Author(s): Joe Mendez, MD, DC, Rachel Reeves, DO
Originally published: September 20, 2013 Last updated: January 3, 2024
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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, including ancient Greece, Rome, China, Indonesia, 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

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. 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.

Pathoanatomy/physiology

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). Evans3 and Karageanes4 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. Karageanes4 and Haldeman5 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.

How to describe the dysfunction

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.”6 A dysfunction may be acute, subacute, or chronic, depending on the duration and may be physiologic, induced traumatically, or may be a reflex change.7 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.

Treatment considerations

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.

Are manual therapies only beneficial after injury?

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.

Do manual therapies end in the office?

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.

Now to discuss the types of manual therapies in detail, specifically massage, osteopathic manipulative medicine, and chiropractic medicine.

See figure 1 for the relationship of all the disciplines and how they overlap.

Massage

Definition

The Massage Therapy Body of Knowledge (MTBOK) defines massage as “a patterned and purposeful soft-tissue manipulation accomplished by the use of digits, hands, forearms, elbows, knees and /or feet, with or without the use of emollients, liniments, heat and cold, hand-held tools or other external apparatus, for the intent of therapeutic change.”8

Origin/history

Massage may be the earliest and most primitive tool to treat pain.9 Massage was first documented in first century BC Chinese medicine. It was well established in sixth century AD China and starting to spread to Japan and India. Massage continued to grow, and many techniques began to form throughout the world. Massage therapy made its way to the US in the 19th century and was heavily influenced by physical therapy in the 19th and 20th centuries.10

Theory of practice/basis/rationale

The philosophy of massage is rooted in the instinctive and intuitive response to the body’s aches and pains. The purpose of massage is to maintain good health and promote wellness by addressing soft tissue structures, such as muscles and fascia.

Techniques/classification

Techniques that fall under massage therapy include acupuncture, Rolfing, Swedish massage, reflexology, decongestive lymphatic therapy, effleurage, petrissage, tapotement and deep friction. These techniques are a combination of Eastern and Western variants of massage.

Contraindications

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.11,12

Absolute contraindications to massage include the following

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

Relative contraindications to massage include the following

  • Incompletely healed scar tissue
  • Fragile skin
  • Calcified soft tissue
  • Skin grafts
  • Atrophic skin
  • Inflamed tissue
  • Malignancy
  • Inflammatory muscle disease
  • Pregnancy2

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.

Risk/benefits

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. As with any technique which disrupts the skin (e.g., acupuncture) there is the risk of infection, abscess formation, sepsis and death. Benefits include improved function and form.

Osteopathic Manipulative Therapy (OMT)

Definition

The definition of OMT by the American Association of the College of Osteopathic Medicine is “the therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.”13

Origin/history

Osteopathic medicine 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 1875,14 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.

Theory of practice/basis/rationale

The philosophy of osteopathic medicine is rooted in 4 osteopathic principles:

“1. The body is a unit; the person is a unit of body, mind and spirit. 2. The body is capable of self-regulation, self-healing, and health maintenance. 3. Structure and function are reciprocally interrelated. 4. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.”15

Techniques/classification

The techniques that fall under OMT include muscle energy, strain-counterstrain, myofascial release, facilitated positional release, lymphatic drainage, mobilization, balanced ligamentous tension, cranio-sacral, and high-velocity, low-amplitude (HVLA).

Contraindications

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

  • Patients with vertebral malignancy
  • Infection or inflammation
  • Myelopathy
  • Multiple adjacent radiculopathies
  • Cauda equina syndrome
  • Vertebral bone disease
  • Bony joint instability
  • Cervical rheumatoid disease

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

  • Spinal deformity
  • Systemic anticoagulation treatment
  • Severe diabetes or atherosclerotic disease12,16,17,18
  • Degenerative joint disease
  • Vertebral basilar disease or insufficiency
  • Spondyloarthropathies
  • Ligamentous joint instability or congenital joint laxity
  • Aseptic necrosis
  • Local aneurysm
  • Osteoporosis
  • Acute disk herniation
  • 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.

Risk/benefits

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. Benefits include improved function and form.

Chiropractic Manipulation

The Association of Chiropractic Colleges states the “practice of chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and the effects of that relationship on the preservation and restoration of health.”19

Origin/history

Chiropractic philosophies also started in Midwestern United States around the same time as OMT. 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.19

Theory of practice/basis/rationale

The basic foundation of chiropractic medicine is the use of spinal manipulation to treat neuromusculoskeletal conditions as a complimentary alternative to medicine or surgery.

Techniques/classification

Chiropractic manipulation or adjustments are 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. 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.18

Contraindications

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

  • Patients with vertebral malignancy
  • Infection or inflammation
  • Myelopathy
  • Multiple adjacent radiculopathies
  • Cauda equina syndrome
  • Vertebral bone disease
  • Bony joint instability
  • Cervical rheumatoid disease

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

  • Spinal deformity
  • Systemic anticoagulation treatment
  • Severe diabetes or atherosclerotic disease12,15-17
  • Degenerative joint disease
  • Vertebral basilar disease or insufficiency
  • Spondyloarthropathies
  • Ligamentous joint instability or congenital joint laxity
  • Aseptic necrosis
  • Local aneurysm
  • Osteoporosis
  • Acute disk herniation
  • Osteomalacia2

Risk/benefits

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. As with any technique which disrupts the skin (e.g., acupuncture) there is the risk of infection, abscess formation, sepsis and death. Benefits include improved function and form.

Relevance to Clinical Practice

There are many types of manual therapies, and techniques vary based on clinical experience and training. The particular training, background, licensure of the provider, and the dysfunction will determine which techniques are employed and effective. As a reminder manual therapies and techniques overlap greatly and are performed by different types of providers.

Under the umbrella of massage, Acupressure/Shiatsu/reflexology focuses on pressure points according to meridian lining to restore balance to patient’s qi (energy force). Tu ina 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.20 Deep tissue massage usually targets tense, contracted muscles. Swedish massage is a gentler form of manual treatment. Neuro mobilization or neurodynamic techniques involve restoring balance to nerves and surrounding tissues by unloading pressure around the nerves.

For chiropractors, the most common spinal manipulation used is high-velocity, low-amplitude (HVLA) thrust to spinal segments. There are other mobilization techniques utilizing instrument assisted manipulations, such as the activator technique, which uses a small spring-loaded instrument to deliver gentle force over specific spinal segments. This may be helpful in patients with abnormal bone density, for example, who may not be candidates for HVLA.

Osteopathic manipulation has techniques common to the other manual styles mentioned above.

Other techniques 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.13 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.20 There can be some overlap as well.

There are some instruments which a patients can use on themselves for myofascial release.21 Such devices include 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.

Manual-Treatments-Table-1

**Clinical applications/indications column does represent an exhaustive list of conditions treated with these techniques.

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

Manual-Treatments-Table-2

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, restless leg syndrome and musculoskeletal conditions which have trigger points.22-27 Acupressure has grade A evidence for nausea and vomiting with mostly grade C evidence for other medical conditions28 due to poor quality and design of studies.29

Reflexology has been shown to be beneficial for anxiety, depression, pain, restless leg syndrome, hypertension, sleep, chemotherapy induced nausea, and fatigue.30-38

Chest physiotherapy (CPT) can be used as an adjunct in removing mucus from the lungs and treatment for pneumonia,39 which has a short-term benefit for cystic fibrosis patients.40 However, CPT and Osteopathic manipulative CPT have little to no effect on death, cure rate, duration of hospital stay, fever or antibiotic use. High-frequency chest wall oscillation may reduce the duration of the ICU stay, and mechanical ventilation.41,42 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.28 Osteopathic manipulative CPT also reduced duration of total and IV antibiotic duration.28 Long term benefits of CPT may not improve mortality rates, cure rates, or chest X-ray improvement rate.28,29 Pulmonary rehabilitation which involves breathing techniques and posture showed some short-term benefit for bronchiectasis patients with improved exercise capacity, dyspnea and fatigue but no evidence for long-term benefit at this time.43

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.44 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.45,46 Acupuncture, dry needling and cupping have also shown to relieve neck pain after treatment and in the long-term.47 Neuro mobilization techniques seem to be effective for neck pain.48

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.49 Spinal manipulation had modest improvements for those with acute low back pain up to 6 weeks.50 OMT is able to provide substantial improvement in low back pain and low back functioning.51-53 Manual therapy was similar to spinal stabilization exercises for low back pain and quality of life.53 Combined chiropractic interventions and neuro mobilization also showed improvement in low back pain.54 A 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.”55 Myofascial release (MFR) and OMT on the thoracolumbar fascia was able to immediately effect the spine shape parameters, leg length discrepancy and kyphotic angle in low back patients.56 MFR did show moderate evidence of improvement in pain, physical function and quality of life in chronic low back pain patients.57

In patients with carpal tunnel syndrome, manual treatments were equally as effective as surgical carpal tunnel release (GRADE B evidence).58 There is fair evidence (GRADE B) for manual and manipulative therapy (MMT) with exercise in carpal tunnel and lateral epicondylopathy.59

For those with shoulder pains and shoulder girdle disorders, there is moderate evidence (GRADE B) that manipulative therapies are of benefit.59

In patients with tendinopathy, joint mobilization and manipulation improve tendon pain.60

There is moderate evidence (GRADE B, Level 2) for manipulative therapies for lower extremities in short term treatments of hip osteoarthritis and plantar fasciitis.61 There is strong evidence (GRADE 1B) evidence for manual therapy in addition to therapeutic exercise in lateral ankle sprain to reduce swelling, pain, improved mobility and normalize walking parameters. 62

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).63,64 Lymphatic drainage may also be helpful in muscle recovery post-exercise by reducing lactate and muscle enzymes65 which can be used to facilitate edema drainage from musculoskeletal injuries in addition to conventional RICE therapy.66 Abdominal lymphatic drainage has been shown to acutely relax patients with psychological distress.67 Myofascial release and acupuncture in addition to stretch, compressive bandaging, exercise, and scar massage has weak evidence (GRADE C) for improvement in lymphedema in breast cancer patients.68

For fibromyalgia, myofascial release, lymph drainage, Shiatsu, and connective tissue massage improved quality of life for patients while Swedish massage did not.69 Acupuncture has low to moderate evidence of improvement of pain and stiffness in fibromyalgia.70

There is evidence that moderate pressure massage with oils can increase weight gain in preterm infants although the mechanisms are not entirely clear.71 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”.72 A 2016 literature review by Field demonstrated massage has beneficial effects on “prenatal depression, preterm infants, full-term infants, autism, skin conditions, pain syndromes including arthritis and fibromyalgia, hypertension, autoimmune conditions including asthma and multiple sclerosis, immune conditions (…) breast cancer and aging problems including Parkinson’s and dementia.”73 Massage is effective for reducing cancer pains.74 Massage can be used to reduce pain and prevent delayed onset muscle soreness (DOMS) after exercise.75 In a small pilot study, it was shown that massage improved pain, sleep, and fatigue in patients with multiple sclerosis.76

For adolescent idiopathic scoliosis (AIS), myofascial release and spinal manipulation are beneficial adjuncts to conventional conservative medical care.77

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).78,79

In a most recent 2017 small study involving women with dyspareunia secondary to pelvic floor pain, thiele (transvaginal) improved sexual function and dyspareunia.80,81 However, thiele massage for chronic pelvic pain patients only improved pain.81

Massage and heat modalities may help partum patients with pain reduction,82 reduction of labor time, but evidence has so far been poor due to low quality studies.83 Osteopathic manipulation was helpful for low back pain, and pelvic pain in postpartum and partum patients.84 In small studies OMT had some benefit for primary dysmenorrhea, PCOS, and menopause.85 Acupressure has not been shown to be beneficial for inducing labor.83

In individuals with coccydynia, manual treatments are recommended for pelvic floor dysfunctions if ergonomics, NSAIDS, or topical pain creams do not work.86 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.87

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. This theoretical concept is based on the fascia and its impact on the structure-function relationship present throughout the human body. The most current definition of fascia is broad and encompasses “any tissue that contains features capable of responding to mechanical stimuli (…) constantly transmits and receives mechano-metabolic information that can influence the shape and function of the entire body.”88 Biotensegrity is the concept that the musculoskeletal system functions through the balance of tensile forces of the muscles and bones to maintain stability and function. 88 Fascintegrity builds on this theory of biotensegrity by including fluids such as blood, lymph, extracellular matrix and interstitial fluids to the fascia. 88 Holographic fascia also includes the interaction of the electromagnetic field and the body to influence form and function. 88 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. 89 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.89-93 Biotensegrity is taught to osteopathic physicians to aid in the evaluation, analysis and treatment of patients with somatic dysfunction. To explain further consider a patient presenting with low back pain. The initial instinct for many clinicians is to assess only the low back, however a DO or DC might start with the feet. They do this as they know, each person’s base of support is their feet, if there is somatic dysfunction here the body will compensate, and the effect will be seen in their knee, pelvis, and low back. In order to evaluate, analysis and treat the low back pain the feet must also be evaluated and treated.

Gaps in Knowledge/Evidence Base

Manual therapies are very difficult to properly investigate. Study limitations include inadequate sham treatments, inconsistent/variable treatment styles, techniques and approaches, inability to blind patients and providers and other factors which are difficult to control.  The consensus from recent studies, reviews, and metanalyses is that more research is needed, because manual therapies can provide improvement of pain and function in many patients. 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. 9/20/2013

Previous Revision(s) of the Topic

Bittu Kuruvilla, MD, Lawrence Chang, DO, MPH, Yusik Cho, MD. Manual Treatments. 12/6/2019

Author Disclosure

Joe Mendez, MD, DC
Nothing to Disclose

Rachel Reeves, DO
Nothing to Disclose