Spinal Manipulation: Lack of Precision Doesn’t Mean Lack of Skill

By: Mark Shepherd, PT, DPT, DSc

Spinal thrust manipulation has been used for centuries, with evidence supporting its inclusion in neck and low back guidelines.1,2 Yet, how it’s taught and applied varies widely across and within professions, sparking debate among educators, clinicians, and researchers.3,4

Nim et al.’s recent systematic review5 and JOSPT blog6 challenge us to reconsider the importance of precision when using spinal thrust manipulation. They argue that exacting biomechanical accuracy may not be the linchpin we once believed, and that our focus should shift toward the broader clinical encounter. I completely agree that precision, in the strict biomechanical and spinal segmental sense, has been overvalued in both clinical communication, research, and teaching. However, my concern for readers of Nim et al’s work is the risk that people may interpret this to mean precision no longer matters leading to a “press and guess” mentality. That is not the message we should take from Nim et al.

Historically, I think of time spent focused on “finding the right segment” for the most biomechanically “correct” position. And yet, as Roger Kerry and others have pointed out, this level of specificity is not valid nor does it improve clinical outcomes.7 The question for educators is how to adapt without losing the importance of teaching technical skill.

From my perspective as both an educator and clinician, here are four principles that guide this balance:

• Shift our focus. Educators and clinicians alike should focus on delivering skilled manipulative technique through safe, comfortable and confident handling vs. focusing on specificity of the technique.5,7 In my own practice, I aim for precision but do not get lost in the minute detail. For me, precision of technique is directed more towards keeping my hands “soft” to reinforce comfort. To allow my hands to respect the non-verbal cues a person may demonstrate and respond appropriately. This reinforces the importance of skill refinement despite lack of precision.
• Integrate, don’t isolate. Technique in isolation from sound clinical reasoning invites bias and randomness. This may be called “manual therapy”, but this is not orthopedic manual physical therapy (see Silvernail et al’s8 recent publication for more).
• Repetition builds confidence. In Kerry’s 2024 article7 on modern teaching of manual therapy, they call for a focus on efficiency through a well-organized, competent approach that minimizes effort and wasted time. This requires deliberate practice. Repetition in both the lab and clinic will only improve one’s confidence and efficiency, refining the clinician’s ability to “listen with their hands”, an ability to use non-verbal communication to guide the refinement of a technique to modulate nociception when indicated.
• Less is more. Clinicians often have “favorite” spinal thrust techniques they use most frequently. Nim’s work suggests we may not need to teach or use a large variety. Focusing on a few evidence-informed techniques allows learners to become truly proficient while accommodating the fact that some techniques are more comfortable for certain clinicians and patients.

I write all of this not to dispute the research and message Nim et al have delivered, but to reinforce an important point the authors state in their JOSPT blog,

“Importantly, this shift does not mean abandoning a focus on technical skills. On the contrary, for SMT to remain relevant, students should be taught a range of competencies such as the ability to modulate SMT force-time characteristics (i.e., knowing when to apply minimal force and when higher forces may be appropriate), and psychological aspects, including building clinician confidence in applying SMT effectively and enhancing comfort and patient trust. A major challenge will be to move towards an adaptable and clinically relevant framework that emphasizes evidence-based clinical reasoning and clinician and patient safety.”6

In conclusion, abandoning rigid specificity doesn’t mean abandoning deliberate practice of technical skill. Our role as educators is to develop clinicians who can apply spinal manipulative techniques with safety and adaptability in a clinical reasoning framework that ensures patient comfort. By shifting our focus away from the narrow pursuit of technique specificity and instead integrating spinal thrust manipulation into a systematic, evidence-informed reasoning process, we can deliberately refine a smaller set of techniques to a higher level of competence. This approach values skill over volume, reinforces safety and comfort, and better serves the needs of the people we serve.

References

1. George SZ, Fritz JM, Silfies SP, et al. Interventions for the management of acute and chronic low back pain: Revision 2021: Clinical practice guidelines linked to the international classification of functioning, disability and health from the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2021;51(11):CPG1-CPG60.
2. Blanpied PR, Gross AR, Elliott JM, et al. Neck pain: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2017;47(7):A1-A83.
3. MacDonald CW, Osmotherly PG, Rivett DA. COVID-19 wash your hands but don’t erase them from our profession – considerations on manual therapy past and present. J Man Manip Ther. 2020;28(3):127-131.
4. Reid D, Cook C, Sizer PS, Froment F, Showalter CR, Brismée JM. Is orthopaedic manipulative physical therapy not fashionable anymore? Lessons learned from 2016 IFOMPT meeting and future directions. J Man Manip Ther. 2017;25(1):1-2.
5. Nim C, Aspinall SL, Cook CE, et al. The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: A systematic review and network meta-analysis. J Orthop Sports Phys Ther. 2025;55(2):109-122.
6. Nim C, Aspinall SL, Cook CE, Juhl CB, Hartvigsen J. Spinal Manipulation: Time to Rethink How We Deliver and Teach It. blog. Accessed August 12, 2025. https://www.jospt.org/do/10.2519/jospt.blog.20250626/full/
7. Kerry R, Young KJ, Evans DW, et al. A modern way to teach and practice manual therapy. Chiropr Man Therap. 2024;32(1):17.
8. Silvernail JL, Deyle GD, Jensen GM, et al. Orthopaedic manual physical therapy: A modern definition and description. Phys Ther. 2024;104(6). doi:10.1093/ptj/pzae036