The four letters blur the difference between spinal manipulation, a procedure practiced by chiropractors, medical physicians, osteopaths, physical therapists, and perhaps others, and the practice of chiropractic or osteopathy. These issues are related but distinct; our review, however, dealt primarily with spinal manipulation.

Dr. Plaugher believes that there is a difference in the efficacy of different techniques of manipulation and cites the study of Meade and colleagues [1]. The authors, however, drew no such conclusion. No well-conducted, randomized, controlled trials have been done comparing different techniques of manipulation for patients with low-back pain. We do not state that spinal manipulation is contraindicated for patients with low-back pain and sciatic nerve irritation. Considering the lack of a scientific basis for the efficacy of manipulation in these patients and the evidence that disastrous complications may occur, we conclude that it is premature to recommend it. Although Dr. Plaugher is correct that the bulk of the indications concerning patients with acute low-back pain and sciatic nerve irritation were rated "appropriate" by an all-chiropractic panel of experts, these same indications were rated "of uncertain appropriateness" by a multidisciplinary panel of experts [2].

We correct the oversight noted by Drs. Abend and Morehouse; an osteopathic physician was part of our multidisciplinary expert panel. As for the concern that we omitted "many important publications by ... osteopathic physicians," our review concentrated on randomized, controlled trials of spinal manipulation for low-back pain. The references are substantially the same as two recent reviews of this subject [3, 4] and include studies done by osteopathic physicians. We are confident that we did not ignore well-conducted scientific literature and that our conclusions accurately reflect the current state of knowledge. We agree that a need exists for more collaborative research among the professions interested in spinal manipulation.

Dr. Patmas is concerned that we underestimate the risk of spinal manipulation. We based our estimate on the best available information, but we also believe that more information about the risk of spinal manipulation is needed. Our review dealt with serious complications of lumbar spinal manipulation; Dr. Patmas lists two references (his references 3 and 4) that deal exclusively with cervical spinal manipulation and one reference (his reference 2) that lists "injuries" that are caused by nonlumbar manipulation (six cases), are caused by misdiagnosis (two cases), are trivial (one case), or are not documented well enough to reasonably infer a cause-and-effect relation between the presumed lumbar manipulation and the "injury" (three cases). Several of our references are review articles, and we did not separately cite the many case reports they reviewed.