Omar Baiyasi

PTH 661
Zipple
7/18/16
Joint Manipulations: For Specialists Only or All Physical Therapists Alike
High-Velocity Low-Amplitude (HVLA) techniques are advanced manual therapy
techniques that carry a significant amount of risk with them. If performed incorrectly a patient
can sustain major structural damage; however if performed correctly they can be very beneficial
in correcting patients orthopedic dysfunctions.2 When oscillatory mobilizations or other less
extreme joint mobilization techniques fail, HVLA maneuvers can prove to be very useful. Thus,
HVLA manipulations may currently be performed by entry-level physical therapists, following
patient informed consent. The question to be explored in this paper is whether or not HVLA
techniques should continue being performed by general physical therapists or whether they
should be restricted to use by manual therapy specialists.
Due to the potential danger that accompanies HVLA techniques, some therapists have
suggested that these advanced techniques be limited in their use. This topic has been explored in
many different scenarios, and has resulted in a multitude of research experiments and articles.
One observational research article, titled Joint Manipulation Curricula in Physical Therapist
Professional Degree Programs,1 specifically looks at the thoughts and opinions on joint
manipulation of primary faculty members of professional degree programs. With the purpose of
the study described by the researchers as the status of physical therapy curriculas focus on joint

mobilization in the United States,1 the authors reached out to the 199 physical therapy
professional degree programs accredited in the United States. The surveys sent to the programs
included information about joint manipulation curricula, the qualifications of faculty within each
individual program, attitudes and experience, and each programs plans for teaching
manipulative techniques in the future.1 The researchers reported that 116 programs responded to
surveys, and 87 of these such programs reported that they either currently include joint
manipulation or will soon (which comes to 75%).1 Only 51 (44%) of the responding programs
were found to currently include joint manipulation in their curriculum, however.1 The faculty
members teaching manipulation techniques were found to be well qualified according to the
researchers, performing an average of 12 hours of clinical practice each week outside of
teaching, but 45% of programs not teaching joint manipulation were doing so because they felt it
was not an entry-level physical therapy skill.1
While some curricula programs within the United States feel as though joint manipulation
should not be taught in entry-level programs because of the difficulty and risks associated with it,
the overwhelming majority of responding programs are either currently teaching manipulation
techniques or plan to do so soon.1 This demonstrates that many therapists feel joint manipulation
should be taught to student physical therapists regardless of the dangers. With skilled, qualified
therapists teaching these more difficult skills, the reward of teaching manipulation techniques
outweighs the risks. Since this study1 was so thorough and reached out to all physical therapy
programs within the United States, the results it gathered are very comprehensive and applicable
to the question at hand. Every single entry-level physical therapy program within the country at
the time (in 2004) was sent the survey created by the authors and almost 60% responded.1 This
shows just how beneficial the study was in examining the use of joint manipulation by student

therapists. To further investigate whether HVLA techniques should be integrated in entry-level

physical therapy programs, however, a study polling physical therapy programs around the world
would be useful. The study1 shows that most programs within the United States agree that
HVLA techniques should be taught to student physical therapists, but investigating the thoughts
and sentiment of programs in Europe or the Pacific, for example, would be valuable as well.
As the aforementioned study1 shows, most physical therapy programs within the United
States believe HVLA techniques should be taught to entry-level therapists. While beneficial in
the right circumstances, the risks shouldnt be overlooked, however. Students need to understand
just what all the dangers of joint manipulation include. Most injuries associated with
manipulation occur due to poor selection criteria, the arrogance of the performing therapist, or
discrediting the internal alarm system and not backing off from a manipulation when necessary.2
Joint mobilization of extremities, when performed incorrectly or in improper situations,
generally cause minor muscle tearing, joint capsule or ligament sprains, or inflammation and
internal edema at the synovial membrane.2 While no deaths have been attributed to
manipulations by physical therapists,2 these potential risks are still very serious and can
contribute to major structural damage. As stated previously, however, manipulation techniques
can be quite beneficial for patients lacking range of motion and are thus very useful in clinical
practice. Completely removing HVLAs from entry-level programs would be taking away a very
useful skill from recently graduated therapists. With well qualified faculty members teaching
joint manipulation and giving student physical therapists a strong understanding of the
techniques, entry-level clinicians will be well prepared to perform manipulations. It is very
important that these manipulations be taught by skilled therapists in curricula, and if this
condition is met then HVLAs should continue being taught at entry-level programs.

References
1. Boissonnault WG, Bryan JM, Fox KJ. Joint Manipulation Curricula in Physical Therapist
Professional Degree Programs. Journal of Orthopaedic and Sports Physical Therapy J Orthop
Sports Phys Ther. 2004;34(4):171-181. doi:10.2519/jospt.2004.1239.
2. Zipple JT. PTH 661: Manual Therapy I. Lecture/Lab Packet. July 2016.