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1. OVERVIEW AND DESCRIPTION

Manual therapies are among the oldest types of medical treatment in the world. There are historical records of some form of manual therapies in nearly every culture, from ancient Greece and Rome to China and Indonesia to Mexico, Russia, and Norway.1 Although there is no consensus on the complete physiology of these treatments, it is generally accepted that there is more to these approaches than just the interaction of mechanical forces and human anatomy. There is a long history of touch as a natural, essential component to healing and health maintenance.2

There are many types of manual therapy, most, if not all, of which overlap in treatment intention and could be considered subsets of other treatment systems. Manual treatments are provided by physicians, chiropractors, physical therapists, nurses, athletic trainers, naturopaths, lay practitioners, and others.

A consensus definition of manipulation is “the use of the hands in a patient’s management process using instructions and maneuvers to achieve maximal painless movement of the musculoskeletal system and achieve postural balance.”3 Manual treatments are generally directed at the neuromusculoskeletal system, with some techniques applied to the viscera.

Massage may be the earliest and most primitive tool to treat pain.4 Massage consists of Eastern and Western variants. Combinations of these 2 variants are generally used in the United States, but Western massage is the most commonly practiced today. Among the most frequently encountered types of massage therapy are acupressure (Shiatsu), Rolfing, Swedish massage, reflexology, decongestive lymphatic therapy, and myofascial release.4 Forms of Western massage include effleurage, petrissage, tapotement, and deep friction,5 with each representing a treatment aim, direction, or intention.

Osteopathic and chiropractic philosophies started in Midwestern United States around the same time at the latter part of the 19th century. Andrew Taylor Still, MD, DO, started the osteopathic profession in Kirksville, Missouri in 1875,6 and the first successful school, the American School of Osteopathy, was opened there in 1892. Early osteopathic practice incorporated osteopathic manipulative therapy (OMT) as an extension of an evaluation, rather than as a separate medical therapy. Osteopathic physicians are trained in the use of both manual and more standard treatments and have full medical, surgical, and prescribing privileges in all 50 states, as well as in several other countries around the world. Chiropractic was developed in 1895 by Daniel David

Palmer. He went on to found the first school of chiropractic, Palmer Chiropractic College, in 1897 in Davenport, Iowa. The basic foundation of chiropractic treatment is the use of spinal manipulation to treat musculoskeletal conditions. Over time, the practice has evolved to incorporate other modalities in addition to manipulation, including soft tissue techniques, physiotherapies, such as ultrasound and cryotherapy, acupuncture, corrective and rehabilitative exercises, liniments, and nutritional recommendations.

OMT is traditionally applied to the spine, but may also include treatment of nearly every other body structure. Chiropractic manipulation is most commonly applied to the spine and paraspinal regions, but may also include treatment of peripheral joints and soft tissues, depending on the training of the treating chiropractor. Massage therapy most directly addresses soft tissue structures, such as muscles and fascia. Acupressure points are commonly applied to extremities, back, and at times visceral organs. Variations exist on these categorizations, but these are some general introductions to these disciplines.

For each type of manual therapy, some form of dysfunction is identified through palpatory and structural examination of the body. A dysfunction may be referred to as somatic dysfunction, a subluxation, or a restriction, among other terms. A definition for somatic dysfunction, most commonly used in osteopathic terminology is “impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic and neural elements.”7 A dysfunction may be acute, subacute, or chronic, depending on the duration and may be physiologic, induced traumatically, or may be a reflex change.8 A physiologic dysfunction may occur through the normative range of motion and represent a change in that range as a result. A reflex type of dysfunction may reflect a change elsewhere in the body that is neurologically mediated. This is sometimes referred to as a viscerosomatic reflex. An illustration of this phenomenon is the commonly reported right shoulder pain that may accompany cholecystitis, or the left mandibular pain or left upper limb symptoms associated with cardiac conditions, such as an acute myocardial infarction.

The exact pathoanatomy/physiology underpinning the use of manual therapies is not well defined, although there are many theories to explain the derived treatment effect(s). Evans9 and Karageanes10 proposed the following, in relation to the effects of joint mobilization: release of entrapped synovial folds, relaxation of hypertonic muscle, disruption of articular or periarticular adhesions, unbuckling of motion segments that have undergone disproportionate displacements, and neurophysiologic effects. Karageanes10 and Haldeman11 include theories, such as the alteration of mechanoreceptors in the spinal apophyseal joints as a source of pain and altered joint function and the release of endorphins that may be associated with the sensation of pain reduction following a treatment. What is clear regarding the effects of manual therapies is that the effects likely take place on multiple levels, from microscopic neurophysiologic and biochemical levels to the macroscopic joint, muscle, and connective tissue level.

There are some theories that manual therapies applied before there is any injury or dysfunction may prevent such a thing from occurring by helping the body maintain homeostasis, and thereby aid in proper circulation of blood and lymph and maintain proper nerve and neuromuscular function and myofascial equilibrium.3 In most cases, the use of manual therapies occurs once an individual presents with a complaint of pain, tension, paresthesia, or similar symptoms. Standard imaging studies are generally of limited to no benefit for the types of presenting complaints that benefit from manual treatment, but they may be helpful in eliminating other, more potentially serious, causes of the patient’s symptoms.

Using manual therapies, may be a beneficial part of a treatment program that may also include lifestyle modification and an active corrective exercise program to reinforce the benefits of the manual treatment and, ideally, prolong the benefits and decrease reliance on the manual therapies as the mainstay of treatment. Not all patients respond favorably to manual therapies, and there is no consensus on frequency of treatment or duration of treatment. It is likely best to allow at least several days following a treatment for the patient’s body to respond and adjust and the response to be determined before another treatment is performed. Re-treating the body too early before it attains a proper musculoskeletal response to manipulation may impede or terminate the treatment’s intended beneficial effects.

There are some contraindications and adverse effects to be aware of regarding manipulative and massage therapy. Massage is contraindicated when it could cause worsening of a particular condition, unwanted tissue destruction, or spread of disease. Malignancy, thrombi, atherosclerotic plaques, and infected tissue could be spread by massage.⁶¹⁻⁶²

Absolute contraindications to massage include the following:

  1. Deep venous thrombosis, has potential of propagating emboli from increased blood flow in a limb causing thrombus detachment from the vessel wall
  2. Acute infection
  3. Bleeding
  4. A new open wound

Relative contraindications to massage include the following:

  1. Incompletely healed scar tissue
  2. Fragile skin
  3. Calcified soft tissue
  4. Skin grafts
  5. Atrophic skin
  6. Inflamed tissue
  7. Malignancy
  8. Inflammatory muscle disease
  9. Pregnancy2

Absolute contraindications for manipulative therapy are rare, especially for indirect techniques, but some relative contraindications exist with some overlap with massage.

Articulatory techniques are contraindicated for the following:

  1. Patients with vertebral malignancy
  2. Infection or inflammation
  3. Myelopathy
  4. Multiple adjacent radiculopathies
  5. Cauda equina syndrome
  6. Vertebral bone disease
  7. Bony joint instability
  8. Cervical rheumatoid disease

Direct manipulation (eg, high velocity/low amplitude) is contraindicated in those cases and in the presence of the following:

  1. Spinal deformity
  2. Systemic anticoagulation treatment
  3. Severe diabetes or atherosclerotic disease⁶²⁻⁶⁴
  4. Degenerative joint disease
  5. Vertebral basilar disease or insufficiency
  6. Spondyloarthropathies
  7. Ligamentous joint instability or congenital joint laxity
  8. Aseptic necrosis
  9. Local aneurysm
  10. Osteoporosis
  11. Acute disk herniation
  12. Osteomalacia2

Side effects for manual therapies are generally minimal and may include a temporary increase in discomfort in the treatment location, localized erythema, or perhaps bruising, depending on the style of treatment provided.

2. RELEVANCE TO CLINICAL PRACTICE

There are many types of manual therapies, and techniques vary based on clinical experience and training. Acupressure/Shiatsu/reflexology/tuina focuses on pressure points according to meridian lining to restore balance to patient’s qi (energy force). Tuina is Chinese massage that involves using the fingers, knuckles, hands, elbows, and feet for treating tender pressure points and tight muscles and works via endorphin release and increased blood circulation to a dysfunctional region to reduce muscle tension.⁶⁵ Deep tissue massage usually target tense, contracted muscles. Swedish massage is a gentler form of manual treatment. Neuro mobilization or neurodynamics techniques involve restoring balance to nerves and surrounding tissues by unloading pressure around the nerves. The most common spinal manipulation used by chiropractors is high-velocity, low-amplitude (HVLA) thrust to spinal segments, although other mobilization techniques (low velocity, higher amplitude) can be used in addition to, or in place of, HVLA manipulation. Osteopathic manipulation has techniques common to the other manual styles mentioned above. Other treatments common to osteopathic and chiropractic manipulative treatments include muscle energy, myofascial release (which can include active release techniques), functional, articulatory, strain counterstrain, facilitated positional release, craniosacral, soft tissue treatment, and vibrational release. Direct techniques engage the motion barrier, whereas indirect techniques allow the body’s inherent neurologic or intrinsic forces to release the restriction, by placing the area to be treated in the opposite direction of a restriction. Examples of direct techniques include HVLA and articulatory, whereas strain counterstrain and functional techniques are generally considered indirect. There can be some overlap as well.

In addition to hands on mobilization and manipulation, some practitioners use instrument assisted manipulation, such as the activator technique, which uses a small spring-loaded instrument to deliver gentle force over specific spinal segments. These instrument assisted devices can also be used by the patient’s themselves for myofascial release.⁵⁹ Foam rollers, compressive wrapping, stones, beads, moxibustion, heat lamps, oscillating devices, ultrasound heat, lasers, or cupping can be used to further assist with manipulation. Selection of manipulation type depends on patient age, condition, health history, and area of complaint. Patients with abnormal bone density, for example, may be candidates for spinal mobilization or the activator technique rather than HVLA. The particular training, background, licensure of the provider, and patient preference will also determine which techniques are employed.

Manual therapies have many clinical applications. Below is the current evidence for such.

Acupressure has been studied for a wide variety of conditions and applicable to nausea and vomiting in pregnancy and chemotherapy, labor pains, dysmenorrhea, fatigue, insomnia, and musculoskeletal conditions which have trigger points.¹⁵⁻¹⁶ Acupressure has grade A evidence for nausea and vomiting with mostly grade C evidence for other medical conditions.¹⁷ due to poor quality and design of studies.¹⁸

Reflexology has been shown to be beneficial for anxiety, pain, sleep, and fatigue.¹⁹⁻²⁰

Chest physiotherapy (CPT) can be used as an adjunct in removing mucus from the lungs and treatment for pneumonia,²¹ which has a short term benefit for cystic fibrosis patients.²² Osteopathic manipulative CPT reduced mean hospital stay by 2 days as opposed to positive expiratory pressure CPT which reduced mean hospital stay by about 1 day. ²¹ Osteopathic manipulative CPT also reduced duration of total and IV antibiotic duration. ²¹ Long term benefits of CPT may not improve mortality rates, cure rates, or chest X-ray improvement rate. ²¹⁻²²

For chronic mechanical neck pains, a single session of spinal manipulation yielded immediate effects on pain reduction as opposed to mobilization, ischemic compression, traction or massage.²³ Mobilization is not necessary for improving neck pains and that a combination of physical therapy with manual therapy yields better outcomes than manual therapy alone.²⁴ Neuro mobilization techniques seem to be effective for neck pain.²⁵

In patients with carpal tunnel syndrome, manual treatments were equally as effective as surgical carpal tunnel release (GRADE B evidence). ²⁶

For those with shoulder pains and shoulder girdle disorders, there is moderate evidence (GRADE B) that manipulative therapies are of benefit.²⁷

There is moderate quality (GRADE B) evidence that patients with chronic low back pain may benefit from manipulation and mobilization with manipulation having a larger effect than mobilization.²⁸ Spinal manipulation had modest improvements for those with acute low back pain up to 6 weeks.²⁹ Manual therapy was similar to spinal stabilization exercises for low back pain and quality of life.³⁰ In a more recent study, neuro mobilization, had been shown to have benefits for back pain. ²⁵

There is moderate evidence (GRADE B, Level 2) for manipulative therapies for lower extremities in short term treatments of hip osteoarthritis and plantar fasciitis.³¹

Lymphatic drainage may have benefits for reducing upper respiratory infections in autistic patients, cancer symptoms in children, and breast cancer swelling in deep cervical lymph nodes (GRADE C, Level 3 evidence).³²⁻³³ Lymphatic drainage may also be helpful in muscle recovery post-exercise by reducing lactate and muscle enzymes³⁴ which can be used to facilitate edema drainage from musculoskeletal injuries in addition to conventional RICE therapy.³⁵ Abdominal lymphatic drainage has been shown to acutely relax patients with psychological distress.³⁶

For fibromyalgia, myofascial release, lymph drainage, Shiatsu, and connective tissue massage improved quality of life for patients while Swedish massage did not.³⁷

There is evidence that moderate pressure massage with oils can increase weight gain in preterm infants although the mechanisms are not entirely clear.³⁸ In a 2017 systemic review, it was reported that NICU infants have a clear benefit from massage with increased weight gain, “a positive effect on brain development, a reduced risk of neonatal sepsis, a reduction in length of hospital stay and reduced neonatal stress”.³⁹  A more recent 2019 literature review by Prevost et al. revealed manual therapy had moderate evidence (GRADE B)“for [pediatric] low back pain and pulled elbow, and premature infants”.⁴⁰

For adolescent idiopathic scoliosis (AIS), myofascial release and spinal manipulation are beneficial adjuncts to conventional conservative medical care.⁴¹

Myofascial scar release can be used to break up scar tissue adhesions after breast surgery, post caesarian section, and chronic caesarian scar pains (GRADE C, Level 4 evidence).⁴²⁻⁴³

Massage is effective for reducing cancer pains.⁴⁴ Massage can be used to reduce pain and prevent delayed onset muscle soreness (DOMS) after exercise.⁴⁵ In a small pilot study, it was shown that massage improved pain, sleep, and fatigue in patients with multiple sclerosis.⁴⁶

In a most recent 2017 small study involving women with dyspareunia secondary to pelvic floor pain, thiele (transvaginal) improved sexual function and dyspareunia.⁴⁷⁻⁴⁸However, thiele massage for chronic pelvic pain patients only improved pain.⁴⁸

Massage and heat modalities may help partum  patients with pain reduction,⁶⁰ reduction of labor time, but evidence has so far been poor due to low quality studies.⁴⁹ Osteopathic manipulation was helpful for low back pain in postpartum and partum patients.⁵⁰ Acupressure has not been shown to be beneficial for inducing labor.⁴⁹

In individuals with coccydynia, manual treatments are recommended for pelvic floor dysfunctions if ergonomics, NSAIDS, or topical pain creams do not work.⁵¹ In one case report, osteopathic manipulation was combined with anesthetic injections to successfully improve radicular symptoms and lower extremity range of motion from chronic coccydynia.⁵²

SUMMARY OF MANUAL TREATMENTS, EVIDENCE LEVELS, & STRENGTH OF RECOMMENDATION

Manual TreatmentsConditionsLevel of Evidence (GRADE Criteria)Strength of Recommendation (SORT Criteria)
Acupressure1.Nausea, Vomiting

2.Other Medical Conditions

3. Labor Pain, Inductio

A

C

C

B

B

C

ReflexologyAnxiety, pain, sleep, fatigueBB
ShiatsuFibromyalgiaCA
Chest PT1. Pneumonia

2. Cystic Fibrosis

C

C

B

B

Spinal Manipulations1. Chronic Neck Pain

2. Low Back Pain

3. Scoliosis

B

B

C

B

B

C

Manual Therapies1. Chronic Neck Pain

2. Carpal Tunnel Syndrome

3  Shoulder Pain/Disorders

4. Low Back Pain

5. Lower Extremities

6. Coccydynia

C

B

B

B

B

D

B

B

B

B

B

C

Neuro-Mobilization1. Chronic Neck Pain

2. Low Back Pain

C

C

B

B

Mobilization1. Chronic Neck PainCB
Lymphatic Drainage1. Upper Respiratory Infection, cancer in children, breast cancer swelling

2. Muscle recovery

3, Psychological distress

4. Fibromyalgia

C

 

 

C

C

C

B

 

 

C

C

A

Osteopathic Manipulative Treatment (OMT)1. Labor Pain, Induction

2. Coccydynia

B

D

B

C

Myofascial Release (MFR)1. Fibromyalgia

2. Scoliosis

B

C

A

C

Myofascial Scar ReleaseScar Tissue after surgeriesCC
Thiele (Transvaginal) MassagePelvic Floor DysfunctionBB
Massage1. Labor Pain, Induction

2. Cancer Pains

3. Delayed Onset Muscle Soreness (DOMS)

4. Multiple Sclerosis

5. Preterm/NICU infants

6. Pediatric pulled elbow, LBP

7. Pediatric Scoliosis, Torticollis

C

B

C

 

C

B

B

 

C

C

B

C

 

C

A

A

 

C

 

3. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES

In recent years, there has been an evolving and emerging theoretical concept on understanding how manual therapies work through the connective tissue system and its clinical importance on healing.The BioTensegrity model proposes that osteopathic fascial techniques work  by inducing inherent cellular changes in the fascial network which have clinically beneficial effects on the human body.⁵³ Fascia, a fibrous sheet of connective tissue which envelops the body and encloses the muscles and organs, is formed by fibroblasts.⁵⁴ Myofascial releases or manual treatments targeting the fascia can deform fibroblasts through mechanotransduction to restore normal fluid pressure gradients and muscle tension via tensional memory, repair tissue microscopically, and alters the dynamics of pain and inflammation. ⁵⁴⁻⁵⁵

4. GAPS IN KNOWLEDGE/EVIDENCE BASE

Manual therapies are very difficult to properly investigate. Study limitations, including inadequate sham treatments, inconsistent and variable treatment styles, techniques and approaches, lack of blinding, and other difficult to control for factors, often lead to unclear or generally underwhelming results. The general consensus from recent studies, reviews, and metaanalyses is that more research is needed, because manual therapy continues to have high utilization of health care expenses with seemingly variable benefits. Perhaps investigating manual therapies as part of a comprehensive rehabilitative treatment program with the goal of improving overall quality of life, rather than as a single stand-alone treatment, would yield better data.

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Original Version of the Topic

Adam P. Cugalj, DO and Kathleen McManus, DC. Manual Treatments. 09/20/2013

Author Disclosure

Bittu Kuruvilla, MD
Nothing to Disclose

Lawrence Chang, DO, MPH
Nothing to Disclose

Yusik Cho, MD
Nothing to Disclose