Role of Manual Therapies in Musculoskeletal Disorders

  1. Disease/Disorder:

    Manual medicine is a "hands on" approach to assessment and treatment of musculoskeletal disorders that encompasses massage, energy stretching and soft tissue manipulation.


    Methodologies have been an integral part of the human experience for thousands of years. Osteopathic and chiropractic approaches dominate this field of treatment in the United States.

    Epidemiology including risk factors and primary prevention

    Numerous musculoskeletal injuries respond to manual medicine treatments. Spinal pain remains the most common reason manual medicine is employed. There is an 85% prevalence in adults under age 50, with nearly all having at least one recurrence. As the second most common illness given for a missed workday, lower back pain is the most frequent cause of work-related disability.

    1. The therapeutic principles of manual medicine are based upon the understanding that the human body functions as a unit with an inherent ability to self-regulate and self-heal.
    2. Holistic osteopathy is based on the bio-medico-psycho-social model of health care.
    3. The physician attempts to identify a manipulable lesion to apply a resolving technique. Despite many terms used to categorize these lesions, osteopaths accept "somatic dysfunction" as the most appropriate.
    4. In the musculoskeletal system within the osteopathic model,1 structural or functional abnormalities include:
      1. asymmetry of related parts;
      2. impaired range of motion (hyper- or hypomobility);
      3. abnormal texture of soft tissue.
      Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
      1. Practitioners of manual medicine see the musculoskeletal system broadly as an "integral and interrelated part of the total human organism."1 Unresolved somatic dysfunction often leads to postural abnormalities and asymmetries. Areas of tightness persist and inhibit muscle function, causing areas of profound weakness. These asymmetries then increase the risk of further musculoskeletal injury and pain.
      2. Numerous studies have found value in manipulation to treat acute low back pain.2 Haas and colleagues showed efficacy in chronic patients, but not in acute patients.3
      3. Lafferty and colleagues recommended that complementary and alternative medicine techniques be used on a case by case basis to relieve pain in terminally ill patients.4
      Specific secondary or associated conditions and complications
      1. Unresolved acute pain carries the risk of becoming chronic. Persistent chronic pain causes disability, worsens the sedentary condition, and worsens psychological pathologies.
      2. Complications from manual medicine are rare but incidents of myelopathy or peripheral nerve damage have been described.
    5. Essentials of Assessment

      The most common presenting complaint is pain or lack of motion in a structure at risk for repetitive strain or postural dysfunction. These areas include the lateral hips, buttocks (sacroiliac joints), trapezius area, wrists, elbows, shoulders, groin (iliopsoas) or low back.

      Physical examination
      1. Prior to the structural exam, a full neurological exam must be completed to "clear" the patient.
      2. The physical exam then attempts to identify those areas of asymmetry, abnormal range of motion and tissue texture abnormalities that would qualify as somatic dysfunction. "Hands on" inspection, palpation, active ranging of the patient's joints, and gait analysis can identify functional deficits. 
      3. Additional areas of focus include leg lengths, iliopsoas length (Thomas test), and sacroiliac excursion and obliquity. Areas of spinal hyper- and hypomobility may also be identified.
      Functional assessment
      1. Function can be affected negatively, including basic activities of daily living, work and leisure activities.
      2. Psychological consequences include dependence and depression, which reinforce lack of self care.
      3. The sedentary state leads to further increased chronic pain and disability, and greater depression sets in, creating a vicious cycle.
      Laboratory studies

      Bloodwork can rule out systemic disorders such as rheumatoid arthritis, lupus, ankylosing spondylitis and some malignancies. 

      1. Magnetic resonance imaging with and without contrast can rule out infections, malignancies and neurological compromise that may increase the risks of manipulation.
      2. Standing radiographs can be used before and after manipulation to check pelvic symmetry, scoliosis or leg lengths. Fann and colleagues used such radiographs to measure pelvic obliquity.5
      Supplemental assessment tools
      1. Goniometry to measure joint or spine range of motion can be used before and after treatments to attempt to objectively measure effectiveness.
      2. Pain diagrams can be used to measure effectiveness of pain interventions.
      3. Many surface measurement devices advertised as methods for measuring tissue texture and temperatures correlating to pain levels are largely unproven.
      Early predictions of outcomes

      Licciardone found that patients who received osteopathic manipulation reported greater improvements in back pain, greater satisfaction with back care throughout the trial, better physical functioning and mental health one month posttreatment, and at six months had fewer co-treatments compared to control subjects who had no interventions.6


      The environment can influence the outcome of any musculoskeletal treatment including manual techniques. Initial skepticism bias for manual treatment may reduce compliance. A challenging work environment can cause a higher rate of pain recurrences. Certain recreational sports such as golf have increased risk of injury.

      Social role and social support system

      When pain becomes chronic, the roles at home may become reversed. The breadwinner may become the dependent person. An active person may become passive. Such role reversals can become barriers to recovery despite effective manual techniques.

      Professional Issues

      P​atients must give consent for treatment with manual techniques. Initial distrust of manual treatments may need to be overcome. Cases of neurological impairment resulting from manipulation are rare but have been described.

    6. Rehabilitation Management and Treatments
      Available or current treatment guidelines
      1. Manual medicine became more widely accepted after an evidence review policy statement was promoted as a successful treatment modality in a set of National Low Back Pain Guidelines.7
      2. In osteopathy, Principles of Manual Medicine is considered the authoritative textbook.1
      3. In 2007 the Academy for Chiropractic Education published updates to their guidelines, entitled Manual Medicine Guidelines for Musculoskeletal Injuries (updated in 2009).7
      At different disease stages
      1. Acute: Interventions at this stage may be limited by severe pain, because "guarding" may not allow the manipulation to occur safely. In such situations, other modalities such as medications, modality applications or injections must be utilized to reduce pain acutely. As they become more relaxed, the muscles can better benefit from manipulation techniques.
      2. Subacute
        1. Rehabilitation in the form of stretching and strengthening exercises must be employed in this stage.
        2. Physical therapy is critical in order for the patient to participate in the rehabilitation correctly.
        3. Manipulation at this stage should still be effective for symptom relief and may result in the use of less pain medication or injections.
        4. Prevention discussions should begin at this stage. These topics may include configuration of the work station, attempts to improve fitness, and risky behaviors such as poor lifting technique.
      3. Chronic/stable
        1. The chronic/stable patient can benefit not only from manual medicine treatments, but also from a multidisciplinary rehabilitation approach.
        2. Attention to "re-activation" must occur and restore the patient to a better functioning state despite the pain they may have.
        3. Manipulation can be used as a palliative strategy if recurrent treatments preserve function and lead to fewer medications with potential side effects.
      4. Pre-terminal or end of life care: Complementary and alternative treatments (CAM) have been found beneficial in certain patients with terminal illnesses such as cancer. The goal is to reduce pain, suffering and reliance on pain medications that may cause side effects that can decrease the quality of life. In such cases, recurrent manipulation to reduce pain and preserve function seems justified.
      Patient & family education

      Manual medicine has been met with some skepticism and distrust. The practitioner needs to educate the patient and family about the reasons manual medicine may work in their case, including understanding the basis for treatment.

      Emerging/unique Interventions

      Many studies have reported high patient satisfaction scores with practitioners who employ manual medicine, regardless of pain outcomes.

      Impairment-based measurement: 

      Some examples of musculoskeletal and spinal pain impairment measures include:

      1. The Rowland-Morris Back Pain Questionnaire;
      2. Oswestry Low Back Pain Questionnaire (and disability index);
      3. Medical Outcomes Study Short-form 36 (SF-36) and SF-12;
      4. Western Ontario and McMaster Universities Osteoarthritis Measure (WOMAC);
      5. Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH).
      Translation into practice: practice "pearls"/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
      1. New techniques that challenge the manual medicine practitioner and improve outcomes for the patients are continually being developed.
      2. Osteopathic physicians are trained in some of them, and allopathic physicians are challenged to receive training in all areas of manual medicine (e.g., craniosacral technique and energetic healing that may require one-on-one training).
    7. Cutting edge/emerging and unique concepts and practice
      Cutting edge concepts and practice
      1. The advantages of new machines/devices are not proven.
      2. Manipulation under anesthesia may offer some advantages when pain is too severe to mobilize. Published studies are limited to small case series or single case reports without controls or blinding of outcome measures.
        1. One increasingly popular technique is manipulation under anesthesia. Published studies are limited to small case series or single case reports without controls or blinding of outcome measures.
        2. As the population ages, more aggressive "thrusting" techniques have given way to less aggressive active stretching techniques such as "muscle energy," "myofascial release," and "craniosacral technique.
      3. The concept of "holistic" care in the bio-psycho-social model is becoming increasingly accepted as the preferred model for treatment of chronic pain.
    8. Gaps in the evidence-based knowledge
      Gaps in the evidence-based knowledge

      Despite numerous positive case series, a lack of randomized, double-blind, placebo controlled studies exists for manual medicine treatments.

      1. Greenman, P. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins. 1996.
      2. Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM. NASS Contemporary concepts in spine care: spinal manipulation therapy for acute low back pain. Spine. 2010;10(10):918-940.
      3. Haas M, Sharma R, Stano M. Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain. J Manipulative Physiol Ther. 2005;28(8):555-563.
      4. Lafferty WE, Downey L, McCarty RL, Standish LJ, Patrick DL. Evaluating CAM treatment at the end of life: a review of clinical trials for massage and meditation. Complement Ther Med. 2006;14(2):100-112.
      5. Fann AV, Lee R, Verbois GM. The reliability of postural x-rays in measuring pelvic obliquity. Arch Phys Med Rehabil. 1999;80(4):458-461.
      6. Licciardone JC, Stoll ST, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spin.e 2003;28(13):1355-1362.
      7. Braddock EJ, Greenlee J, Hammer RE, Johnson SF, Martello MJ, et al. Manual Medicine Guidelines for Musculoskeletal Injuries. Sonora, CA: Academy for Chiropractic Education; 2009 May 1. 64p.

      Additional Resource
      National Guideline Clearinghouse. http://www.guideline.gov. Accessed March 31, 2010.

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