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1 도수치료가이드라인 : 종류와테크닉그리고적용 이화여자대학교의과대학재활의학교실 1, 고려대학교구로병원재활의학과 2, 연세대학교의과대학재활의학교실및희귀난치성신경근육병재활연구소 3, 서울아산병원재활의학과 4, 중앙대학교의과대학재활의학교실 5, 대구가톨릭대학교의과대학재활의학교실 6, 고려대학교의과대학재활의학교실 7, 건국대학교의학전문대학원재활의학교실 8, 서울대학교의과대학분당서울대학교병원재활의학과 9 배하석 1 ㆍ강석 2 * ㆍ박중현 3 * ㆍ김원 4 ㆍ이상윤 5 ㆍ권동락 6 ㆍ이상헌 7 ㆍ이인식 8 ㆍ임재영 9 The Manual Therapy Guideline: Types and Techniques of Manual Therapy and Its Application Hasuk Bae, M.D., Ph.D. 1, Seok Kang, M.D. 2 *, Jung Hyun Park, M.D., Ph.D. 3 *, Won Kim, M.D. 4, Sang Yoon Lee, M.D., Ph.D. 5, Dong Rak Kwon, M.D., Ph.D. 6, Sang Heon Lee, M.D., Ph.D. 7, In-Sik Lee, M.D., Ph.D. 8 and Jae-Young Lim, M.D., Ph.D. 9 1 Department of Rehabilitation Medicine, School of Medicine, Ewha Womans University, Seoul, 2 Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, 3 Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, 4 Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 5 Department of Physical Medicine and Rehabilitation, College of Medicine, Chung-Ang University, Seoul, 6 Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Daegu, 7 Department of Physical Medicine and Rehabilitation, College of Medicine, Korea University, Seoul, 8 Department of Rehabilitation Medicine, Konkuk University School of Medicine and Konkuk University Medical Center, Seoul, 9 Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea Manual therapy or manipulation is a treatment using hands to improve function in musculoskeletal disorders. The segmental and somatic dysfunctions, which are indications of the manual therapy, refer the dysfunction and abnormality 접수일 : 2016 년 11 월 17 일, 게재승인일 : 2016 년 11 월 22 일책임저자 : 강석, 서울시구로구구로동로 , 고려대학교구로병원재활의학과 Tel: , Fax: 박중현, 서울시강남구언주로 , 강남세브란스병원재활의학과 Tel: , Fax: *These authors contributed equally. in musculoskeletal system, joints, fascia, and related vascular, lymphatic and nervous tissues. Recently, many physicians in Korea perform the manual therapy for management of musculoskeletal disorders. There are three types of manual therapy according to the principle of treatment; orthopedic manual therapy, osteopathy and chiropractic. Although the principles are different, the treatment techniques are similar among the types. The treatment techniques could roughly be classified to thrust technique and non-thrust techniques. In chiropractics, the thrust techniques are mainly used, while the non-thrust techniques are also used diversely in orthopaedic manual therapy and osteopathy. The thrust techniques should be performed by medical doctors because there are risks of serious complications, such as carotid or vertebral artery dissection, stroke, or fracture. Even the non-thrust techniques should be performed under supervision of medical doctors in hospital. (Clinical Pain 2016;15:65-70) Key Words: Manual therapy, Chiropractic, Osteopathy, Orthopeadic manual therapy, Guideline 서 도수치료는기능장애가있는근골격계질환등을대상으로손을이용하여신체기능향상을유도하는치료법이다. 도수치료는인류의시작과함께존재하였다고할수있을정도로오랜역사를가지고있다. 의학의아버지라일컬어지는히포크라테스는그의관절에관한글에서척추측만증의치료를위해중력을이용한도수치료법을처음으로언급하고있다. 1,2 로마의외과의사인클라우디우스갈렌은기능에이상이있는척추위에서거나, 걷는방식등을포함하는도수치료의근거를제시하였다. 1,3 근대도수치료는서양전통민간의학의접골사들에의해시작되었으며, 1 현대도수치료의여러학파의원형을이루었다. 현재도수치료는크게카이로프랙틱, 정골의학, 정형의학의세학파가주류를이루나, 그테크닉은서로유사하거나동일하다. 최근우리나라에서는많은의사들이근골격계질환의치료를위한도수치료를시행하고있다. 하지만아직도수치 론 CLINICAL PAIN 65

2 료의이론과개념그리고적응증과금기증에대한정보가부족하고, 치료테크닉에대한표준화된지침이없어의료현장에서치료자의경험에의존하여치료를시행하고있다. 이에본글에서는도수치료의종류와그이론에따른테크닉, 그리고적응증과금기증에대해고찰해보고자한다. 본 론 1. 도수치료의정의와분절과신체의기능장애 도수치료는신체의기능장애가있는근골격계질환등을대상으로해부학적및척추운동역학적병변에대한지식을가진시술자가손을이용하여통증이없는최대한의가동범위와자세의균형을확보하여신체기능향상을유도하는치료법이다. 4 도수치료의대상이되는분절과신체의기능장애 (segmental and somatic dysfunction) 라함은근골격계, 관절, 근막및이와연관된혈관, 림프, 신경조직의기능저하및이상을일컫는다. 4,5 장벽모델 (barrier model), 분절촉진모델 (facilitated segmental model), 완화 - 결속 (ease and bind) 과긴장 - 이완 (tight-loose) 개념등을통해분절과신체의기능장애를설명할수있다. 장벽모델에서는분절과신체의기능장애가기능을방해하는장벽에의해발생한다고설명한다. 능동관절운동범위를생리학적장벽 (physiologic barrier), 수동관절운동범위를해부학적장벽 (anatomic barrier), 이장벽들이대칭이되는중간지점을중립점 (neutral point) 라고한다. 비정상적근육수축, 관절막이나인대의단축등이발생하면새로운생리학적장벽이형성되고, 움직임의제한과장벽들사이의비대칭이발생하여새로운중립점과해부학적장벽이생긴다. 이장벽을직접적혹은간접적인방법으로정상적인상태로되돌리는것이장벽모델에서도수치료의목표이다. 분절촉진모델에서는분절과신체의기능장애가과도한신경신호의항진으로인해발생한다고설명한다. 관절의구축이나근육의과도한활성으로인해척추체의만성적인위치이상 (malposition) 이움직임의제한이발생하고이에따라부적절한고유수용감각자극 (proprioceptive impulse) 이지속된다. 이로인하여같은분절의운동신경및자율신경의신호가항진되고관련된체성 (somatic), 내장성 (visceral) 신호들의상호작용으로신체의기능장애가발생한다. 이분절촉진모델을통해근골격질환으로인해내장질환의기능장애가발생할수있고, 이러한질환들의촉진진단과도수치료가가능하다고설명한다. 완화 - 결속개념은척추를예로들어설명할수있다. 척추는모든방향에서동일하게조직에저항이가해지는대칭점 (symmetric point) 주변에서움직임이일어나는데, 병 변이있는척추에서는이균형점이해부학적인중립점과일치하지않아서한방향에서는다른방향 ( 완화, ease) 보다더큰조직의저항이발생 ( 결속, bind) 한다. 이개념은간접적테크닉 (indirect technique) 의핵심이되는개념으로완화점 (ease point) 으로수동적움직임 (passive motion) 을주는치료를설명할때주로이용된다. 근방추 (muscle spindle) 가신전되면근육을이완시키는기능을하는데완화점 (ease point) 으로움직임을주면결국근육톤이작아지면서이완되고근방추의신호를작아지도록리셋 (reset) 하여치료한다. 또한긴장-이완 (tight-loose) 개념은작용근주변의근막은긴장하고길항근주변의근막은이완한다는개념으로근막이완요법의핵심개념이다. 분절과신체의기능장애는시진, 촉진등의이학적검사로진단한다. 중요한이학적검사소견은다음과같이정리할수있으며이를줄여 TART라고명한다. 4,5 T: tissue texture abnormality ( 조직질감의이상 ) A: asymmetry ( 비대칭 ) R: restriction of motion ( 움직임의제한 ) T: tenderness ( 압통 ) 분절과신체의기능장애를기술할때에는다음의 3가지요소에대해기술해야한다. 4 첫번째는어느부위에이상이있는지혹은어떤자세에서이상이있는지를기술한다. 두번째는어떤동작혹은어느방향으로움직일때더자유로운지를기술한다. 마지막으로는제한이있는동작이나방향에대해기술해야한다. 분절의기능이상을표현할때에는동작의 3가지측면 ( 굴곡-신전, 회전, 측굴 ) 을포함하여기술하며, 위분절의아래분절에대한관계에따라기술한다. 4 척추움직임은척추체의가장위, 앞쪽부위의움직임에따라정하는데전방이동은굴곡, 후방이동은신전, 우측이동은우측측굴등으로표현한다. 회전을기술할때는극돌기 (spinous process) 를기준으로기술한다. 척추측만증과같은여러부위의굴곡을기술할때에는전통적으로쓰이는볼록한 (convex) 쪽의방향을기술한다. 2. 도수치료의종류및원리 1) 정형도수치료 (Orthopaedic manual therapy, OMT): 1950년대에영국의정형외과의사인 James Cyriax가주창한인체의연부조직의진단과비수술적치료에대한학문인정형의학 (Orthopaedic medicine) 에서발전하였다. 치료의범위는인대, 힘줄, 활액낭, 근육, 척추의병변등근골격계전반에대한치료를다룬다. 정형도수치료의개념은모든통증에는원인이있고, 치료는반드시그원인에대한것이어야하며, 통증을해결하기위해서치료는그원인에대해효과적이어야한다는것 66 CLINICAL PAIN

3 배하석외 8 인 : 도수치료가이드라인 : 종류와테크닉그리고적용 이다. 대부분의근골격계통증원인은특정한조직으로국한할수있고, 전신적인관점에서통증의원인을찾아내어진단하며, 정확한진단이성공적인치료로이어질수있도록하는것이정형도수치료의원리이다. 2) 정골의학 (Osteopathy): 1874년미국의외과의사인 Andrew Taylor Still, MD, DO가정골의학이라는용어를사용하고, 정골의학의술기들을개발하였다. 몸의근골격조직에대한 manipulation을강조하는대체의학으로발전하였다. 6 유럽및다른국가들과달리미국에서는정골의학의사들 (doctor of osteopathic medicine, DO) 은현대의학의수련을받은의사의한부류 (a branch of the medical profession) 로인식되고있으며, MD들과다름없는근거중심의학 (evidence-based medicine) 을수련하고있다. 6,7 하지만정골의학이요통을제외한어떠한의학적질환을치료하는데효과적이라는근거는적다. 6,8 정골의학에서는사람은하나의유닛이며, 모든기관은연계되어있다고생각한다. 9 몸은스스로조절하고, 스스로치유하고, 건강을유지하는기능이있으며, 기관과기능은서로상호연계되어있다. 이러한원칙들에대한이해를바탕으로합리적인치료를한다. 정골의학은도수치료를이용하여생리적기능의향상과신체적기능이상에의해변화된항상성을개선하는것을목표로한다. 10 신체적기능이상이란골격, 관절그리고근막및그와연관된현관, 림프, 신경계의기능에이상이발생한것을의미하며그본질적인치료방법을다음과같이크게네가지로분류한다. 10 ㆍ능동적방법 (active method): 환자가스스로치료자가유도하는방향으로움직임. ㆍ수동적방법 (passive method): 자발적근육수축을하지않은상태에서하는술기ㆍ직접적방법 (direct method): 제한장벽 (restrictive barrier) 과관련한신체의기능이상을교정하기위해적용하는방법. 이상이있는신체부위를제한장벽이있는방향으로움직임. ㆍ간접적방법 (indirect method): 제한장벽이관련하지않는신체기능이상에서시행하는도수치료방법. 신체의기능이상이있는부분이제한장벽에서멀어지도록해서조직의장력이모든면과방향에서하나로동일해지도록함. 3) 카이로프랙틱 (Chiropractics): 근골격계, 특히척추의기계적질환 (mechanical disorder) 에초점을맞추어치료하는일종의대체의학 11 으로 1895년미국의자석치료사 (magnetic healer) 인 Daniel David (D.D.) Palmer에의해창시되었다. 1966년미국의사협회 (AMA) 에서카이로프랙틱을비과학적집단 (unscientific cult) 으로간주하였으나, 1987년미국법원이 AMA가학문적교류에대한이유없 는제재를가하고있다고보고이를금지하는판결을하여 AMA 의카이로프랙틱에대한사실상의보이콧이끝나게되었다. 하지만아직미국에서도카이로프랙틱사들은의사와같은진료권과처방권을보장받지못한다. 카이로프랙틱의개념은서양전통의학인접골학 (bonesetting) 에서유래 12 하여활력학 (vitalism), 영적인영감 (spiritual inspiration), 그리고합리주의 (rationalism) 등을포괄하는개념으로발전하였다. 13 건강의전체론적인 (holistic) 개념을강조 14 하면서, 인체의스스로치유하는능력을믿고척추의아탈구 (vertebral subluxation) 15 나기능이상이인체의기능이나내재적정보 (innate intelligence) 13 를방해하고, 신경계를통해전반적인건강에영향을준다고믿는다. 16 여기서척추의아탈구는카이로프랙틱의핵심개념이지만, 정의가모호하고, 증명된바가없다. 또한내재적정보는항상성의은유적표현 (metaphor) 으로생각된다. 3. 도수치료의테크닉 도수치료의테크닉은그종류와원리에따라여러가지이름으로불리우고있으나, 사실상혼용되어적용하고있는실정이다. 도수치료의기법은크게 Thrust technique과 Non-thrust technique으로나눌수있다. 주로카이로프랙틱은 Thrust technique을강조하는반면, 정형도수치료나정골의학에서는 Non-thrust technique도다양하게적용한다. 1) Thrust technique: 다른용어로충격 (impulse), 17 고속 / 저강도 (high velocity/low amplitude), 교정 (adjustment), 척추도수치료 (spinal manipulative therapy) 라고한다. 5 시술자가자세나움직임의이상, 촉진이나움직임시에유발되는압통과같은조직변화를통하여비기능적인척추분절을인지하고, 그이하척추분절의회전, 측방굴곡, 굴곡, 신전을통하여제한된범위까지후관절을움직인상태에서잠시고정했다가짧은시간동안힘을가하는방법이다 제한범위관절로움직인상태에서수초간정지하는기간 (pre-tension period) 동안에환자의증상이악화되거나어지러움과같이부가적인불편함을호소하는경우치료를즉시중단하여야하며, 그이외에도관절염, 척추동맥부전, 염증소견이있는경우는치료의금기대상이다. 20 시술자는환자의근육이충분히이완되었을때힘을가하게되는데, 이를위하여환자는들숨과날숨을반복하고, 시술자는환자의호흡사이클을유심히관찰하다가가장깊게호흡을내쉬었을때힘을가하는것이좋다. 20 힘은관절표면의수직혹은수평방향이며, 매우짧은기간, 약 msec 동안힘을가하게된다. 20 이때피막과힘줄이경미하게신장되며, 때때로찰칵하는소리 (pop or click sound) 가동반되기도하는데이소리는윤활후관절에서의공동화 21 와질소분비에기인한다고알려져있다. 소리가나는경우소리 CLINICAL PAIN 67

4 가나지않는경우에비하여좀더짧은시간동안반사적근육수축과같은기계학적인과정이일어난다고생각할수있다. 이것은소리가발생하는 thrust technique이다른도수치료와비교하였을때다른작용메커니즘과효율성을가진다고제안할수있을것이나, 아직임상적인관련성은논란이있다. 17,19,22 모든 thrust technique은잠재적으로힘이정확하게국소화되지않거나비기능적척추분절을교정하기위한방향에서어긋나는경우가발생할수있다는것을감안할때잠재적으로부작용이있을수있다. 따라서관절과분절의정확한위치와방향을파악하여움직임을가했을때적은힘으로짧은거리를움직여서최대한의치료효과를얻을수있다. 23 2) Non-thrust technique (1) Articulatory Technique: 다른용어로가동술 (mobilization), 저속 / 고강도 (low velocity, high amplitude), 진동요법 (oscillatory techniques) 24 이라고한다. 움직임이제한된범위내에서척추관절을반복적으로움직임으로써움직임제한을정상화시키도록하는방법이다. 5 (2) Positional Techniques: 짧아져있는조직을수동적으로늘리는것이아니라, 척추근육의부적절한행태의기억상 (engram) 이나중추적패턴을바꾸기위하여시도되는방법이다. 5 (3) Counterstrain: 간접적근막요법으로, 관절과신체부분을최대한편안하게한상태에서근막과힘줄의연부조직을이완시키는방법이다. 5 압통부위를촉진한상태에서통증이처음통증정도의 80% 이하로감소되도록환자를움직이게하여 22,25,26 이자세에서압박을유지하다가천천히중립자세로돌아가도록한다. 25 (4) Functional Techniques: counterstrain과비슷하게관절이나신체부분을최대한이완시키는위치가되도록함으로써, 부적절한구심성자극과그로인한원심성알파운동신경의흥분을감소시켜주며, 호흡의정도를조절하여연부조직의이완을최대화할수있다. 22 (5) Muscle Energy: 고유수용성신경근촉진법 (PNF) 과비슷하게표적근육을이완시키기위해신장반사와등척성수축을이용하는방법이다. 25,27,28 시술자가환자를제한장벽까지움직이도록한후, 환자로하여금제한장벽에서멀어지는방향으로등척성수축을하게하고동시에시술자는능동적운동이일어나지않도록같은크기의저항을제공한다. 5 (6) Soft-Tissue Techniques: 운동범위를증가시키기위하여측면신장 ( 활시위 ), 선형신장, 깊은억제압박을통하여피부, 근육, 근막을기계적으로신장시키는방법으로 5 전반적인순환과정맥과림프액의흐름을향상시키는것이이기법의핵심이다. 17 (7) Myofascial Release: 마사지나견인치료와일부분중복되는도수치료법으로, 지속적으로촉진을통하여조직반응을평가하고, 이환된조직이이완될때까지신장, 견인, 압박, 혹은회전을가하고강도를조절하는방법이다. 5 (8) Joint Play: 문제가있는매끄럽지못한관절에있는운동면에수직이나접선방향, 혹은불수의적방향으로의움직임 (joint play) 을다루는치료이다. 5,29 (9) Craniosacral manipulation: 시술자는머리, 천골또는파동감지가예상되는신체부분을촉진하여파동의대칭성, 강도, 규칙성, 빈도를확인한다. 이상이발견되었을때, 시술자는가벼운압박을두개골과천골에가하여파동을정상으로회복시킨다 도수치료의적응증과금기증 도수치료는 ICD 10 질병코드에서분절과신체의기능이상 (Segmental and somatic dysfunction) 에해당하는질환군에적응이될수있다. 4,5 이에해당하는질병코드는 M99 에해당하며이는 Table 1 에정리가되어있다. 종양, 감염, 신경계장애가동반된경우, 관절의불안전성등은일반적도수치료의금기증이다 (Table 2). 5 하지만관절및주위연부조직의손상위험이높은 Thrust technique 은동맥류파열, 출혈등의심각한합병증을유발할수있기때문에출혈성질환, 혈관질환등도금기증으로고려해야한다 (Table 3). 4 Table 1. Indications of Manual Therapy A. ICD-10 질병코드 : 주상병이되는질환의부진단명으로병기할수있음ㆍ 99 Biomechanical lesions, not elsewhere classified (M99.0 M99.9) 99.0 Segmental and somatic dysfunction 99.1 Subluxation complex (vertebral) 99.2 Subluxation stenosis of neural canal 99.3 Osseous stenosis of neural canal 99.4 Connective tissue stenosis of neural canal 99.5 Intervertebral disc stenosis of neural canal 99.6 Osseous and subluxation stenosis of intervertebral foramina 99.7 Connective tissue and disc stenosis of intervertebral foramina 99.8 Other biomechanical lesions 99.9 Biomechanical lesion, unspecified B. 그외근골격계질환 68 CLINICAL PAIN

5 배하석외 8 인 : 도수치료가이드라인 : 종류와테크닉그리고적용 Table 2. General Contraindications of Manual Therapy (1) 척추종양 (vertebral malignancy) (2) 감염증및염증소견 (infection or inflammation) (3) 마미증후군 (cauda equina syndrome) (4) 척수병증 (myelopathy) (5) 다발성신경근병증 (multiple adjacent radiculopathies) (6) 관절의불안정성 [ 골절및탈구 ] 이명확한경우 (joint instability [fractures, dislocations]) (7) 경추류마티스질환 (cervical rheumatoid disease) 으로불안정성이있는경우 (8) 절박유산의가능성이있는임신상태 (9) 진행중인근육염 (10) 조절되지않는인지및감정의이상질환이확인된경우 5. 도수치료처방및시행시주의사항 치료원리에따른분류중카이로프랙틱은, x-ray 등을이용한진단행위를포함하고있고, high-velocity & low-amplitude thrust 등합병증을유발할수있는치료행위가다수포함되므로, 카이로프랙틱에관한모든행위는 의사 만이시행할수있는것으로한정해야한다. 우리나리의법체계상, x-ray 진단행위를할수있는직능군은의사가유일하며, thrust technique 시술전금기증을진단하고, 시술후합병증을진단할수있는직능군도의사가유일하다. 여러치료테크닉중, Thrust Technique 은환자에게불가피하게발생하는합병증 ( 경동맥및기저동맥의찢어짐으로인한사망, 1 개월이내사망을유발할수있는뇌졸중, 하반신마비, 병적골절등 ) 등의위험성이있으므로, 이에대한예방및즉각적대응을위해반드시의사의손으로시행해야한다. 치료의안전성이충분히검증된환자의경우의사의지시감독하에의료기관내에서물리치료사가도수치료를시행하더라도, 아래의결정은반드시의사에의해이루어져야한다. ㆍ도수치료의시행여부결정ㆍ필요한 Technique 결정ㆍ시술하는 Technique 의안전성에따라의사가직접시행할지, 물리치료사가시행할지에대한결정 결 도수치료는근골격계와그주변조직의기능이상으로인한여러증상을개선하고기능을향상시키기위해시행하는치료법이다. 치료자의손을이용하고환자에게지시를통해상호교감하면서치료가시행되어야하며, 일부기구를이용할수도있다. 현대도수치료는그원리에따라정형도수치료, 정골의 론 Table 3. Contraindications of Thrust Technique (1) 출혈의위험도가높은상태 (systemic anticoagulation) A. 항응고치료 B. 출혈질환 ( 선천성및후천성 ) (2) 조절되지않는심한당뇨병 (severe uncontrolled diabetes) (3) 경동맥에심한죽상경화증 (severe atherosclerosis) 이확인된경우 (4) 중증의관절질환 (severe degenerative joint disease) (5) 척골기저동맥순환부전이있는경우 (signs and symptoms of vertebrobasilar insufficiency) (6) 선천성인대이완상태 (congenital ligamentous laxity) A. 마르팡증후군 (Marfans s syndrome) B. 엘러스 - 단로스증후군 (Ehlers-Danlos syndrome) C. 다운증후군 (Down s syndrome) (7) 무균성괴사 (aseptic necrosis) (8) 시술부위에국소적인동맥류 (local aneurysm) 가확인된경우 (9) 가벼운접촉에도골절의가능성이있는골연화증 (osteomalacia) 혹은골다공증 (osteoporosis) 이있는경우 학, 카이로프랙틱의세갈래로나뉘어발전하였지만, 현재는그테크닉에뚜렷한차이가없이시행되고있다. 주요테크닉은 Thrust technique 과 Non-thrust technique 으로나눌수있으며, 특히 Thrust technique 은환자에게치명적인합병증을유발할가능성이있어세심한주의를요하며반드시의사에의해시행되어야한다. Non-thrust technique 이라할지라도반드시의료기관내에서의사의지시와감독하에치료가이루어져야한다. 또한도수치료필요여부, 치료부위의결정, 치료 Technique 선택등은의학적판단이필요한의료행위로반드시의사가처방하고관리해야한다. REFERENCES 1. Pettman E. A history of manipulative therapy. Journal of Manual & Manipulative Therapy 2007; 15(3): Hippocrates, Withington ET. Hippocrates: With an English Translation by ET Withington, Harvard University Press, Schiötz EH, Cyriax JH. Manipulation past and present: with an extensive bibliography, Heinemann Medical, Wolf CJ, Brault JS. Manipulation, traction and massage. In: Braddom RL, Physical medicine and rehabilitation, 5th edition, Philadelphia, Elsevier Health Sciences, 2015, Wieting JM, Adary MT, Holmes TG, Cugalj A, Cross N, Thompson G. Manipulation, massage and traction. In: Frontera WR, Delisa JA, DeLisa's Physical Medicine and Rehabilitation, 5th edition, Philadelphia, Lippincott Williams & Wilkins, 2010, Seffinger M, Buser B, Licciardone J, Lipton J, Lynch J, Patterson M, et al. American Osteopathic Association CLINICAL PAIN 69

6 guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc 2010; 110(11): Gevitz N. Center or periphery? The future of osteopathic principles and practices. The Journal of the American Osteopathic Association 2006; 106(3): National Health Service. Osteopathy evidence, clinical trials. [Internet] United Kingdom (UK): National Health Service; c2015 [cited 2015 Nevember]. Available from: aspx. 9. Stark JE. An historical perspective on principles of osteopathy. International Journal of Osteopathic Medicine 2013; 16(1): Ehrenfeuchter C, William A, Kappler D, Kimberly FP. Glossary of osteopathic terminology. The Principles of Palpatory Diagnosis and Manipulative Technique Chapman-Smith DA, Cleveland III CS. International status, standards, and education of the chiropractic profession. Haldeman S, Dagenais S, Budgell B et al 2005, Ernst E. Chiropractic: a critical evaluation. Journal of pain and symptom management 2008; 35(5): Haldeman S. Principles and practice of chiropractic, McGraw-Hill Medical, Mootz RD, Phillips RB. CHAPTER II CHIROPRACTIC BELIEF SYSTEMS. Chiropractic in the United States: Training, practice, and research Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropractic & Manual Therapies 2008; 16(1): Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, et al. Chiropractic as spine care: a model for the profession. Chiropractic & Manual Therapies 2005; 13(1): Greenman PE. Principles of manual medicine, Lippincott Williams & Wilkins, Herzog W. Clinical biomechanics of spinal manipulation, Churchill Livingstone, Isaacs ER, Bookhout MR. Bourdillon's spinal manipulation, Butterworth-Heinemann Medical, Neumann H-D. Introduction to manual medicine, Springer Science & Business Media, Brodeur R. The audible release associated with joint manipulation. Journal of manipulative and physiological therapeutics 1994; 18(3): DiGiovanna EL, Schiowitz S, Dowling DJ. An osteopathic approach to diagnosis and treatment, Lippincott Williams & Wilkins, Ward RC, Association AO. Foundations for osteopathic medicine, Lippincott Williams & Wilkins, Maitland GD, Hengeveld E, Banks K, English K. Maitland's vertebral manipulation, Butterworth-Heinemann, Basmajian JV, Nyberg R. Rational manual therapies, Williams & Wilkins, Yates HA, Glover JC. Counterstrain: A handbook of osteopathic technique, Y Knot Publishers, Chaitow L. Modern neuromuscular techniques, Elsevier Health Sciences, Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis, and treatment, Lippincott Williams & Wilkins, Magee D, Orthopaedic Physical Assessment. Philadelphia: WB Saunders Company. 1992, ISBN Ernst E. Chiropractors' use of X-rays. The British journal of radiology 1998; 71(843): Harrison DE, Harrison DD, Troyanovich SJ. Reliability of spinal displacement analysis of plain X-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique. Journal of manipulative and physiological therapeutics 1998; 21(4): Sherman R. Chiropractic x-ray rationale. The Journal of the Canadian Chiropractic Association 1986; 30(1): CLINICAL PAIN

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