure, o r a peripheral
joint. We believe that the suitability of
manipulation is dependent on precise
clinical assessment and the patient's
response to treatrt1ent.~J5Various
medical, chiropractic, osteopathic, and
physical therapy clinicians use manipulative procedures and have many

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different terms to describe the

techniques.
In summary, we believe manual therapy is more than the passive movement of joints. Manual therapy is not
exclusive to any profession, and different professionals use a variety of
manual techniques. The practitioner
should decide on the force, amplitude, direction, duration, and frequency of manual therapy techniques
based on his or her educational background and clinical experience together with the patient's clinical
profile.16

Sclentlflc Ratlonale
Professional interest in the application
of manual therapy evaluation and
treatment techniques appear to continue to flourish,7,8,23despite continued slow development of a substantial, scientific rationale for manual
therapy"23824In addition, there appear
to be no active investigative agendas
among researchers and clinical experts. In 1985, in the foreword of the
second edition of Aspects of Manipulative Therapy, Maitland observed
None of us can aford to neglect the
anatomical and physiological componenw: of manipulative therapy, and it is
essential that the clinician should try to
bridge the gap between the practice
and theory of how, when and why
treatment should be administered and
why it is su~cessful.~
Biomechanics, anatomy, and neurophysiology are frequently the disciplines used to provide rationales or
theories for the use of manual therapy,8,24-'6although there are few studies that have specifically examined
whether and how these theoretical
arguments provide a basis for practice. In this issue, articles by Riddle,
Di Fabio, Twomey, Threlkeld, and
Walker critically assess what we know
as well as what we need to know to
provide a scientific basis for practice.
Research in manual therapy is complicated by the following factors: (1)
Various clinicians and researchers
disagree over the etiology of musculoskeletal pain; (2) indications for

manual therapy often revolve around

criteria based on clinical findings
rather than knowledge of the musculoskeletal pathology (eg, similar diagnoses can present different clinical
findings); (3) musculoskeletal conditions often improve with time; and
(4) the clinical application of manual
therapy demands interaction of human beings, and there is the effect of
human beha~ior.6~14~16~27
The medical
and physical therapy professions have
examined the efficacy of manipulation
in the treatment of patients who have
low back ~ain.~%30
Some positive
short-term effects have been found
with application of manipulation o r
m0bilization.28~3~
The majority of research in manual therapy pertains to
spinal conditions, particularly the
lumbar
In this issue, Di
Fabio's article addresses the issue of
efficacyin manual therapy.

Role of Manuai Therapy

in Education
There is evidence that manual therapy
has had an expanding role in physical
therapy curricula. For example, in
1970, Stephens32 surveyed all physical
therapy programs in the United States
(N= 51) regarding the inclusion of
manipulative therapy in entry-level
curricula. In this survey, she used the
term "manipulative therapy," not
"manual therapy," and defined it as a
system of manual therapeutic techniques for the restoration of the integrity of joints, including spinal articulations, by use of normal involuntary
ranges of passive movement. Among
the 40 programs (78%) that responded to her survey, no programs
offered separate courses in manipulative therapy, but 17% offered some
instruction in manipulative therapy,
with class time ranging from 3 to
20 hours. Thirty schools (59%) were
not teaching manipulative techniques,
and the most frequently cited reason
was insufficient time because of curriculum priorities. Her initial definition of manipulative therapy may have
been somewhat restrictive, and she
proposed an expanded definition of
manipulative therapy at the completion of her study. This expanded definition included reference to restora-

tion of the normal anatomical and

physiological relationships of the
synovial joints and skilled, passive
movements delivered to the relaxed
joint within the normal joint ranges of
voluntary and involuntary movement.
In 1988, a similar survey was done
by Ben-Sorek and Davis,7 who investigated the presence of joint mobilization in physical therapy curricula
and compared their results with
those of the 1970 survey by
S t e ~ h e n s . 3No
~ operational definition of joint mobilization was used
in the survey. Only 50 physical therapy education programs were surveyed, and 38 (76%) of those programs responded. Thirty-eight
percent of the programs reported
that mobilization was taught as a
separate course, and 60% had mobilization as a subunit in another
course. These data demonstrated
significant increases in course offerings and content from the data gathered by Stephens in 1970. The most
prevalent manual techniques used by
programs were those of Paris,4 Maitland,6 Cyriax,loand Kaltenborn."
In January 1992, the Evaluative Criteria for Accreditation of Education
Programs for the Preparation of Physical Therapists went into effect.33 These
criteria now include mobilization as
one of the specific skills of the graduate.33 The previous Standards and
Criteria for Accreditation of Physical
Therapy Educational Pr0grarns3~had
referred to the ability of the physical
therapist to be able to perform definitive physical therapy testing of the
musculoskeletal system with no specific mention of mobilization skills.
Physical therapy education has
evolved considerably since 1970,
when just a few programs included
content and skills in "manipulative
therapy." Currently, all entry-level
education programs must have some
content on mobilization. Tracking this
process of curricular change for physical therapy programs raises questions
such as these for the profession: What
elements are essential in our "operational definitions" of certain clinical
procedures (eg, mobilization, manual
therapy)? and What forces drive deci-

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sion making for content in entry-level

physical therapy cumcula?

Comparlson of Evaluatlve
Approaches in Manual Therapy
The philosophical approach to evaluation and treatment has been and
continues to be the strongest point
of identification and argument regarding differences among the various approaches to manual therapy
(Tabs. 1, 2). Our use of a "philosophical approach o r basis" rather
than a theoretical rationale for the
manual therapy approach is purposeful. We believe that the basis for
these manual therapy approaches is
better described by using the term
"philosophy" (ie, the general beliefs,
concepts, and attitudes35 shared by
those who practice) than by the term
"theory." Our definition of theory is
consistent with that of Kerlinger:
(A theory is] a set of interrelated constructs (concepts),definitions, and
propositions that present a systematic
view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the
phen0rncna.3~@9)
In 1979, Cookson and KenP7 and
Cookson38 published review articles
emphasizing the similarities and differences among the various approaches commonly used in orthopedic manual therapy. These articles
provide an overview of the four major
approaches in manual therapy as
espoused by Maitland: Cyriax,IoKaltenborn,ll and MennelL13A comparison of the four evaluation approaches
used in manual therapy, as reviewed
by Cookson and Kent37 and Cookson,38 as well as two other approaches
frequently used by physical therapists
(ie, McKenzie's approach to the
spinel2 and the osteopathic approach
is
to musculoskeletal dysfunction39~~)
presented in Tables 1 and 2. The
selection of these six approaches is
not meant to be exhaustive or comprehensive, but it is representative of
major approaches integrated into
physical therapy practices today.
The philosophical basis presented for
these evaluative approaches also ap-

pears to be a critical factor in understanding how the evaluation will be

structured and how the clinical findings will be interpreted. Table 1 provides an overview of evaluation approaches used in manual therapy that
have been physician-generated (ie,
Cyriax,lo Mennell,l3 and osteopathi~39~40
approaches). Cyriax'slo contribution in devising a logical method
for clinical examination of "soft tissue
structures" or musculoskeletal problems has been a component of many
of the other evaluative frameworks in
manual therapy.3 Common elements
in these three approaches include
gathering of patient data through
taking of a history; active movement
testing; palpation; and mobilization,
manipulation, and patient education
as treatment interventions. Again, the
major differences appear in the philosophical basis for the approach, which
in turn leads to a difference in interpreting musculoskeletal signs and
symptoms. For example, Cyriaxlo
subscribes to an assessment system
closely linked with his interpretation
of applied anatomy (eg, differentiating
contractile and noncontractile structures). Mennell'sl3 primary focus is
examination of synovial joints and
treatment of joint dysfunction with
joint-play techniques. Central to the
osteopathic approach is the belief that
the body is an integrated unit o r total
system; that is, the neuromusculoskeleta1 system is connected with other
systems of the body, and disease processes are frequently visible in the
musculoskeletal system. A second
belief is that structure governs function and an abnormality in structure
can lead to abnormal function. Somatic dysfunction is the impaired or
altered function of the somatic system
(skeletal, arthrodial, and myofascial
structures and related vascular, lymphatic, and neural elemer1ts).39,~~
The physical therapist-generated
evaluative frameworks, like the
physician-generated evaluative
frameworks, subscribe to a philosophical basis. This philosophical
basis often includes integration of
other approaches, but with application of evaluation and treatment
techniques done by the physical

therapist (Tab. 2). The evaluation

frameworks for all three approaches
(ie, Maitland,6 Kaltenborn," and
McKenzieI2 approaches) have many
elements similar to Cyriax'sl0
screening criteria. Each approach
also includes examination procedures specific to the approach. For
example, Maitland6 emphasizes the
importance of continual assessment
in developing working hypotheses
based on evaluation. Kaltenborn"
includes elements that represent his
background as an osteopath (eg,
reference to somatic dysfunction) as
well as biomechanical assessments
of joint motion. McKenzieIZ uses
evaluation of repeated active movements and patient self-treatments as
key elements in his assessment.
Similarities among these three approaches include the use of palpation; testing of joint movements; and
mobilization/manipulation, exercise,
and patient education as treatment
strategies.
As practitioners become more eclectic
in their evaluation and management
of patients, the lines between evaluative approaches are likely to continue
to blur over time. A challenge for
manual therapists will be to search
for and identify the underlying theoretical arguments for manual therapy
evaluation and treatment procedures
that cross the various "philosophical
approaches" so that propositions can
be derived from the theories and
tested.

Implicit Dlmenslon
Musculoskeletal Evaluatlon:
The Role of Critical Analysis
Even though we see that, explicitly,
manual therapy approaches are based
on somewhat different philosophies,
they d o share a common dimension-there is always some form of
systematic evaluation and treatment of
patients with musculoskeletal dysfunction. The implicit dimension, that is,
the values and behaviors that are
central to the work of the manual
therapist, includes perhaps the most
important contribution to the profession made by manual therapy. This

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

Manual Therapy Approach
Cyrlaxlo (Orthopedic
Medlclne) Contentlons

Philosophical basis

Key concepts

Evaluation framework
History

1. All pain has an

anatomical source
2. All treatment must
reach that anatomical
source
3. If the diagnosis is
correct, all treatment
will benefit the source

Diagnosis of soft tissue

lesions
Categorization of
referred pain
Differentiation of
contractile and
noncontractile lesions

Mennelll3 Contentlons

OsteopathlcN.4o Contentlons

1 . Dysfunction is a sign of a serious

pathological process or joint
disease
2. Loss of normal joint movement or
joint play can lead to dysfunction
3. Joint manipulation can restore
normal joint-play movements

1. The body is a total unit, and the

Assessment of joint play

neuromusculoskeletalsystem is
connected with other systems;
therefore, disease processes can be
visible in the musculoskeletal system
2. The structure of the body governs
function; an abnormality in structure
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
Diagnosis of somatic dysfunction
a Clinical examination focuses on the

presence of asymmetry, restriction of

movement, and palpation of soft
tissue texture changes (ie, palpation
of skin, muscle, and other connective
tissue for feeling of thickness,
swelling, tightness, or temperature
change)

Observation, history
Age and occupation
Symptoms (site and
spread, onset and
duration, behavior)
Medical considerations
Inspection

Present complaint
Onset
Nature of pain
Localization of pain
Loss of movement
Past history
Family history
Medical systems review

History
Knowledge of physical trauma, past
visceral and soft tissue problems
Present complaint
a Establish relationship behveen
adaptation, decornpensation, trauma.
and time from patient's history

Physical examination
Active movements
Passive movements
Resisted movements
Neurological
examination
Palpation

Physical examination
Inspection
Palpation
Examination of voluntary
movements
Muscle examination
Special tests (eg.
roentgenography)
a Examination of joint-play
movements

Physical examination
Postural analysis
Regional screening functional units
a Pelvic girdle
Foot
Vertebral column
Shoulder girdle
Hand
Detailed evaluation of regions in
dysfunction

Interpretation of evaluation

Identification of anatomical
structure associated with
lesion

Joint dysfunction

Positional fault
Restriction fault
Segmental or multisegmental

Treatment strategies

Friction massage
Injection
Manipulation
Mobilization
Physical therapy (eg,
exercise, modalities)
Patient education

Manipulation
Mobilization
Physical therapy (eg, exercise,
modalities)
Patient education

Manipulation
Mobilization
Muscle energy
Myofascial techniques
Counterstrain
Exercise therapy
Patient education

Physical

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

ed
Approaches Used in Manual Therapy
Manual Therapy Approach

Philosophical basis

Key concepts

Maltland8 (Australian) Contentlons

Kaltenbornll (Norwegian) Contentlons

McKerulelz Contentions

1. Personal commitment to
understand the patient
2. Think about and apply theoretical
thinking (eg, pathology, anatomy)
and clinical thinking (eg, signs and
symptoms)
3. Continual assessment and
reassessment of data

1. Biomechanical assessment of joint

movements
2. Pain, joint dysfunction, and soft tissue
changes are found in combination

1. Predisposing factors of sitting

posture, loss of extension range, and
frequency of flexion contribute to
spinal pain
2. Patients should be involved in
self-treatment

Examination,technique, and
assessment are interrelated and
interdependent
Grades of movement (I-V)
Testing accessory and
physiological joint movements
Differential assessment to prove or
disprove clinical working
hypotheses

Somatic dysfunction
Application of principles from
arthrokinematics (eg, concave-convex
rule, close- and loose-packed
positions)
Grades of movement (1-111)

During movements of the spine, a

positional change to the nucleus
pulposus takes place
Flexed lifestyle leads to a more
posterior position of nucleus
Intervertebraldisk is a common
source of back pain

Evaluation framework

Subjective examination (as defined by

Maitlands)
Establish kind of disorder
Area of symptoms
Behavior of symptoms
Irritability
Nature
Special questions
History
Planning the objective examination
(as defined by Maitlands)
Physical examination
Observation
Functional tests
Active movements
Isometric tests
Other structures in plan
Passive movements (eg, special
tests, physiological and accessory
joint movements, relevant adverse
neural tissue tension tests)
Palpation
Neurological examination
Highlight main findings

History ("five-five scheme")

1. Immediate case history (eg, assess
symptoms for localization, time,
character, and so on)
2. Previous history (eg, assess for kind
of treatment, relief of symptoms,
presence of similar symptoms or
related symptoms)
3. Social background
4. Medical history
5. Family history
Patient's assessment of cause of
complaint
Physical examination
Inspection
Function (active and passive
movements; testing with traction,
compression, and gliding; resisted
tests)
Palpation
Neurological tests
Additional tests

History
Interrogation (eg, Where did pain
begin, how, constant or intermittent,
what makes it better or worse,
previous episodes, further
questions?)
Physical examination
Posture (sitting, standing)
Examination of movement (flexion,
extension, side gliding)
Movements in relation to pain
Repeated movements
Test movements
Other tests (eg, neurological, other
joints)

Interpretation of
evaluation

Initial assessment-relate examination

findings to
Behavior of patient's symptoms
The diagnosis
Stage of disorder
Stability of disorder
Irritability of disorder

Biornechanical assessment (ie,

restriction of joint mobility) and
assessment of soft tissue changes

Postural syndrome
Dysfunctionalsyndrome
Derangement syndrome

Treatment strategies

Based on continual assessment

Mobilization
Manipulation
Adverse neural tissue mobilizationa
Traction
Exercise
Patient education

Mobilization
Exercise (emphasis on proprioceptive
neurornuscular facilitation)
Tractionldistraction
Soft tissue mobilization
Manipulation
Patient education

Patient self-treatment using repeated

movements
Exercise
Mobilization or manipulation (if needed)
Patient education

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

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contribution is an emphasis on systematic evaluation as well as analysis

and interpretation of the clinical data.
We have seen increased integration of
manual therapy in practice and educati0n.7~23~32.33
Along with this growth
has been an increased emphasis on
the evaluative process as well as the
thinking and reasoning behind clinical decision making. For example,
Cookson and KenP7 argue that although therapeutic techniques applied for a certain musculoskeletal
condition may vary across the different philosophical approaches, evaluation of the patient to determine
whether to treat or not to treat is
essential. Over the last few years,
several musculoskeletal texts have
been written, not by physicians, but
by physical therapists.5.6.41-'5 These
texts focus on orthopedic assessment,
including evaluation and treatment.
The value of clinical reasoning and
decision making in practice and education also is a theme in recent professional w r i t i n g ~ . ~ 6 9
In our view, this process of not only
using a systematic evaluation scheme,
but investigating the clinical reasoning
and decision making that underlie the
evaluation and the understanding and
interpretation of findings is an extremely important goal for the profession. Professional expertise is described by many educators in the
professions as not only the possession
of technical skills, but also the use of
analytical skills for critical analysis and
deliberate action.sl-53 This critical
analysis requires that the professional
education process assist students in
becoming critical analysts. This process must occur in the "context of
action" or practice. For example, the
practitioner must first make sense of a
situation by imposing a structure or
framework for analysis. This framework is used to help define a problem and judge the potential consequences of action. Students and
practitioners must think about what
they will do and why and then take
action. The initial emphasis for students should be on the thoughtful
analysis of an experience rather than
finding the correct procedure.52-5*

The importance of developing therapists' thinking and analytical skills, as

well as their technical skills, raises
important questions. Do entry-level
degree programs promote critical
analysis of technique and allow time
for thoughtful analysis and reflection?
Are these programs focused on covering a given amount of material, consistent with trends in clinical practice?54 Do we see in continuing
education programs an equal emphasis on critical analysis of scientific
rationales or underlying theories as
well as application and mastery of
clinical techniques?

the interview data collected, which, in

essence, is a clinical judgment or
decision based on the experience,
training, and skills of the clinician. A
"working hypothesis" is formulated
with the intent of identifying the potential musculoskeletal structures
involved in the presenting pathology.
The clinician uses his or her assessment skills and knowledge to rank
the importance of each component of
the working hypothesis according to
the SINS algorithm. (S=severity,
I= irritability, N =nature of the complaint, and S=stage of pathology).49.9
Severity is the term used to describe

The Maitland, or Australian, approach

includes an evaluative framework that
is based on a conceptual model o r
framework.49jw We believe that the
Australian evaluation framework is an
example of how a clinician can facilitate his or her clinical-reasoning process. What follows in this next section
is an example of how the manual
therapist uses the evaluation framework for organizing and interpreting
clinical data.

The Australian Approach:

An Example of a Framework
for Critical Analysis
In the Australian approach, the evaluation process should begin when a
patient walks into the treatment room.
An interview process occurs in which
the manual therapist guides the patient's description of his or her symptoms by defining the location and
behavior of those symptoms, obtaining the patient history, and determining any precautions that may preclude
treatment. The interview (defined by
Maitland6 as the subjective examination) is vital as the first step in determining the source of the patient's
complaint. Maitland uses the term
"subjective" here to represent the
interactive portion of the examination,
that is, the therapist's interview with
the patient in which the therapist
begins to interpret the patient's perceptions of his o r her symptoms. The
term "subjective" is not used in a
scientific manner to represent a subjective measure o r test.55 The clinician
makes an assessment o r appraisal of

the clinician's assessment of the intensity of the patient's symptoms as they

relate to a functional activity. For
example, if the patient has ceased
using his o r her arm to dress and is
unable to find a position to ease pain,
then the symptoms are considered
severe. Nonsevere symptoms are
represented by the patient who is
able to dress with arm o r shoulder
pain, yet the pain is not intense
enough to stop the functional activity
even though pain is experienced.
Irritability is the term used to describe the clinician's assessment based
on (1) the amount of activity needed
to bring on the patient's symptoms
and (2) the amount of time before
the patient's symptoms subside (duration). For example, a shoulder pain
that begins when the patient lifts an
arm and that lasts for 4 hours means
that the patient's condition is extremely irritable (little activity causes
considerable pain that lasts for a long
period of time). Conversely, a shoulder pain that is aggravated when the
patient lifts his or her arm, but eases
when the patient returns the arm to
his or her side, would be considered
a nonirritable condition.
The nature of the complaint is the
term that represents the clinician's
assessment of the patient's pain tolerance, including consideration of cultural differences, stability of the condition, type of pathology, and the
physical therapist's hypothesis of the
structures responsible for producing
the pain complaint. The stage of the
pathology is a term used to describe

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the clinician's assessment of what the

progression of symptoms is for the
patient. For example, if the patient
reports that he or she had low back
pain 2 days ago and now has lowerextremity pain radiating to the ankle,
the clinician may suspect that the
pathological condition is deteriorating. The hypothesis would then be
reranked accordingly.6~45
Clinical decisions that relate to intervention also revolve around assessing
data during and at the conclusion of
the physical examination, during the
application of treatment techniques,
and at the conclusion of the initial
treatment.6150From this form of analysis, treatment goals are established
and a treatment strategy is formulated.
Throughout the course of treatment,
the therapist continues to assess the
effect of treatment on the patient's
hnctional limitations that relate to his
o r her lifestyle and work environment
and the active, passive, o r functional
movement signs and symptoms that
relate to the clinical working hypothesis. Through continual assessment of
each technique, exercise, or modality,
the clinician progresses treatment and
hypothesizes which structures or
body regions most likely contribute to
the patient's problem. For example, if
a patient's active or passive movement
signs, symptoms, and functional status
are not changing at what the clinician
believes is an appropriate rate, the
clinician needs to reassess (ie, rerank,
reject, or reformulate) the working
hypothesis and alter the treatment
accordingly.49
The clinician has a central role to play
in collecting and interpreting clinical
data for individual patients. We propose that the clinician also has a central role to play in the generation of
classification systems that identify
commonalities and differences across
patient cases. In 1989, Rose47 argued
that therapists need to identify and
characterize the relationships between
clinical entities and specific treatments
and management strategies. He argued that clinicians need to use a
process of rational practice and critical thinking to achieve this goal. 0th-

e r ~ 5 ~ ~have
5 7 suggested that the use of
established clinical classification systems may assist physical therapists in
this classification process. As the physical therapy profession moves toward
more systematic observation and
classification of clinical phenomenon,
the manual therapist could serve a
critical role assisting with the develop
ment of this process. In this special
issue, the article by Jones provides
further dialogue about the role of
clinical reasoning in manual therapy.

(authority figures) and that knowledge, like knowledge from tradition,

has not been validated or verified
through research.5B For example, the
philosophical bases of the different
approaches to manual therapy are
generally well-known and central
aspects of the written materials, yet
there has been little focus on developing and discussing application of
theory to practice o r generating testable questions from identified key
theories.

Null Dlmenslon

We cannot ignore that clinical practice combines the elements of art

and science. Clinical observation
We believe that there are other asand manual technique are central
pects of manual therapy that are part
components of the artistry of pracof the null dimension, that is, aspects
tice in manual therapy. Feinstein59
that are often ignored. Grieve desuggests that clinical practice is neiscribes the present state of manual
therapy well:
ther art nor science, but the most
scientific art and the most humanisWe continue to sound as though we
tic science. Several articles in the
know so much, when we know comJuly 1989 issue of Physical Therapy
paratively little. It might be a good
thing to admit this. We make much of
on clinical decision making focused
clinical science, enthusiastically referon discussion and improvement of
ring to this or that part of the massive
clinical mea~ures.47.55~60~61
Delitto60
mountain of literature which best
suggests consideration of Feinstein's
serves our particular interest . . . . Much
(eg, deprinciples of clinimetric~6~
of what we do is simply what has been
velopment of clinimetric indexes
proven on the clinical shop floor to be
that address face validity and content
effective in getting our patients betvalidation
and that have a formal
ter-we do not always know ~ h y . ~ 3 ( p ~ )
expression of the index) as a way of
expanding the scientific basis of
One aspect of manual therapy that is
clinical practice. Many of these prinfrequently ignored is consistent disciples
have application for investigacussion and analysis of the identified
tions
in
manual therapy.
theory o r body of general principles
underlying the knowledge base. We
For example, palpation plays a central
have noted that biomechanics, anatrole in application of sevelal manual
omy, and neurophysiology are often
therapy
techniques. Palpation is a
discussed as providing an underlying
practical
skill that apparently requires
rationale for manual therapy and are
many
hours
of training and practice
enthusiastically referred to as the
to
maste1-.~3
Many
manual therapists
elements that fit our applications.24
of the spine
believe
that
palpation
We need to ask ourselves, What are
and
associated
areas
that
contribute to
the sources of knowledge cited for
the
presenting
symptoms
may be the
manual therapy in either entry-level
most informative aspect of the physio r continuing professional education?
cal examination." Sophisticated imagIs the knowledge base in manual
ing techniques continue to serve as
therapy built on a model of tradition
major tools in the diagnosis of muscuo r authority or the scientific methloskeletal problems, with less reliance
od?58A model of tradition refers to
on palpation. The challenge for physiknowledge obtained from "truths" or
cal therapists will be to integrate
beliefs that were accepted in the past
technology and manual skills so that
and that continue to influence pracboth components can enhance theratice. A model of authority is when
pists' understanding of musculoskeleknowledge is gained from experts
tal problems. For example, Jull et a165

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studied 20 patients, all of whom had

complained of chronic neck o r headache for at least 1year, who underwent manual examination of the cervical zygapophyseal joints and
radiographic assessment. In one
group of patients (n = 11), the presence o r absence of symptoms associated with a joint was established by
radiographically controlled diagnostic
nerve blocks. The manual therapist
was unaware of the diagnosis and
examined the patients 1 to 4 weeks
after the nerve block. The order of
events was reversed in the second
group of patients (n=9); that is, the
manual examination was first, followed by the diagnostic nerve blocks.
Of the 20 patients studied, the manual
therapist identified all 15 patients who
had symptomatic zygapophyseal joints
and also identified the 5 patients who
did not have joint involvement. This
study is an example of systematic
investigation of the "an" of palpation
and represents an initial step toward
investigation of the validity of palpation techniques.
Another area of manual therapy that is
often ignored are investigations regarding the effectiveness and efficacy
of manual therapy. Several investigations have examined the use of manual therapy for treating spinal conditions, particularly low back
pain.1+2112+32 Di Fabio's article in this
issue provides an analysis of this literature. A related issue is exploration of
the potential role of the placebo effect
in manual therapy. Improvement of a
patient's condition after physical therapy cannot be seen as evidence of the
efficacy of manual techniques.
Gielen66 identifies two major elements that contribute to the placebo
effect: (1) the therapist-patient relationship, which is influenced by the
patient's perceptions of the therapist's
expertise, trustworthiness, optimism,
and enthusiasm, and (2) the use of
other modalities. Patient education is
also seen as a component of a manual
therapy intervention (Tabs. 1, 2). In
our theory development for manual
therapy, we may need to consider a
model that not only represents the
dimensions we routinely think of as

underlying musculoskeletal evaluation

and treatment (eg, anatomic, biomechanical, neurophysiologic), but gives
more purposeful consideration to
aspects of human behavior. For example, theories regarding patientprovider interactions, health behavior,
and cultural aspects of illness6- may
also help clinicians develop a fuller
understanding of the context of clinical practice.

This assessment of manual therapy

has provided an introduction to the
current role of manual therapy in the
profession of physical therapy. Manual
therapy represents more than just the
application of passive movements, and
the field continues to evolve as a
subspecialty in physical therapy. The
knowledge base and practice of manual therapy have strong ties to the
philosophical approaches advocated
by several clinicians. The scientific
base of manual therapy is frequently
tied to knowledge from other disciplines (eg, anatomy, biomechanics,
neurophysiology), with few o r no
investigations to substantiate the connections made between knowledge
and practice, o r the efficacy of practice. Systematic and continual assessment is a central component of the
clinical-reasoning process manual
therapists use in confirming o r disconfirming a diagnosis. Investigations
that focus on the clinical-reasoning
and decision-making processes should
be helpful initial steps in addressing
questions such as, Why are patients
getting better? and What kinds of
patients get better with what treatments? Such investigations, ultimately,
should be helpful in developing theories of practice for the profession of
physical therapy.
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Physical Therapy /Volume 72, Number 12December 1992

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Manual Therapy: A Critical Assessment of Role in the

Profession of Physical Therapy
Joseph P Farrell and Gail M Jensen
PHYS THER. 1992; 72:843-852.

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