To begin with a chapter giving a brief outline of the history of manipulative therapy is helpful for several reasons; not least because it is hard to appreciate its unique place in medicine without such an introduction. It is also important for the avoidance of mistakes and a correct appraisal of its further development.

Manipulative therapy is probably as old as the history of humankind. Throughout that history there have been healers who knew how to reposition or ‘set’ joints, including the spine. Among some peoples it was the custom for children to run barefoot over the backs of their weary parents following heavy work.

Importantly in this history, in the fifth century bc, Hippocrates, founder of European medicine, listed rachiotherapy as a further fundamental element of medicine alongside surgery and medicinal therapy. In his treatise on joints, he speaks of parathremata, a concept which corresponded to what chiropractors would recognize as slight dislocation or subluxation. Waerland expresses it in these words: ‘the vertebrae are not displaced by very much; only to a very small extent.’ Hippocrates goes on to say that ‘it is necessary to have a good knowledge of the spine, because many disorders are associated with the spine, and a knowledge of it is therefore necessary for healing a number of disorders.’ He also describes how to treat the spine: ‘This is an ancient art. I have the greatest respect for those who first discovered it, and also for their successors, whose discoveries will contribute to the further development of the art of healing in a natural way. Nothing should escape the eye and hands of the skillful physician, so that he can reposition the displaced vertebrae on the treatment table without harm to the patient. No damage can occur as long as the treatment is undertaken in the correct way.’ According to Hippocrates, the list of disorders caused by displacement of vertebrae includes pharyngitis, laryngitis, bronchial asthma, tuberculosis of the lungs, nephritis and cystitis, inadequate gonadal development, constipation, enuresis, etc.

Manipulation therapy in ancient classical times can be seen on many reliefs. Patients would lie prone on a bed specially constructed for the purpose, while longitudinal traction to the head and legs was carried out. The physician performed manipulation of a particular vertebra. This type of therapy was evidently practiced throughout antiquity; Galen knew that the peripheral nerves emerged from the spinal cord and that they were susceptible to damage at this point, as is clear from his account of the treatment of the Greek Sophist Pausanias.

Over the course of time – particularly in the last two centuries – development took place in the primitive medicinal (herbal) therapy and the surgery of the Ancients, giving rise to modern pharmacotherapy and surgery; however, manipulation therapy continued in the same state as when the ancient classical civilizations had received it from the peoples of earlier antiquity. Consequently the successes of modern medicine completely eclipsed primitive manipulation therapy, causing it to slip to a great extent into oblivion. The medical press, which enjoys generous support from the pharmaceutical industry, contributed to this process. What we now see, therefore, is unequal development in the field of medicine, leading to a situation in which one discipline, failing to keep pace with the progress in the other specialisms, became almost forgotten. All that persisted, as far as we can tell, was a group of lay persons – to some degree established – called ‘bone setters’ who practiced manipulation therapy. This remained the situation until into the second half of the nineteenth century.

It was Andrew Taylor Still (born 1828), who practiced as a doctor in the American Civil War, who rediscovered the importance of manipulation of the spine. In 1874 he founded a school on a professional basis in Kirksville, USA, with 17 students. From the outset he also provided training to lay persons. At first the courses lasted two years; later they were extended to four years. At the present day, the length of training for a doctor of osteopathy (DO) in the United States is the same as that for medical students and permits them both to exercise their profession in general practice and to progress to specialization.

Around the year 1895, DD Palmer founded the chiropractic school in Davenport. Until then he had worked as a grocer and in magnetic healing. According to his own account, he witnessed manipulation being practiced by a physician by the name of Atkinson. Other sources say that he himself received treatment from Still. At first, the courses he provided lasted only around two weeks, and cost 500 dollars. By 1911 the courses lasted a year. At present, the training consists of four years of university-level study in the United States. Graduates obtain the title DC (doctor of chiropractic), which enables them to practice as primary care physicians.

Differences between osteopathy and chiropractic persist to this day. The training given to osteopaths in the United States endeavors to provide a complete body of medical knowledge, whereas schools of chiropractic will not teach pharmacotherapy and surgery. Among chiropractors, there is a substantial difference between those of the older and the younger generation. The older generation adheres dogmatically to the outdated theoretical and technical tradition; the younger rejects the traditional dogmas – it strives for a rational, scientific method and strongly desires to cooperate at the professional level with medical practitioners.

From the technical point of view, chiropractors confine their approach for the most part to high-velocity, low-amplitude (HVLA) treatment using short-lever techniques, taking very little interest in soft-tissue techniques. They are increasingly interested in rehabilitation and lifestyle (dietetics).

Osteopaths, in contrast, place emphasis on soft mobilization and soft-tissue techniques as well as HVLA treatments; however, they show a preference for long-lever techniques, using indirect (unlatching) techniques to be able to work in a targeted way. Neuromuscular techniques – muscle-energy techniques (MET) – derive from the school of Fred Mitchell, sen, Greenman and Mitchell, jun.

Although physicians in Europe initially knew little of manipulative therapy, even completely rejecting the concept, here too they gradually began to take an interest in spinal manipulation. The discovery of a mechanical disorder, the herniated intervertebral disk, was partly responsible for this interest. Attempts were made to provide relief by means of traction, and even to perform manipulation under anesthetic.

While, on the one hand, osteopaths and chiropractors were regarded as charlatans, on the other, attempts at manipulation by physicians of traditional (allopathic) medicine were rough and ready. Nevertheless, physicians in Europe were beginning to concern themselves with maneuvers applied to the spinal column. As long ago as 1903, the Swiss physician O Naegeli published his book on neurological complaints, Nervenleiden und Nervenschmerzen. Ihre Behandlung und Heilung durch Handgriffe.

The most important proponent of manipulation therapy in Europe was the British professor of physiotherapy, JA Mennell. He made no secret of having received instruction from osteopaths. His many publications (including manuals) remain to this day exemplary models of their kind. However, he mainly trained physiotherapists (physical therapists). His successor, J Cyriax, was a passionate proponent of manipulation therapy as well as an outstanding clinician and diagnostician. His Textbook of Orthopaedic Medicine remains to this day a classical textbook of the locomotor system. However, the techniques he describes and teaches do not measure up to comparison with those of Mennell.

Another individual deserving of mention is A Stoddard. He was originally an osteopath, and later studied medicine. His Manual of Osteopathic Techniques can be regarded as a classical textbook of manipulative techniques for the spine. The London College of Osteopathic Medicine was the first institution to provide instruction in osteopathic techniques to physicians trained in traditional medicine, and these individuals played a role in the further development that took place in Europe. The French physician, R Maigne, is one example; he also studied under the neurologist and rheumatologist, de Sèze, who was long the most influential proponent and teacher of manual medicine in France. He systematically held courses for physicians at the medical faculty in Paris and wrote textbooks. Despite the leading role played by Maigne, there are many splinter groups in France. In Britain, on the other hand, the British Institute of Musculoskeletal Medicine (BIMM, and its predecessor the BAMM) is organized in a unified way, holds courses and, under Dr Richard Ellis, publishes probably the most important medical journal in the field, International Musculoskeletal Medicine (formerly entitled the Journal of Orthopaedic Medicine).

The development that has occurred in the German-speaking countries is also of particular interest. After the end of the war, a number of German physicians began, out of necessity, to take an interest in manipulation therapy. Soon they began to found specialist scientific associations concerned both with the critical study of the issue and with courses of instruction. In Germany there were two groups involved at this time, the Forschungsgemeinschaft für Arthrologie und Chirotherapie (FAC), initially based in Hamm but later in Boppard, whose leading figures were G Gutmann, F Biedermann, A Cramer, and HD Wolff, and the Gesellschaft für manuelle Wirbelsäulen-und Extremitätengelenkstherapie (MWE) under K Sell, which was based in Neutrauchburg.

Physicians from the former German Democratic Republic of East Germany also took part in these courses up until the beginning of the 1960s. After 1961 this was no longer possible. Students of the FAC were therefore commissioned to organize courses in East Germany, which were to be on the same lines as the FAC, and at the Charité in Berlin, under Professor H Krauss and K Lewit from Prague. This task was more than could be done by just one person, so it was necessary to train instructors who would later take over the leadership of the Association. The most important of these were E Kubis, J Sachse, K Schildt-Rutlow, and H Tlustek. After the reunification of Germany this group became established as the Ärzteseminar Berlin (ÄMM).

Today the FAC, MWE and ÄMM together make up the Deutsche Gesellschaft für Manuelle Medizin (DGMM).

The development in former Czechoslovakia is also of great interest, as a result of the profoundly different political situation and especially in view of the fundamental role it served as a model for other then-communist countries (including East Germany). At the end of 1951 the Ministry of Health commissioned the university hospitals to undertake a review of the methods used by lay practitioners and practitioners of complementary medicine. To this end a chiropractor with a practice in Prague was reviewed at the neurological clinic (under Professor Henner). It was an ideal moment, when interest was focused on the intervertebral disk problem, and also on exploring the feasibility of reflex therapy. An additional factor there was the position of neurology in Czechoslovakia in Professor Henner’s time: there was an interest in problems of pain and the locomotor system, and neurology also had a leading role in the development of rehabilitation.

This made it possible for the technique of manipulation therapy to be reviewed in a clinical domain. Later there came the provision of instruction too, emanating from a prominent university hospital and later also provided by the Institute of Postgraduate Medical Training (under Professor Z Macek). Instruction was given in the form of a series of three two-week courses. Later, physiotherapists began increasingly to be trained in neuromuscular mobilization techniques. This is done in association with their university training.

This model was then taken up in East Germany, Poland, the former Soviet Union, and to some extent in Hungary and Bulgaria.

Professional bodies for physicians working in manual medicine were founded in most of the countries of Europe, beginning in Switzerland, as well as in Australia and New Zealand; a body was also set up in cooperation with osteopaths in the United States. The International Federation for Manual Medicine (FIMM) was founded in 1965 in London, with the Swiss physician JC Terrier as its first president. His son, B Terrier, has held this post since 2004. A world congress is held every five years. In this way manual therapy has become a medical discipline.

A professional body whose name refers merely to a method is not entirely satisfactory to physicians, however, given that the object concerned is the locomotor system and especially its dysfunctions. A number of bodies therefore decided to reinterpret the initials FIMM to represent the name Fédération Internationale de Médecine Musculosquelettale (International Federation for Musculoskeletal Medicine).

Despite considerable activity in scientific work, manipulation has continued to be regarded by a great number of traditional physicians as an outsider’s method; dysfunctions are little understood and, in matters at the practical level, physicians find it difficult to keep pace with physiotherapists, osteopaths, and chiropractors.

Pain – both in general and in disorders of the locomotor system – is a curse that humanity has always suffered. The constant search for relief has led to a great range of treatments of all kinds. The traditional approach has regarded bed rest and – to an extent and with some reserve – pharmacotherapy as the only reliable answer. From another standpoint there are many other methods that belong mainly, although not exclusively, to the realm of physical therapy, and these all have their eager proponents. These include massage, various kinds of electrotherapy, laser and magnet therapies, acupuncture, neural therapy, manipulation, local cold or hot applications, cupping, wheal therapy, remedial exercise, and movement therapy. The common feature of all these methods is their reflex effect.

We may ask why, when treating essentially the same disorders, preference is given sometimes to one method and sometimes to another. This sometimes gives the impression that the choice of method depends on which treatment the practitioner is best able to perform, irrespective of actual suitability.

The pathomechanism underlying most of these methods is the reflex effect; they act on sensory receptors to produce a reflex response in the region where the pain originates. They can therefore be termed methods of reflex therapy. We must next ask which receptors are activated and which structures they supply.

The route by which the control by the nervous system operates is primarily that of reflex reaction; it would be helpful to proceed from this to an understanding of where, how, and why we should apply one or the other method. The better we comprehend the various methods, the more effective the treatment we can deliver. Since these methods are most frequently applied in painful conditions, there follows a description of nociceptive (pain) stimulation.