Manipulation, Monkeys, and Bunches of Bananas

Manual therapy interventions have been used by physical therapists since the inception of the profession1. Of course, in those early days the manual physical therapy (MPT) techniques used could hardly be called sophisticated. But neither were manual interventions in other health care professions. To use chiropractic as a contemporary example: DD Palmer once broke a mirror in his treatment room after he saw a patient observing him during an adjustment; he was afraid that this observation would allow the patient to replicate the techniques and set himself up as a competitor2. Since these early beginnings, the techniques and the rationale for their use have developed significantly in all manual medicine professions. Physical therapists have provided and they continue to provide major contributions to technique development, hypothesis generation, and research in manual medicine.

In the US and most other countries, MPT training is part of an integrated educational continuum. This continuum starts in the entry-level professional program with specific MPT and related foundational courses and continues throughout professional practice with post-professional educational opportunities in the form of continuing education seminars, clinical residency and fellowship training, post-graduate academic and diploma programs, clinical mentorship, and MPT certification programs3,4.

Over the years, US entry-level physical therapy (PT) education has placed an increasing emphasis on MPT curricular content5-8. With the publication of the Manipulation Education Manual9, the American Physical Therapy Association has clearly shown its commitment and intent to standardize, to a greater degree, the MPT entry-level curricular content and to include both thrust and non-thrust techniques. This inclusion seems to shift the emphasis on skill development in MPT diagnosis and management, including thrust manipulation, from the post-graduate to the entry-level and has led to the question: Are these skills in fact entry-level skills? It is my opinion that not only are MPT diagnosis and management, including thrust manipulation, entry-level skills but also that the research evidence available on efficacy and efficiency of thrust manipulation requires the inclusion of these techniques to a greater degree in entry-level PT curricula worldwide.

Opponents of the increase in MPT entry-level curricular content may argue that skills in MPT diagnosis and management can only be developed with clinical exposure. Research on this topic is, however, limited. A Medline search using the terms “novice OR student AND manipulation” and a hand search of my personal library yielded only five relevant references.

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