Spinal manipulative therapy (SMT), that is high velocity thrust techniques to vertebra, in its most restrictive physical therapy definition consists of a series of manual techniques to increase range of motion and decrease pain in the spinal regions. Other professions, notably chiropractic also use these techniques for the same purpose but additionally frequently utilize them for treating non-musculoskeletal conditions. The use of manipulation for the treatment of colic, diabetes, cardiac conditions, ulcers, etc. is certainly beyond my competence to comment on except as a statement of opinion. As my opinion is worth about as much as anybody else's, I shall refrain from doing so especially as it is not germane to the present article.

Spinal manipulation has recently become an even more controversial issue than it has been in the past. Certainly there has been many and varied opinions on its various aspects. Is it safe, who should and should not manipulate, on which patients it should be done, the indications and contra-indications for manipulation, whether it is an appropriate treatment for physical therapists, whether it is a valid treatment or not, informed consent, its efficacy, training, examinations and so on. The physical therapist's rights to practice manipulation have been challenged by the physicians (especially the neurosurgeons), the chiropractors and even, as amazing as it might seem, from within our own profession. Manipulative therapists have been challenged to present evidence that manipulation is effective. And although it is not the clinician's responsibility to rise to this challenge, we have (we not being me but a host of other more motivated PTs). To the point where, perhaps, at the moment, manipulative therapy is among the most studied and validated of physical therapy techniques in use in any of our fields of practice.

We are increasingly being challenged by the chiropractors to prove that we are competent to serve as a provider of manipulative therapy. I do not think that this is a frivolous challenge to our scope of practice. Many motives have been attributed to the chiropractors the most common of them being protection of their turf. I am sure that a natural inclination to protect their scope of practice is a factor in their challenge of our right to practice manipulation. Personally I have no problem with this, I would hope that we are as jealous of our scope of practice. But I also think that they have loftier motives. The well being of the patient among them. I believe that that the main motivation for their challenge is their belief that we are inadequately trained to perform spinal manipulation safely and effectively. Certainly this is the reason that the chiropractors give and even if you do not believe it, it is the one that we must answer. And answer it we must. We can no longer simply to refuse to respond with disdain. Managed care, dwindling resources and the persistence of the chiropractors in bringing this issue to the attention of the powers that be ensures that we must be able to give a credible response.

There can be no doubt that the chiropractic profession is the profession that is trained to utilize spinal manipulation as its forefront technique. Their training in differential diagnosis, radiology, pathology, epidemiology and marketing are all aimed at the successful use of spinal manipulation if not to the exclusion of other therapies then certainly as their premier therapy. If they are having doubts about our profession's training in manipulative therapy, then perhaps we should investigate that training and the inclusion of spinal manipulation in our scope of practice which is present in almost every state's and province's legislation. Should we react to another profession's challenge? Why not! Do we have anything to hide? If we continue to be so defensive, then maybe we do and even if we do not, we will be perceived in that light. We should realistically and impassionately look at our training, at our attitude to competitive professions, at our relationship to the medical profession and even at the orthopedic therapist's place within the physical therapy profession.

I would suppose that one starting place in any introverted study we make is whether or not we as a profession want to continue to be a provider of manipulative care. This may seem a self-evident truth but is not. Two state associations, Washington and South Dakota, gave up the right to perform spinal manipulation in exchange for chiropractic support in their bid to be a primary care provider. The statement made by these two states was essentially that the right to perform spinal manipulation was unimportant to the extent that it was bargainable. Fair enough, but perhaps before elements of the profession put a lot of time, effort and money into defending our right to perform SMT, the national associations of Canada and the USA should poll their members. Is performing SMT an issue that we want to defend, or are we are content to have it removed from our scope of practice. If so, the PTs who are putting out the time, effort and money to safeguard our right to perform SMT can channel their resources into forming a new profession outside of physical therapy. The Washington State Physical Therapy Association is desperately trying to recover the right to SMT and I believe South Dakota will soon learn the same lesson. Any other state considering bargaining SMT for anything would do well to consult with Washington before doing so. Within the last few months, I heard a story form a very reliable and responsible source who told me that he heard a very senior and influential Canadian physiotherapist state that we should stop doing manipulation and let the chiropractors sink with it. All I can say is that I would like to know what color the sky is in this PT's universe. He cannot live in the one that I inhabit where the chiropractors have prestige among the public, a dedicated following among their patients and an expanding role in health care. Do we want to manipulate as part of our treatment of spinal pain or not. A simple question demanding a simple answer.

Over the next few weeks, I shall discuss other aspects of spinal manipulation including safety issues, training etc and I would welcome and will print any comments or contributions you might wish to make on these issues.