The witch on your right should stir more!
The witch on your right should stir more!

I am not speaking of the force a practitioner needs to provide in order to manipulate a joint, but, the commanding value of manipulation on patients.  Let me explain further.

I recently had a past patient of mine call to schedule as he recently (within 2 days) hurt his low back while lifting a small object at home.  He described it as giving way and he thought something was ‘out of place’. He was under my care about 6 months ago for a different condition (3 visits for mid-thoracic spine pain) and one of the interventions provided was manipulation, which he enjoyed and attributed to his success.

Now even though in the last episode of care and this one, I combined the effects of manipulation and exercise, the patient’s values and perceptions really played a large role in his successful outcome.  I knew deep in my head that he would need more than manipulation to the low back, but it was a factor that would be idiotic to leave out. I would probably say only ~20% of my treatment is manual whilst 80% is assessment and exercise-driven, but that 20% (or if you want to think of simply one manipulation…5%) of the total treatment time when I saw him 6 months ago is what stuck in his head.  This is what he remembered.  It was possibly the mechanical stimulus needed to get neurophysiological effects and even affect descending signals from the brain, who knows.

Nevertheless, when he injured himself at home, he knew directly who he wanted to see….his physical therapist.  Not his massage therapist, chiropractor or primary care physician.  The physical therapist.

I don’t normally “use all my tools” (even though I really don’t like this term!) on every patient, it is something to think about when providing an intervention.  We do know there are subgroups of individuals who benefit from manipulation (or mobilization, traction, etc.) looking through impairments, but don’t forget the patient preference. That 3rd aspect of evidenced-based medicine may be what is needed.  Don’t forget its power.


  1. I feel that we as PT’s are in a bit of a sticky situation here. The client is always right from a business stand point. They will find someone to do the treatment whether it is us or not. On the other had grade 5 mobs/manipulations are not always indicated. Sometimes you can educate the patients, other times you cannot.
    I think it is important to “get your hands on the patient” every treatment. Whether it is a grade 1 oscillation or grade 5 manipulation, I feel that the manual techniques add significant value (clinically and to the patient) to our care.
    I think that my care is now close to 40% manual (I preach doing the HEP as instructed almost every visit) and the results are supporting the increase.
    I also think it is hugely important to educate everyone on the fact that WE DO manipulations, are highly trained in them, and will perform them whenever indicated.

    1. i agree with you, but at seminar after seminar i find many PT’s to be subpar manipulators. I don’t know if its fear or them buying into what’s jammed in a lot of our heads about “cavitation not being necessary” or only do manipulation as a last resort, but you need to want to get good at it and use it.

      1. Unfortunately Bill, you are right. I think 5-10 yrs from now this statement may be reversed but as clinical education and even entry level academic education is taught, the emphasis on HVLAT is last resort and therefore, how can someone be good at it?! Even top manual therapy certifications such as Maitland and even the force progression through McKenzie put manipulation at last resort too.

        We got to teach the new grads young! That’s my plan 🙂

        Thanks for the comment. Oh and on the cavitation, yeh I believe Flynn and Cleland have put out some research on the effects that cavitation doesn’t matter, but I disagree. It is such a strong psychological effect that if you are going to perform it, well perform it and get the outcome.


      2. I just graduated 3 years ago and I’ve had half a dozen students or so and I can tell you that in these programs (including mine) we are starting to heavily push grade 5 mobs/manips. more than ever. We spent a considerable amount of time on them in my program.
        I have never heard the “cavitation is not necessary”, but I agree with Mr. Vaughan. Ignoring any physical response, the psychological response when people hear the “crack” is “Wow, now that did something…”

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