History of Orthopaedic Manual Therapy
The first recorded evidence of manual therapy was Tui Na (2700 B.C.), which means "to push and grasp", a form of Chinese manipulative therapy. In traditional Chinese Medicine, Tui Na is used to improve the flow of Qi, the body's energy and vital life force. Tui Na is performed over meridians that run through the body to release areas of stagnant Qi, re-establish harmony, and promote health and well-being. Tui Na was introduced in Japan around (700 A.D.) and over time was modified and renamed Shiatsu.
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In 2500 B.C. Egyptian tomb paintings depicted the massage of the hands and feet, known as reflexology, as part of their medical tradition. The Egyptians believed that points on the hands and feet corresponded to internal organs of the body, and applying pressure to these points would improve the function of such organs. The Ebers Papyrus, one of the oldest medical textbooks in the world, describes the Egyptians' use of massage and cupping for medical purposes.
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A Sanskrit text on Ayurveda indicates that massage was practiced in ancient India (1500 B.C.). Hindus used a form of healing touch in the practice of Ayurvedic "life health" medicine. Ayurvedic massage was performed with oil applied to the entire body, from the scalp to the soles of the feet. The intention of the massage was to balance the mind, body, and spirit.
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In his writings, Greek physician Hippocrates (460-385 B.C.), often referred to as the "father of medicine," described using traction and manipulating a "Gibbus" or prominent vertebrae back into place by using his hand, foot, or body weight. Hippocrates recommended following manual therapy with movement and exercise. Roman surgeon Claudius Galen was named "Prince of Physicians" when he manipulated a well-known scholar's neck, restoring function to his paralyzed hand. Galen often commented on the works of Hippocrates.
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In the 18th and 19th centuries, bone setting, a form of folk medicine, was common practice in Great Britain (England, Scotland, and Wales). It was a skill passed on from one family member to another. Bone setters had no formal training and believed the "pop" was little bones going back into place. James Paget, a renowned British surgeon, reported in the British Medical Journal in 1867 on the effectiveness of bone setting. Another eminent physician, Wharton Hood, published "On Bone Setting" in 1871, the first book on manipulation by an allopathic medical doctor (MD). Hood described the snapping sound as the breaking of per articular adhesions.
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Per Hendrik Ling was a physiologist, gymnast, and expert fencer who 1813, founded the Royal Central Institute of Gymnastics (RCIG) in Stockholm, Sweden. Ling taught corrective exercises and different forms of manipulation and massage. Practitioners came from throughout Europe to learn his techniques. Ling combined his knowledge of physiology and gymnastics with Chinese, Egyptian, Greek, and Roman manual therapy. His massage techniques would later be known as "Swedish Massage." A Dutch massage practitioner, Johan George Mezger, applied French terms to name the five basic massage techniques: effleurage, petrissage, tapotement, friction, and vibration.
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In 1874, a physician named Andrew Taylor Still developed the practice of Osteopathy. As a young man, Still suffered from chronic headaches of which doctors were unable to provide him any relief. One day, he fell asleep for a few minutes with his neck wedged between the roots of an old oak tree, and when he awoke, his headache was completely gone. At that moment, he had a revelation that the musculoskeletal system must play an important role in other functions of the body. Still believed that by restoring mobility to restricted joints and soft tissues, various ailments and diseases could be cured. He proposed that these joint and soft tissue restrictions reduce the flow of blood, and by releasing the restrictions, blood flow is normalized. He called this concept "The Law of the Artery." The first school of Osteopathy was opened in Kirksville, MO, in 1892 and was based on four basic principles: the human body functions as a biologic unit, the body possesses self-healing mechanisms, structure and function are interrelated, and abnormal pressure in one region of the body places a strain on other parts of the body.
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Some of Still's students brought the osteopathic philosophy to Europe, where they founded the British School of Osteopathy. Osteopathy in the United Kingdom, Australia, and New Zealand is limited to manipulative therapy. In contrast, Osteopathic Medicine in the United States became a total school of medicine and surgery while retaining some Osteopathic philosophy.
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​Physiotherapy was founded in 1894 by a group of nurses in England who trained at the Royal Central Institute of Gymnastics in Sweden. First named the "Society of Trained Masseurs," which in 1920 became the "Chartered Society of Massage and Medical Gymnastics" and finally, in 1944 the "Chartered Society of Physiotherapists." Students worldwide would come to train in this new profession, including Mary McMillan, the founder of physical therapy in the United States. Manual therapy and corrective exercise were central to the new profession.
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Daniel David Palmer immigrated to the United States from Canada when he was twenty. He worked as a beekeeper, school teacher, and grocery store owner. Palmer was interested in alternative medicine and practiced magnetic healing. In 1895, he was working in Davenport, Iowa, when he discovered Chiropractic. Chiropractic is derived from a Greek word meaning "done by hand." The story goes that Palmer manipulated the neck of a man named Harvey Lillard, a janitor that worked in his office building, when he slapped him on the back after Harvey told him a joke. The manipulation supposedly restored the hearing that Harvey had lost years ago. Palmer concluded that if a subluxated vertebra was adjusted back into place, nerve flow would improve, and the disease would be cured. Palmer called this "The Law of the Nerve." Some say that Palmer attended a lecture by A. T. Still and borrowed his ideas to develop Chiropractic. In 1897, Palmer established the Palmer College of Cure, which later became the Palmer College of Chiropractic in Davenport, Iowa. Although DD Palmer is given credit for the origin of Chiropractic, it was his son Bartlet Joshua Palmer (1881-1961), who gave Chiropractic its momentum. If it were not for B.J., Chiropractic would probably never have survived the scrutiny of orthodox medicine.
While studying Osteopathy in 1899, William Garner Southerland was examining the bones of a disarticulated skull when he observed the beveled edges on the sphenoid bones and thought to himself, "beveled like the gills of a fish, perhaps to allow for some type of respiration." Dr. Sutherland was the first to perceive and document subtle movement within the bones of the cranium. Southerland's initial discovery led to his life's work and the development of Cranial Osteopathy.
In 1907, James Mennell, MD, instructed joint and soft tissue techniques to physiotherapists at St. Thomas Hospital in London. Assisting Mennell in his courses was a physiotherapist named Edgar Cyriax. Cyriax was originally from Sweden and studied at the Royal Central Institute of Gymnastics. Cyriax later attended Edinburgh University and became a medical doctor, and continued to practice in the area of manual medicine. Mennell wrote his first textbook in 1917, "Treatment by Movement and Massage." He later published "The Science and Art of Joint Manipulation, Volume I: The Extremities" (1949) and Volume II: "The Spine" (1952).
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Physical Therapy in the United States was founded in 1921 by Mary McMillan, the 1st president and one of the founders of the American Woman's Physical Therapeutic Association. In 1925, Mary McMillan wrote a book based on the teachings of Pier Henrig Ling and described techniques that involved the manipulation of muscles and joints. The AWPTA changed its name in the late 1930s to the American Physiotherapy Association, and men were admitted into the organization. Early physical therapists were rehabilitation aides who assisted medical doctors in rehabilitating injured soldiers. With the onset of World War II and a nationwide polio epidemic, physical therapy in the United States grew rapidly in the 1940s and 50s. By the late 1940s, the organization changed its name to the American Physical Therapy Association. Since its inception, manual therapy has been a core part of the physical therapy profession.
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In 1954, James Cyriax, son of Edgar Cyriax, a British orthopedic physician, published the "Textbook of Orthopedic Medicine". Cyriax believed that a sudden onset of back pain was due to a crack and displacement of the annulus that could be manipulated back into place. He also proposed that a gradual onset of back pain was due to a protrusion of the nucleus, and this would best be drawn back in by traction. Cyriax popularized the terms end feel, capsular pattern, and selective tissue tension testing. He founded the Society of Orthopedic Medicine.
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Janet Travell, a U.S. physician, also known for being the physician to President John F. Kennedy, in the 1950s, described nodules in taught bands of muscle that referred pain to specific areas of the body and named them "myofascial trigger points". Travell prescribed a rocking chair for President Kennedy to relieve the trigger points in his lower back. Travell wrote a two-volume book, Myofascial Pain and Dysfunction: The Trigger Point Manual. These books serve as valuable resources for manual therapists today.
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Injections into trigger points were introduced by medical doctors Janet Travell and David Simons in the early 1940s. These physicians injected corticosteroids, analgesics, and saline into the trigger points using hypodermic needles. In 1979, "Dry" needling vs. "Wet" needling was found to be equally effective by Karl Lewit, a Czech physician, who used fine filament needles vs. hypodermic needles.
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The "American Association of Masseurs and Masseuses" was formed in 1943 to legitimize massage therapy due to years of being associated with ill repute. The organization was renamed in 1958 to the "American Massage and Therapy Association" and later in 1983 to the "American Massage Therapy Association." Today, massage therapists are required to graduate from an accredited program, typically 9 months to 1 year in duration, and sit for a national board exam.
Muscle Energy Technique was first developed in 1948 by osteopathic physician Fred Mitchell. The soft-tissue technique utilizes the action of the muscle spindle or Golgi tendon organ to inhibit a muscle, which allows it to be stretched further and improve joint range of motion. MET was later refined and promoted by Mitchell's son, Fred Mitchell Jr. Another osteopathic physician, Lawrence Jones, developed an indirect technique to lengthen shortened muscles called strain-counterstain. Jones discovered this phenomenon by accident when he helped a patient to get into a comfortable sleeping position and left him resting for a few minutes. When he returned and the patient stood up, his pain was much improved. Jones developed a whole manual therapy system based on the position of comfort. These two techniques became part of osteopathic and physical therapy practice.
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In 1960, Dr. John Mennell, MD, son of Dr. James Mennell, MD, published "Joint Pain," in which he proposed that the principal cause of low back pain was from the facet joints and not the intervertebral discs. Mennell developed the concepts of joint play and joint dysfunction. Mennell advocated for physical therapists to work with physicians in performing joint manipulation. Mennell was the founding member of the North American Academy of Manipulative Medicine.
Freddy Kaltenborn, a physiotherapist from Norway, was an apprentice to James Cyriax, MD, at St Thomas Hospital in London. In 1961, Kaltenborn published the book, "Extremity Manipulation"; in 1964, he published "Spinal Manipulation." He coined the term arthokinematics and promoted the convex/concave rule to govern joint mobilization. Kaltenborn was a founding member of the International Federation of Orthopaedic Manual Physical Therapists (IFOMPT) and the American Academy of Orthopaedic Manual Physical Therapists (AOMPT) and spent his career educating physical therapists on how to perform joint manipulation.
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In 1956, Robin McKenzie, a physiotherapist from New Zealand, developed a treatment method for low back pain. One day, while treating patients in his clinic, McKenzie asked a patient to undress and lie down on a treatment table, and he would be in to see them shortly. McKenzie did not notice that the head of the table was lifted from the previous patient. When Mckenzie returned, the patient was lying with his upper body extended. Mckenzie expected his patient to be in severe pain. However, to his surprise, the patient's leg pain improved significantly. Mckenzie is most known for the concepts of directional preference and centralization.
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In 1964, Geoffrey Maitland, a physiotherapist from Australia, published "Vertebral Manipulation" and later, "Peripheral Manipulation". Maitland used oscillatory mobilization to treat "reproducible signs." He would identify a painful active or passive movement, oscillate the joint, and test again. If the movement hurt less, he would continue with the oscillations. If there was no change, then he tried a different oscillatory technique or direction. Maitland was less concerned about specific arthrokinematics and more focused on movements that alleviated symptoms.
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Associated with Maitland at this time was Gregory Grieve from the U.K., a physiotherapist who trained at St. Thomas Hospital and worked closely with James Cyriax. He taught manual therapy courses in the U.K. and founded the Manipulation Association of Charted Physiotherapists.
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In the early 1970, Stanley Paris, a New Zealand physiotherapist, began teaching manipulation courses to physical therapists in the United States. He founded the Institute of Physical Therapy, which certified physical therapists in manual therapy. The institute later became the University of St. Augustine For Health Sciences, the only free-standing physical therapy school in the U.S. Dr. Paris was a founding member of the International Federation of Orthopaedic Manipulative Physical Therapists, the American Academy of Orthopedic Manual Physical Therapists, and the first president of the Orthopaedic Section of the American Physical Therapy Association. He was the founding co-editor of the Journal of Manual & Manipulative Therapy. No physical therapist or individual has contributed more to the advancement of manual therapy in the United States than Dr. Paris.
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Ola Grimsby, a certified manual therapy instructor in the Norwegian national program, moved to the U.S. and started teaching manual therapy courses for Stanley Paris. He eventually founded the Ola Grimsby Institute, offered courses leading to a manual therapy certification, and later established residency and fellowship programs.
Structural Integration is a method of bodywork developed by Ida Rolf, Ph.D. that rebalances the body by bringing its major segments (head, shoulders, chest, pelvis, and legs) into vertical alignment to promote structural harmony and well-being. Throughout her life, Ida was interested in alternative healing. She spent endless hours studying and experiencing homeopathy, Osteopathy, Chiropractic, and yoga. She eventually developed her own system of bodywork that she named "Structural Integration." Ida practiced and taught her bodywork techniques to practitioners from all disciplines. In 1971, she opened the Rolf Institute of Structural Integration in Denver, Colorado.
While assisting with surgery to remove a calcified plaque from the membrane that surrounds the spinal cord, Dr. John Upledger D.O. witnessed the pulsing of the cerebrospinal fluid. He observed that the pulsing was not in synch with the patient's respiration or heartbeat. He was so intrigued by the idea of a separate functional system that he attended a course at the cranial academy taught by Harold Magoun, one of Dr. Southerland's students. Dr. Upldeger spent most of his career researching this subtle movement of cerebral spinal fluid. His work supported and confirmed what Sutherland had discovered: the cranial bones, the membranes attaching to them, the membranes surrounding the spinal cord, and the sacrum, together with the cerebrospinal fluid, make up a functional body system. Through his clinical practice, Dr. Upledger discovered that by correcting subtle restrictions in this system, many brain and spinal cord conditions could be successfully treated. Dr. Upldeger set up a teaching foundation, The Upledger Institute, to train practitioners from all disciplines in his techniques.
In the 1960s, Osteopath Robert Ward, a student of Ida Rolf, coined the term "Myofascial Release," previously referred to as connective tissue mobilization. The concept was first proposed in the 1890s by Andrew Taylor Still, founder of Osteopathy. John F. Barnes, a physical therapist, pioneered a sustained pressure myofascial release approach and promoted it through continuing education courses for bodywork therapists.
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At the 1970 World Confederation of Physical Therapy (WCPT) conference in Denmark, a group of therapists was tasked with working with the WCPT to create its first sub-group on manual therapy. In 1974, the International Federation for Orthopaedic Manipulative Physical Therapists (IFOMPT) was Founded in Montreal, Canada, by Paris, Maitland, Kaltenborn, and Grieve to establish standards for education in manual therapy.
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In 1983, Canadian physiotherapists Earl Pettman, James Meadows, Cliff Folwer, and David Lamb founded the North American Institute of Manual Therapy in the United States. NAIOMPT certifies manual therapists and offers fellowship training.
In 1986, Bob Elvey and Geoff Maitland first introduced the concept of neuromobilization, a manual therapy treatment of neural tissues and the non-neural structures surrounding the neural tissue, to improve nerve physiology and relieve pain. In 1989, Butler and Gifford expanded on the work of Elvey and Maitland and promoted the technique worldwide. Michael Shacklock further developed the concepts and techniques in the mid-1990s.
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In 1990, Brian Mulligan, a physiotherapist from New Zealand, introduced to the United States "Mobilization with Movement." With this method, the therapist applies a sustained accessory glide while the patient actively moves. Mulligan discovered the concept while working with a patient with a painful finger. In 1989, Mulligan published Manual Therapy "NAGS," "SNAGS," "MWMS."
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During the summer of 1991, Freddy Kaltenborn and a group of manual therapists formed the American Academy of Orthopedic Manual Physical Therapists (AOMPT). The founding members included Richard Erhard, PT, DC, Joe Farrell, PT, Ola Grimsby, PT, Kornelia Kulig, PhD, PT, Michael Moore, PT, Stanley V. Paris, PhD, PT, Mike Rogers, PT, and Buorn SVensen, PT. The academy works collaboratively with the American Physical Therapy Association to establish manual therapy fellowship standards for physical therapists in the United States.
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Manual therapy, a "hands-on" approach, has been practiced throughout history, and no one profession owns manual therapy. The Society of Orthopaedic Manual Therapy is eclectic, inclusive, and dedicated to training all bodywork professionals in the Art and Science of manual therapy.