Journal of Manual & Manipulative Therapy

ISSN: 1066-9817 (Print) 2042-6186 (Online) Journal homepage: http://www.tandfonline.com/loi/yjmt20

A History of Manipulative Therapy Through the

Ages and Up to the Current Controversy in the
United States

Stanley V. Paris

To cite this article: Stanley V. Paris (2000) A History of Manipulative Therapy Through the Ages
and Up to the Current Controversy in the United States, Journal of Manual & Manipulative
Therapy, 8:2, 66-77, DOI: 10.1179/106698100790819555

To link to this article: http://dx.doi.org/10.1179/106698100790819555

Published online: 18 Jul 2013.

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A History of Manipulative Therapy Through the Ages and Up
to the Current Controversy in the United States
Stanley V. Paris PhD, PT

Abstract: Joint manipulation is an ancient art and science that can trace its origins to the earliest
medical and lay practitioners. Today, it is practiced principally by physical therapists and chiro-
practors and to a lesser degree, by osteopathic and medical physicians. Self-manipulation of both
joint and soft tissues is also a common practice in those who “crack” their own knuckles and
spines. This article traces the history and development of manipulation from its origins to the
present with a special emphasis on developments in the United States as a background for under-
standing current licensure and practice issues.
Since the beginning of this century, physical therapy has enjoyed a close relationship with
medicine and has developed its knowledge base and practice in spinal and extremity manipulation
from the medical profession. Manipulation in physical therapy has become a significant part of its
rehabilitation practice, often encompassed in the terms therapeutic exercise, active and passive
movement, or manual therapy. Instruction in manipulation begins with pre-professional educa-
tion; for those who wish to specialize in this field, instruction continues at the post-professional
level, following the medical model of specialization. Since the 1960’s, physical therapists have
developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced
physical function.
By contrast, since its independent origins in the late 19th century, chiropractic has practiced
manipulation for most of its history as a primary therapeutic tool to correct spinal sublux-
ation. It provides spinal adjustments to facilitate the free flow of nerve energy, which, in
turn, relieves many human ailments. Unlike physical therapy, chiropractic has not been practiced
in cooperation with medicine but has existed as an alternative during most of its history. In
recent years, the chiropractic profession has divided along philosophical lines: those who
strongly defend the subluxation theory (straights) to those who do not (mixers), with the
later group now holding sway. This change in chiropractic philosophy and practice has brought
practitioners into a practice model more closely aligned with the comprehensive model of
rehabilitation therapy modeled by physical therapists. Consequently, many chiropractors now
use physical therapy procedures even though they are prohibited from calling themselves
physical therapists. As a result, competition in the market place has heightened, with con-
comitant licensure and political challenges.
This article discusses the history and evolution of the practice of manipulation against
a background of other key developments in health care; as such, it should provide under-
standing for today’s current practice scene.

Key Words: History, Manipulation, Physical Therapy, Chiropractic, Osteopathy

Definitions: For the purpose of this paper, joint manipulation is defined as a skilled passive
movement to a joint, ranging from the gentlest oscillations to thrust and including traction.
Additionally, joint manipulation and joint mobilization are used here as synonymous terms.

The American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) has approved
the following two definitions 1:
Manipulations/mobilization
The skilled passive movement to a joint and/or to the related soft tissues at varying speeds
and amplitudes including a small-amplitude, high-velocity therapeutic movement.

The Journal of Manual & Manipulative Therapy

66 / The Journal of Manual & Manipulative Therapy, 2000 Vol. 8 No. 2 (2000), 66 - 77

Manual Therapy
A clinical approach utilizing skilled, specific hands-on
techniques, including but not limited to manipulation/
mobilization; used by physical therapists to diagnose and
treat soft tissue and joint structures for the purpose of
modulating pain, increasing range of motion, reducing
or eliminating soft tissue inflammation, inducing relax-
ation, improving contractile and non-contractile tissue
repair, extensibility and or stability, facilitating move-
ment, and improving function.
In practice, however, especially within American physical
therapy, the term mobilization is frequently used to refer
to non-thrust techniques and the word manipulation to
thrust techniques. This artificial distinction was created
during the 1960’s when the American Medical Associa-
tion, through its Committee on Quackery, strongly op-
posed the practice of chiropractic; by association they
also opposed the word manipulation. Thus, physical
therapists sought to use less controversial terms such as
articulation and later mobilization.2
The Beginning
Manipulation and Ancient Art
The beginnings of massage and even joint manipu-
lation are in man himself, for who has not witnessed the
relief obtained from the “cracking” of joints or the stretching
of muscles. From drawing back the shoulders, pulling
the knees to the chest, stretching the hamstrings, or cracking
knuckles or joints of the low back, since the beginning
of time man has sought to free soft tissue and joint re-
strictions.
Walking on a subject’s back is a primitive method of
manipulation, predating recorded history; among the Indian
tribes of North America, it was well known that general
bone-setting was skillfully practiced, particularly by the
Sioux, Winnebagos, and Creeks. However, the first re-
corded description and illustration of joint manipulation
and traction techniques occurs in Hippocrates (460-355
BC), who wrote at least three works on the bones and
joints, including “On Setting Joints by Leverage”, in which
he describes a combination of extension (traction) and
pressure (manipulation) exerted on a patient lying prone
on a wooden bed.3 Hippocrates has often been referred
to as the Father of Medicine and physicians worldwide
are aware of the Hippocratic Oath, which deals princi-
Address all correspondence and request for reprints to:
Stanley V. Paris
University of St. Augustine for Health Sciences
1 University Boulevard
St. Augustine, FL 32086-5783
USA
A History of Manipulative Therapy Through the Ages and Up to the
pally with patient care and which admonishes all to do
no harm. Hippocrates also wrote on a number of tech-
niques, including the reduction of dislocated extremity
joints, particularly of the shoulder, which was undoubt-
edly related to the popularity of wrestling in his time.
With regard to spinal manipulation, he wrote, “It’s not
harmful to either sit on the back during traction and do
a shaking movement while easing and sitting down again.”
Claudius Galen4 (131-202 AD), a famous Italian sur-
geon, wrote and illustrated extensively. In 18 of his 97
surviving theses, he comments on the work of Hippocrates,
with illustrations of many of his manipulative techniques.
These illustrations frequently adorn texts and treatises
dealing with the history of medicine.
The Middle Ages and Renaissance
The Middle Ages represented a decline in medical knowl-
edge throughout the Western World. The established Church
became responsible for most healing. St. Lawrence was
appointed as the patron saint for those with backache-a
position held until 1970 when, along with St. Christo-
pher (patron saint of travel), he was removed from saint-
hood by the Vatican Council.
The Renaissance in medicine began with Andreus
Versalius, who described in 1543 the detailed anatomy of
the entire human body and outlined the anatomy of the
intervertebral disc, including differentiation between the
annulus and the nucleus.
In 1579, Ambrose Pare, famous surgeon to four suc-
cessive French kings, did much to raise the standard of
what is now orthopaedic surgery. For instance, he was
the first to attempt trunk support using anterior and pos-
terior metal plates made by armorers. He used a consid-
erable amount of manipulation, including many of the
techniques described by Hippocrates. He also wrote, “When
the vertebrae are dislocated posteriorally and protrude,
it is a good idea to put the patient in a prone position on
the table. Fasten him to this with ties under his armpits,
around the waist and the thighs and after that pull and
stretch as much as possible upwards and downwards though
without violence.”5
Dawn of Modern Medicine
John Hunter (1728-1793) taught the value of move-
ment to joints after injury in order to prevent stiffness
and adhesions. Hunter recommended that adhesions re-
maining as the end product of inflammation be stretched.
Pott (1714-1788) gave his name to Pott’s disease (known
today as tuberculosis of the spine) and to Pott’s fracture,
the common characteristic break of one or both bones
above the ankle (which incidentally he sustained when
he fell from his horse in 1769). Pott condemned exten-
sion exercises and manipulation as useless and danger-
ous in the management of the spine.
Current Controversy in the United States / 67
 By the mid-18th century, Andre synthesized the term
orthopaedic “from the Greek roots orthos (straight) and
paidos (child).”
In the late 18th century, Hay described cases of ma-
nipulating the semilunar cartilage of the knee, relieving
the condition by resting the knee in its normal position.
In 1784, Harrison, a graduate of Edinburgh Univer-
sity, developed a sizable reputation using manual medi-
cine procedures including manipulation.
In 1817, Parkinson became interested in disorders
of the cervical spine as a possible cause of spinal cord
disease. This concept did not receive much attention
until more recent times when Lord Brain and Marcia
Wilkinson, in 1956, described how advanced stages of cervical
spondylosis may result in myelopathy and simulate spi-
nal cord diseases such as multiple sclerosis.6
In 1842, Riadore, a London physician practicing ma-
nipulation, wrote,”If an organ is insufficiently supplied
with nervous energy or blood, its function is decreased
and sooner or later its structure becomes endangered.”7
This statement would be mirrored later in the century
by the founder of chiropractic.
In 1846, Morton began using ether as an anesthetic
and demonstrated it at Massachusetts General Hospital.
In 1864, Lasegue described the posture that is com-
mon with sciatic leg pains; his name was later added to
a modification of the straight leg raise test.
Bone-setting
During the 17th and 18th centuries, a practice known
as “bone-setting” was flourishing in Britain. Bone-set-
ting was a family affair, passed on from father to son and
occasionally to daughter. It was based on the belief that
“little bones” could become out of place and that the click
that followed manipulation was that of “little bones” going
back into place.
Bone-setters, along with barber surgeons, were the
forerunners of orthopaedics and surgeons in the United
Kingdom. Their practice flourished during the 18th and
19th centuries with bonesetting dying out only in the
middle of the 20th century when physical therapy and
osteopathy assumed its place.
In 1867, Sir James Paget (1814-1899) lectured on
“Cases That Bone-Setters Cure,” later published in the
British Medical Journal. He gave the following advice:
“...Learn then, to imitate what is good and avoid what is
bad in the practice of bone-setters...too long a rest is, I
believe, by far the most frequent cause of delayed recov-
ery after injury of joints and not only to injured joints,
but to those that are kept at rest because parts near them
have been injured.”
In 1871 Wharton Hood published On Bone-Setting8,
the first such book by an orthodox medical practitioner.
Hood believed that the snapping sound frequently heard
with manipulation was that of adhesions being broken,
68 / The Journal of Manual & Manipulative Therapy, 2000
not that of bones going back into place. Hood’s father,
also a physician, had been treated effectively by a well-
known bone-setter named Hutton. This led Hood, the
younger, to study the topic.
Thus by 1870, manipulation was firmly established
in contemporary medicine. It was the topic of meetings
and papers, and a first book had been devoted to the subject.
It is important to note that 1870 preceded both the founding
in America of osteopathy by 4 years and chiropractic by
28 years.
In 1882, bone-setting was the main topic at the annual
meeting of the British Medical Association’s Section on
Surgery. Marsh9 and Fox 10 both considered manipula-
tion in favorable terms but used instead the term “bone-
setting.”
During the early part of the 20th century, Marlin11,
Blundell-Bankart,12 Burrows, Coltart,13 and Humphris14
were among the medical practitioners publishing on
manipulation.
Osteopathic Medicine
Osteopathic medicine and surgery was founded by
Andrew Taylor Still in 1874. Still was an eccentric non-
conformist who had raised considerable wrath among his
medical contemporaries, who had little time for him or
his views. He attended the Physicians and Surgeons College
of Kansas City. July 22, 1874, is the date he gave for his
founding of osteopathy: “Like a burst of sunshine the whole
truth dawned on my mind...” Through careful study of
the patient, Still observed that when joints restricted in
motion due to mechanical locking or other related causes
were normalized, certain disease conditions improved.
Still made much of blood and nerve “flow” and wrote,
“...I proclaim, though, the disturbed artery marked the
beginning to an hour in a minute when the disease be-
gan to sow its seeds of destruction in the human body.
But in no case could this be done without a broken or
suspended current of arterial blood, which by nature, was
intended to supply and nourish every nerve, ligament,
muscle, skin, bone and the artery itself. He who wishes
to successfully solve the problem of disease or deformity
of any kind in every case without exception would find
one or more obstructions in some artery or vein...The
rule of the artery is absolute, universal, and it must be
unobstructed, or disease will result.” Thus was enunci-
ated what was to become known in osteopathy as “The
Law of the Artery.”
The osteopathic concept has been briefly stated as:
(1) the body is a unit; (2) structure and function are
reciprocally interrelated; and (3) the body possesses self-
regulatory mechanisms for rational therapies based on
an understanding of body unity, self-regulatory mecha-
nisms, and the interrelation of structure and function.
Osteopathy continued to grow and develop as well
as to embrace the advances being made in medicine. As
a result, by the late 19th century, osteopathy was losing
some of its appeal as it no longer claimed to be a stand-
alone “cure-all.” Osteopathy was clearly becoming more
orthodox and, in the process, creating a void.
By 1928, osteopathic physicians (D.O.) in the United
States gained equal rights with allopathic physicians (M.D.)
in the Armed Forces, and within each state by 1970. Today’s
osteopaths are mostly engaged in maintaining the nec-
essary medical knowledge so that few have the time to
be active in manipulative practice. In quite a few osteo-
pathic hospitals, physical therapists provide the manipulative
care and in some cases give instruction to osteopaths15,16 .
One offshoot of osteopathy was begun by William Garner
Sutherland who, in 1966, marveled at the intricacy and
design of the cranial sutures and founded soon thereaf-
ter a clinical technique to be known as cranial osteopa-
thy 17. Current practitioners of craniosacral technique claim
great skills at detecting cranial rhythm dysfunction and
treating it by gentle touch.
Chiropractic
Into the void created by osteopathy strode, in 1895,
Daniel David Palmer, a former green grocer and practic-
ing magnetic healer who founded chiropractic (from the
Greek cheir, meaning hand; and praxis, meaning done
by hand). Some proponents of chiropractic attribute the
discovery of manipulation to Palmer. However, Palmer
himself makes it quite clear in his book The Chiropractor’s
Adjustor 18 that this was not the case and that indeed he
had learned it from a medical practitioner: “The art of
repositioning subluxed vertebra has been practiced for
thousands of years... My first acquaintance of this refers
to physician Jim Atkinson, who practiced in Davenport,
Iowa, 50 years ago, and who during his lifetime tried to
announce his principles, which are now known as
‘chiropractique.’” A little further on, Palmer writes, “But
I insist on being the first who has repositioned a dislo-
cated vertebra by using the spinous and transverse pro-
cesses as balance levers ... and out of this fundamental
fact I have founded a science which is decided to revo-
lutionize the art of healing’s theory and practice...”Thus
the foundation of chiropractic manipulation was, by the
founder’s admission, from medicine. Interestingly,
Hippocrates and Galen could both challenge Palmer’s
assertion as the first to reposition a “dislocated” verte-
bra.
In his writings, Palmer made it perfectly clear that
he did not originate the art of chiropractic and that it
was a “rediscovery and revival of the ancient Hellenic
healing practice...” This statement, of course, refers to
the works of Hippocrates. This history and its principles
were recommended to Palmer by scholars and travelers,
and from this he developed what we know as chiroprac-
tic.
Janse, Houser, and Wells (1947) defined the theoretical
A History of Manipulative Therapy Through the Ages and Up to the
basis of chiropractic as follows: (1) that a vertebra may
become subluxed; (2) that this subluxation tends to impinge
other structures (nerves, blood vessels, and lymphatics
passing through the intervertebral foramen); (3) that, as
a result of impingement, the function of the corresponding
segment of the spinal cord and its connecting spinal and
automatic nerves is interfered with and the function of
the nerve impulse impaired; (4) that, as a result thereof,
the innervation to certain parts of the organism is ab-
normally altered and such parts become functionally or
organically diseased or predisposed; and (5) that adjust-
ment of a subluxed vertebra removes the impingement
of the structure passing through the intervertebral fora-
men, thereby restoring to diseased parts their normal
innervation and rehabilitating them functionally and
organically19 . In chiropractic, the above philosophy be-
came known as “The Law of the Nerve.”
Traditional chiropractic, whose practitioners are known
as “straights,” and which is still the primary teaching
emphasis in several chiropractic schools including two
of the largest, is on the wane; most chiropractors today
are “mixers” a term that describes those chiropractors
who mix traditional chiropractic with modern physical
therapy rehabilitation techniques. In many states, chi-
ropractors can state that they perform physiotherapy al-
though in no state are they able to promote themselves
as physical therapists.
Since chiropractic traditionally claimed to be a “cure-
all” by manipulation, it was for many years the target of
orthodox medicine.
In Washington, DC, in 1970, at a conference spon-
sored by the National Institute of Neurological Disease
and Stroke on the the Research Status of Spinal Manipu-
lative Therapy20 , chiropractic redefined the term “sub-
luxation” to include virtually every known dysfunction
of the spine as part of a successful effort to gain Medi-
care reimbursement. To do so, chiropractic needed to
prove the subluxation by redefining the term so as to be
inclusive of all currently recognized dysfunctions.
In 1981, the traditional opposition to chiropractic
and other practices considered cultist by the American
Medical Association was neutralized when, in Chicago,
Chester Wilkes, D.C., et al successfully sued the AMA,
most notably its Committee on Quackery, on the grounds
of restraint of trade21. Consequently today’s current graduates
of medical schools do not receive negative chiropractic
literature as had previous generations of physicians.
Physical Therapy and Medical Manipulation
It is not possible to speak of manipulation in physi-
cal therapy without speaking of manipulation in medi-
cine since medicine created physical therapy to aid re-
habilitation. Physicians trained these aides who later became
physical therapists. Hence the history, philosophy, and
practice of medicine vis-a-vis physical rehabilitation,
Current Controversy in the United States / 69
including manipulation and all areas of manual therapy,
evolved into physical therapy (physiotherapy).
In 1899, physiotherapy was founded in England. It
already existed under other names, such as massage and
medical gymnastics, or massage and movement, in a number
of countries, including England and Scandinavia.
The two medical names most associated with instruction
of manipulation to physical therapists were James and
John Mennell, father and son, and Edger and James Cyriax,
father and son.
In 1907 James Mennell, M.D., associated himself with
the newly formed Society of Trained Masseuses, later known
as the Chartered Society of Physiotherapy. He instructed
joint and soft tissue manipulation techniques, and he
encouraged his medical colleagues to send patients to
“these ladies” by prescription. One masseuse, Hislop, trained
with Mennell during World War II and carried her knowledge
to New Zealand after the war22. James Mennell also published
a number of texts on the subject, largely directed at physical
therapists23 .
By 1949, James Mennell was awarded the Golden Keys
with Life membership in the American Congress of Physical
Medicine and in the American Physical Therapy Associa-
tion 24. He may also have been the first to use the term
manual therapy, which he chose for the title of a book
in which he exclusively addressed the topics of massage,
passive movement, assisted movement, resisted move-
ment, and joint manipulation 25.
At a meeting convened by the National Institute of
Health and Neurological Disease (1975) to explore the
practice of manipulation, John Mennell stated that physical
therapists use a confusing array of terms, which “... cloud
the issue by talking about degrees of manipulation using
such terms as articulation and mobilization leading up
to manipulation”. This confusing array resulted from the
reputation that manipulation had earned in the hands of
chiropractors and the poor press manipulation had re-
ceived at the hands of the American Medical Association
in its efforts to counter chiropractic. Over time, how-
ever, the term manual therapy has become inclusive of
all forms of joint and soft tissue manipulation.
Another famous name in the early days of coopera-
tion between medicine and physiotherapy, Edgar Cyriax
wrote extensively on manual therapeutic methods 26. In
1917, he published a paper, “Manual Treatment of the
Cervical Sympathetics,”27 in which he outlined the tech-
niques for palpating the cervical sympathetic ganglions
and treating them by transverse friction in order to stimulate
their function. Later James Cyriax instructed in England,
America, and throughout the British Commonwealth as
well as publishing a number of texts and articles28 .
In 1921, physical therapy was established in the United
States as the American Women’s Physical Therapeutic
Association “to make available efficiently trained women
to the medical profession”29 . The need for such trained
individuals had been clearly demonstrated during and
70 / The Journal of Manual & Manipulative Therapy, 2000
following World War I.
Writing on “Physiotherapy in Stiff & Painful Shoul-
ders,” Granger30 stated that “on forceful manipulation it
is found that the scapula moves coincidentally with the
arm.” Other treatments recommended included:
1. Heat, external and internal baking
2. Chlorine ionization, for its resolvent effect
3. Massage, for its circulatory effect and also to regain
muscular relaxation
4. Stretching, to break up adhesions, to increase
the arc of motion, and, by lessening the
pressure, to relieve pain
5. The blue pencil static brush discharge or monipolar
high frequency vacuum tube to minimize the
reaction after breaking up the adhesions
6. Exercises
In 1923, speaking to the American Physiotherapy As-
sociation, McKenzie advocated, “If we will only pay at-
tention as we should to the study of physiological effects
of physiotherapy to the technique of manipulation, to
the procedures of massage, and to this question of re-
education, we will go far to establish, in its proper rela-
tionship, the kinship of Physiotherapy to the general practice
of medicine, and we will be able to show up in their true
light those pseudo cults which have flourished so luxu-
riantly because of our neglect”31. He was, of course, referring
to chiropractic and, at that time no doubt, to osteopathy
as well.
Also in 1923, in Physiotherapy Technic: A Manual of
Applied Physics, Sampson wrote of the physiotherapy staff:
“All of the aides were highly trained in massage, manipu-
lation, exercises, etc. and most were trained in one or
more departments where electrical treatments were given.”
He also noted, “No fibrosed joint should be pronounced
hopeless until...progressively strenuous manipulations have
failed.”32
The 1930’s saw the emergence of arthrokinematics
and clinical assessment. Movement had been tradition-
ally described as the spatial relationship of the limbs (or
trunk) to the axis of the body. Thus joint movement was
described as adduction, abduction, flexion, extension, ro-
tation, etc., with very little attention to the actual move-
ments taking place within the joints themselves, such as
roll, glide, and spin. In 1927, Walmsley33 began intro-
ducing a new terminology, known as arthrokinematics,
which was later adopted by Gray’s British Anatomy. Walmsley
noted, among other observations, that the articular sur-
faces of joints are incongruous except in one special position
(Walmsley’s Law). This position we now call “close packed.”
Some years later, Kaltenborn, a physiotherapist, saw
the significance of the emerging field of arthrokinematics
and applied it to joint manipulation, thus developing an
entirely new approach to manipulation distinctive to physical
therapy.
In 1930, Leadbetter published in The Physiotherapy
Review (American) a discussion of “mechanistic derange-
ments” of the lumbar spine and sacroiliac region; “in cases
of unilateral sacro-iliac strain which resist the above treat-
ment, one should consider the necessity of manipulation”34.
In 1932, Humphris and Stuart-Webb defined the me-
chanical effects of physiotherapy as “massage and ma-
nipulation, with exercises active and passive and
mechanovibration”35 . Rank Romer contributed a chap-
ter on massage and manipulation in which he wrote,
“Generally speaking the movement should be performed
in a swift, even and firm manner, so that a joint under-
goes the notions of its normal action, though not nec-
essarily to the full extent of its range”.
In 1933, Ghormley described what he called the “Facet
Syndrome”36 . He felt that arthritic changes in the facets
or a narrowing of the intervertebral foramen as a result
of these changes were the etiology of many cases of sci-
atica. As it turned out, his description of the facet syn-
drome, one that did not have an operable solution, was
soon to be overshadowed by the discovery of disc protru-
sions.
On September 30, 1933, Mixter and Barr presented
an epoch-making paper to the annual meeting of the New
England Surgical Society in Boston. They pointed out
a chondroma causing a herniation of the nucleus of an
intervertebral disc and suggested surgery. Published in
the New England Journal of Medicine in 1934, this pa-
per forever changed the way surgeons would look at low
back pain37. The “dynasty” of the disc was born.
Frieber and Vinke described the “Piriformis Syndrome”
in 1934, in which sciatica was claimed to be produced by
inflammation and spasm of the piriformis muscle with
irritation of the sciatic nerve38.
In 1934, Codman of Boston published his book The
Shoulder in which he advocated repetitive motions, which
have become well known as Codman’s exercises, the prin-
ciples of which could be applied to all joints, including
the spine, to centralize the pain. He also described the
“paradox” of shoulder motion39.
In 1935, Ober described a syndrome that resulted in
the production of low back pain and sciatica from fascia
lata 40. The operation of fasciotomy was developed for its
cure.
In 1936, Herman, in “The Art of Mobilizing Joints”
published in Physical Therapy, stated in discussing joint
injuries that “...the speed of recovery will be slow and
the degree of recovery restricted because of lack of treat-
ment and supervision of the process of mobilization of
the affected adjacent joint”41 .
In 1936, in Physical Therapy in Joint Surgery: Prin-
ciples and Practice of Physical Therapy, Mock admon-
ished the lack of “treatment and supervision of the pro-
cess of mobilization.” He added, “Preservation of joint
function following an injury to, or operation upon, a joint
presents one of the commonest and often one of the most
difficult problems in surgery.”42
In 1936, Thornhill, writing in Physical Therapy, re-
A History of Manipulative Therapy Through the Ages and Up to the
ported on a presentation by Troedsson at the Annual Session
of the American Congress of Physical Therapy. The pre-
sentation was titled “Manipulative Treatment for the
Lumbosacral Derangement for the Relief of Pain in the
Lumbosacral Region.” The paper was submitted for
publication “because,” to quote Troedsson, “the manipulation
can be carried out by the technician, even though the
patient may be large and muscular.” Also, “until the muscle
spasm subsides or some change in the position of the
facets takes place, as by manipulation, pains may per-
sist”43.
In 1939, two physicians, Burrows and Coltart, wrote
in their book Treatment by Manipulation that manipu-
lation is concerned principally with the passive move-
ment of joints and, in its broad sense, is therefore part
of the armamentarium of the masseur or physiothera-
pist44.
In 1946, Sir Morton Smart wrote extensively con-
cerning adhesions forming within a joint following in-
jury and that these adhesions are common even from minor
joint injuries. Being a surgeon, he spoke of manipula-
tive surgery as the art of moving a joint through all its
ranges. He also wrote on “end feel” when he stated that
adhesions have a “springy feel” similar to muscle spasm,
and ligaments do not45 .
Lindblom described the first discography in 194846,
a process in which the disc nucleus is injected with a
radio-opaque contrast medium in order to visualize the
structure.
Also in 1948 Leube, working with Dicke of Holland,
published a book entitled Massage of the Reflex Zones in
the Connective Tissue.47
In 1948, James Cyriax published his theories on practice
in the British medical journal, The Lancet48 and in 1957
he published the third edition of his Textbook of Ortho-
paedic Medicine in two volumes 49. Volume I had already
become a classic and is valuable to this day for its clarity
in differentiating between the soft tissues when examin-
ing for dysfunction. Cyriax envisaged that a sudden on-
set of back pain was due to a crack and displacement of
the annulus that could be manipulated back into place;
by contrast, a gradual onset in back pain was due to a
protrusion of the nucleus and this could best be drawn
back with traction.
Cyriax also popularized the term “end feel” to draw
attention to the sense of resistance that can be felt in all
joints at the end of their range, and he attempted to
distinguish between those that were normal and those
that were abnormal. He also trained physiotherapists and
advocated that they, more than the physician, were the
correct person to perform manipulative techniques. More
than any practitioner before him, he pleaded for empha-
sis first on evaluation and then on treatment and stated
quite categorically that “his girls” were as good as any
physician.
In 1955, Steindler, in his work Kinesiology of the
Current Controversy in the United States / 71
Human Body under Normal and Pathological Conditions,
summarized earlier research and added a great deal of
additional arthrokinematic knowledge in both joint function
and dysfunction50. This information would later be used
by physical therapists wanting to adapt manipulative therapy
techniques to their understanding of joint function. Thus,
the new science of arthrokinematics, which had begun
with Walmsley, was to shape much of the future practice
of joint manipulation, which had reached mainstream
American medicine.
In 1955, Cave said that the Lushka joints (lateral
interbody articulations between cervical 2 and 7) were
usually the seat of osteoarthritis that commonly distorts
the intervertebral foramen51.
In 1960, Harrington began spinal instrumentation
for the correction of scoliosis52.
In 1960, John Mennell published his book, Joint Pain,
in which he ascribed the principle cause of joint pathol-
ogy and pain to synovial joints and not to intervertebral
discs. In this manner, he supported the earlier work of
his father. John Mennell may also have been the first to
use the term “joint play” to describe that quality of motion
in a joint or mechanical structure that provides for tol-
erance to aberrant motions or insult. He described joint
play as the “wiggle” or “slack” that is present in all
mechanical and biomechanical structures53.
John Mennell also wrote Foot Pain and Back Pain.
Mennell lived first in New Zealand and later in the United
States where, like his father, he instructed techniques
principally to physical therapists 54.
In 1960, in New Zealand, the British Medical Asso-
ciation made the following statement to the Health
Committee, which was considering a Chiropractic Bill:
“The medical profession readily acknowledges that spi-
nal manipulation is of great value for certain spinal ail-
ments, but emphasizes that these maneuvers should be
carried out by properly trained personnel-the orthopaedic
surgeon, the specialist in physical medicine, or the phys-
iotherapist under medical direction.”
In 1961, Kaltenborn, then of Norway, published Ex-
tremity Joint Manipulation, which has since passed into
several editions and languages. His text was the first to
relate manipulation to the new knowledge of
arthrokinematics. Kaltenborn spent most of the years after
1971 instructing manipulation to physical therapists
worldwide 55.
In 1962, the Congress on Manual Medicine held its
first meeting in Nice, France. The Congress later be-
come known as the International Federation of Manual
Medicine.
In 1963, the British Association of Manual Medicine
was formed. At a 1966 meeting of the association, James
Cyriax supported physiotherapists continuing to learn ma-
nipulation.
In 1963, while on the faculty of the New Zealand School
of Physiotherapy, Stanley Paris published “The Theory
72 / The Journal of Manual & Manipulative Therapy, 2000
and Technique of Specific Spinal Manipulation” in the
New Zealand Medical Journal. He wrote, “Degeneration
will commence in any joint in which there is loss of
movement...while this is happening, other joints above
and below...will have to compensate...they will become
hypermobile and suffer injury and degeneration.” His
teachings spoke of the spinal lesion, which later he called
“dysfunction.” In 1965, he further developed these ideas
in a book The Spinal Lesion56.
In 1964, Maitland of Australia published Vertebral
Manipulation, in which he refined the art of oscillatory
manipulation and used it almost exclusively to treat
“reproducible signs.”57 His approach was to identify ei-
ther an active or passive movement that was painful, to
oscillate that joint, and to test again. If it hurt less, he
continued with the oscillations; if there was no change,
then he tried a different oscillatory technique that he
had observed would be the next most likely to succeed.
Maitland’s two books, Peripheral Manipulation58 and
Vertebral Manipulation, explain his method. He has in-
structed extensively in Australia, where he resides, and
in England and Switzerland.
In 1966, Paris and John Mennell met with Northrup,
the editor of the DO, resulting in an article by Paris entitled
“Joint Manipulation: How You [osteopaths] Can Make
Manipulation Succeed”59.
On October 26, 1966, physical therapists Maitland,
Grieve, Kaltenborn, and Paris met for the first time in
London and discussed setting up an international body
to exchange educational ideas and to maintain standards
in manual and manipulative therapy. Other therapists
present were Hickling, Martin-Jones, Dyer, and Williams.
In all, five countries were represented. Eight years later,
as an outgrowth, the International Federation of Ortho-
paedic Manipulative Therapy (IFOMT) was formed.
In 1966, Melzack and Wall proposed the “gate con-
trol” theory of pain60 , providing an explanation of how
large nerve fiber stimulation from joints and muscles can
block the transmission and perception of pain. Their theory
enabled a better understanding of how such modalities
as acupuncture, TENS, and other pain-blocking techniques,
including spinal cord implants, could result in pain re-
lief. While manipulation was widely accepted as having
psychological and mechanical effects, the gate control
theory provided a possible explanation for neurophysi-
ological effects. It would be some years before manipu-
lation was shown to release endorphins, thus account-
ing for a chemical effect.
In 1966, the World Confederation for Physical Therapy
was formed in London. Four years later in Amsterdam,
a group interested in spinal and extremity manipulation
and other manual therapy techniques set up a steering
committee to form an international body. This they achieved
four years later in Montreal, forming IFOMT.
In 1968, the North American Academy of Manipula-
tion Therapy was founded in Boston, Massachusetts, and
chaired by Paris. It represented physiotherapists from
Canada and physical therapists from the United States in
their efforts to have spinal and extremity joint manipu-
lation further recognized by their profession with addi-
tional post-professional education.
In 1969, McCaleb, a physical therapist influenced by
Mennell, published “An Introduction to Spinal Manipu-
lation” in Physical Therapy, where he set out the con-
cepts of joint play and stated that manipulation was helpful
for joint dysfunction. He described the latter as a “...partial
absence or total absence of joint movement, called a joint
lock.”61
In 1970, John Mennell published “Rationale of Joint
Manipulation” in Physical Therapy. He outlined his
philosophy and stated, “Then you may say ‘But I cannot
use manipulative techniques even if I learn them unless
they are prescribed.’ If you say this you are ignorant of
the resolutions which the House of Delegates of the APTA
made last year...”62
In 1974, the Orthopaedic Section of the American
Physical Therapy Association was formed and the North
American Academy of Manual & Manipulative Therapy
was dissolved as it had reached its objective of seeing
manipulation become a specialty section of the Ameri-
can Physical Therapy Association. Paris became the first
president of the Section.
Also in 1974, The International Federation of Ortho-
paedic Manipulative Therapy (IFOMT) was founded in
Montreal, Canada, during the meeting of the World Congress
for Physical Therapy under the chairmanship of Paris.
There were 13 member nations at the inaugural meeting
and Erhard from the United States was elected president.
In 1976, Rocabado of Chile introduced American physi-
cal therapists to the role of physical therapy in the diag-
nosis and management of craniomandibular (TMJ) dis-
orders.
In 1978, the IFOMT became the first specialty sub-
section of the World Confederation for Physical Therapy
(WCPT), a status that has since helped member nations
gain increasing acceptance for joint manipulation within
physical therapy.
In 1979, Paris published “Mobilization of the Spine”63
in Physical Therapy in which he presented the indica-
tions, contraindications, and biomechanical basis for ma-
nipulation. In 1982, he co-authored “Reliability in Evalu-
ating Passive Intervertebral Motion” with Gonnella and
Kutner 64.
In the late 1970’s, McKenzie began to popularize the
concept of spinal extension for the treatment of low back
pain. He felt that the centralization of pain that often
follows repetitive motion was due to reducing disc pro-
trusions. His methods have gained wide acceptance, in
part due to his extensive research comparing the results
of his regime with others such as Williams Flexion Ex-
ercises and proponents of “back schools”. He also instructs
manipulative techniques.
A History of Manipulative Therapy Through the Ages and Up to the
In 1989, McKenzie cautioned the profession: “I be-
lieve we have overvalued the benefits of manipulative therapy,
overcomplicated the teaching of manipulative therapy,
and have applied the technique with inadequate discrimi-
nation” 65 .
In 1982, Farrell and Twomey, physical therapists, com-
pared two approaches in conservative treatment and
produced a paper often quoted in meta-analysis as hav-
ing met the rigors of research design66. Their study showed
that the duration of low back pain symptoms was signifi-
cantly shorter in patients who received mobilization and
manipulation as compared with those who received standard
physical therapy treatment consisting of microwave di-
athermy, isometric abdominal exercises, and ergonomic
instruction; this relief was also accomplished in fewer
treatment sessions.
In 1983, in an article titled “Conservative Therapy
for Low Back Pain,” 67 Deyo commented on the quality of
numerous studies that failed to validate the practices they
often advocated. On exercise, he wrote, “The best study
was that by Kendall and Jenkins,68 which demonstrated
an advantage of flexion exercises over either general
mobilization exercises or extension exercises.” On ma-
nipulation, he wrote, “Spinal manipulation remains highly
controversial, partly because in the United States it is
often equated with the practice of chiropractic. In Great
Britian and other Commonwealth countries, however, spinal
manipulation by physicians or physical therapists is more
common and several clinical trials have been conducted.”
In 1988, Ben-Sorek and Davis 69 surveyed physical
therapy schools and found that 37% taught mobilization
as a separate course and 60% taught mobilization as a
subunit in another course. The most prevalent techniques
taught for extremity mobilization were those of Kaltenborn70
and Maitland71,72 with 73% each, followed by those of Paris 73
(70%) and Cyriax 74 (58%). Other methods, such as those
of Mennell and Grimsby, accounted for 54% of the course
content.
In 1998, a similar study conducted by Setcliff75 con-
cluded that 100% of accredited physical therapy schools
include non-thrust mobilizations and 20.6% include thrust.
Significantly he noted that there is a reluctance to teach
thrust techniques “...attributed to the general belief...that
the therapeutic skill of manipulation (thrust) cannot be
obtained at entry level.”
In 1990, the prestigious International Society for the
Study of the Lumbar Spine, which has in its restricted
membership physicians, surgeons, biomechanists, physical
therapists, and chiropractors, published its anthology
Lumbar Spine; the only chapter on manipulation was written
by a physical therapist76.
In the early 1990’s, Mulligan, a New Zealand-trained
physiotherapist, introduced the concept of manipulation
with movement into the United States. His premise in-
cludes the notion that applying manipulative pressure
to the joint or soft tissue during performance of an ac-
Current Controversy in the United States / 73
tive movement will greatly facilitate its return to nor-
mal function 77.
In a somewhat similar development, this time regarding
neural tension, Elvey of Australia explored and developed
neural mobilization, which has become popular in physical
therapy practice 78.
In 1991, the American Academy of Orthopaedic Manual
Physical Therapists (AAOMPT) was founded with Farrell
as first president. The Academy was later accepted for
membership in IFOMT (International Federation of Or-
thopaedic Manipulative Therapists). The AAOMPT estab-
lished residency standards for manual therapy training
in the United States. The President of the American Physical
Therapy Association (APTA) is the official liaison to the
Academy.
In 1993, the House of Delegates of APTA79 defined
physical therapy, noting that “an exhaustive list of things
to be enumerated is not possible but the following should
be considered:…exercise with and without devices, joint
mobilization, manipulation,...massage.”
In 1995 Maitland of Australia received the highest award
of the World Confederation of Physical Therapy, the Mildred
Allison Award, for his many years of service and instruc-
tion in spinal and peripheral joint manipulation.
Present Day Practices and Attitudes
Osteopathic Manipulation
Mainstream osteopathy has all but abandoned ma-
nipulation. No doubt for many the pressure of remain-
ing current in medicine does not permit the time nec-
essary to be a skilled practitioner of manual techniques.
Consequently, many osteopaths refer out to chiroprac-
tors and physical therapists.
There are, of course, osteopaths who still practice
traditional manipulation paying attention to movement
restrictions. However, the most vocal group follow the
teachings of Mitchell, who placed great emphasis on the
perceived position of the vertebra. It is ironic that at a
time when chiropractic has almost completely moved away
from positional faults to motion, Michigan State Univer-
sity, which has the largest program in graduate manipu-
lation education, is describing and treating positional faults80.
Osteopathy has a record of not opposing the devel-
opment and use of manipulation by other appropriately-
trained health-care practitioners. In fact, many of its prac-
titioners have been prominent instructors in physical therapy
and osteopathic journals have accepted articles from physical
therapists, advocating increased use of physical thera-
pists to provide these skills81.
Medical Manipulation
Manipulation within medicine is represented in America
by the North American Academy of Manipulative Medi-
74 / The Journal of Manual & Manipulative Therapy, 2000
cine, which has both osteopathic (DO) and allopathic (MD)
members. Internationally, the Federation of International
Manual Medicine speaks for manipulation techniques.
Generally, however, American medicine today refers
manipulation treatments to physical therapists and in-
creasingly to chiropractors and other alternative health-
care practitioners.
Chiropractic Manipulation
The chiropractic profession has, by and large, rec-
ognized that it is movement of joints, not the position of
vertebra, that they must treat. However, all chiropractic
schools teach traditional theory and two, namely Life in
Atlanta and Life in California, remain principally tradi-
tional.
In April 1997, Craig Little, DC, the current Ameri-
can Chiropractic Association’s representative to the AMA’s
Health Care Professional’s Advisory Committee (HCPAC),
wrote in a letter to Helene Fearon, Chair of the Practice
Committee of the Orthopaedic Section, American Physi-
cal Therapy Association, redefining chiropractic terms.
Their redefinitions are:
Manipulation:
A manual procedure that involves a directed thrust
to move a joint past the physiological range of motion,
without exceeding the anatomical limit.
Mobilization:
Movement applied singularly or repetitively within
or at the physiological range of motion, without impart-
ing a thrust or impulse, with the goal of restoring mo-
bility.
It should be noted that up until the late 1980’s, many
chiropractic schools did not use “manipulation” as a term
and as a technique, but instead used the term “adjust-
ment.” This change of term from “adjustment” to “ma-
nipulation” is an important political point since physi-
cal therapists have been using the term “manipulation”
for many years more than have chiropractors.
Physical Therapy Manipulation
Since the very beginning, physical therapists have
practiced therapeutic exercise, both active and passive,
including manipulation and mobilization, first as mas-
sage and therapeutic exercise practitioners, later as re-
construction aides and medically-trained technicians, and
now as independent professionals with direct patient access.
More recently, since the 1950’s, the profession has built
upon the basic medical sciences, especially in the area of
arthrokinematics and neural tension, to devise newer, more
relevant treatment techniques and management strate-
gies, initially unique to physical therapy but now being
adopted by chiropractic. Kaltenborn, Maitland, Grieve,
Paris, McKenzie, Elvey, and Mulligan, to name a few, have
added to a unique body of knowledge that today consti-
tutes the science and art of physical therapy and manipu-
lation in the musculoskeletal arena. Physical therapists
make their diagnosis based not on disease, as in the medical
model, but on functional limitations and pathomechanics.
Since manipulation consists of both thrust and non-thrust
techniques and is accompanied by soft-tissue treatment
both manually and by modalities, the field of practice is
increasingly referred to as manual therapy or more correctly
manual physical therapy.
The practice of manipulation by physical therapy is,
for the most part, quite eclectic, with no single philoso-
phy dominating. Most practitioners have incorporated me-
chanical, isometric (muscle energy), and oscillatory tech-
niques. Rarely within physical therapy is manipulation
practiced in isolation from therapeutic exercise, patient
instruction, and supportive modalities.
Physical therapy has not fought to establish itself as
the only profession to manipulate nor to oppose its prac-
tice by chiropractors and osteopaths. To the contrary, it
recognizes, but does not condone, a host of practitio-
ners who use manipulation, including chiropractors and
osteopaths as well as massage and movement therapists,
athletic trainers, and kinesiotherapists. Within physical
therapy itself, an emerging struggle is directed at physi-
cal therapist assistants, who, while not able to evaluate,
feel that they should be able to manipulate82 .
As to the terms manipulation and mobilization, both
will no doubt continue to be used in physical therapy as
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Current Controversy in the United States / 77