Manual treatments

Author(s): Adam P. Cugalj, DO and Kathleen McManus, DC

Originally published:09/20/2013

Last updated:09/20/2013


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, including osteopathic and chiropractic manipulative medicine and massage therapy, on which this section will focus. Most, if not all, of these styles of therapy 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, 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. Variations exist on these categorizations, but these are some general introductions to these 3 disciplines.

For each type of manual therapy previously listed, 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 of presence 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, and 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, such as OMT, chiropractic, or massage, 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 to allow the patient’s body to respond and adjust and the response to be determined before another treatment is performed. Re-treating before the full benefit or lack of response is determined may inappropriately influence continuation or termination of the treatment.

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.

Absolute contraindications to massage include the following:

  1. Deep venous thrombosis, because increased blood flow in a limb could cause a thrombus to detach from the vessel wall, creating an embolism
  2. Acute infection
  3. Bleeding
  4. A new open wound

Relative contraindications 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 disease
  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.


There are many types of manual therapy, and techniques vary based on clinical experience and training. Chiropractic adjustment aims to improve biomechanical function and reduce pain by restoring proper motion to a joint complex where restriction is noted on examination. 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. 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. 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.

Other treatments common to osteopathic and chiropractic manipulative therapy include muscle energy, myofascial release (which can include active release techniques), functional, articulatory, strain counterstrain, facilitated positional release, craniosacral, and soft tissue treatment, which may have some overlap with massage. The particular training, background, licensure of the provider, and patient preference will determine which techniques are employed. Direct techniques engage the motion barrier, whereas indirect techniques allow the body’s inherent neurologic or intrinsic forces to release the restriction, because the practitioner positions the area to be treated opposite the 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.




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 meta-analyses 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 treatment program, rather than as a stand-alone treatment, would yield better data.


1. Pettman E. A history of manipulative therapy. J Man Manip Ther. 2007;15:165-174.

2. Medscape Reference. Massage, traction and manipulation. Available at: Accessed February 10, 2013.

3. Greenman PE. Principles of Manual Medicine. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2003.

4. Imamura M, Furlan AD, Dryden T, et al. Evidence-informed management of chronic low back pain with massage. Spine J. 2008;8:121-133.

5. Wieting JM, Andary MA, Holmes TG, et al. Manipulation, massage and traction. In: Fronter WR, ed. DeLisa’s Physical Medicine & Rehabilitation Principles and Practice. 5th ed. Philadelphia, PA: Wolters Kluwer; 2010:1726.

6. Peterson BA. Major events in osteopathic history. In: Ward RC, ed. Foundations for Osteopathic Medicine. Baltimore, MD: Lippincott Williams & Wilkins; 1997:15.

7. Kuchera WA, et al. Glossary of osteopathic terminology. In: Ward RC, ed. Foundations for Osteopathic Medicine. Baltimore, MD: Lippincott Williams & Wilkins; 1997:1138.

8. Sergueef N. Cranial Osteopathy for Infants, Children and Adolescents. Philadelphia, PA: Churchill Livingstone; 2007.

9. Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. J Manipulative Physiol Ther. 2002;24:251-262.

10. Karageanes SJ. Principles of Manual Sports Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

11. Haldeman S. Spinal manipulation therapy in sports medicine. Clin Sports Med. 1986;5:277-293.

12. Miners AL, Bougie TL, Chronic Achilles tendinopathy: a case study of treatment incorporating active and passive tissue warm-up, Graston technique, ART, eccentric exercise and cryotherapy. J Can Chiropr Assoc. 2011;55:269-279.

13. Graston Technique. Available at: Accessed May 5, 2013.

14. Active Release Technique: A.R.T. Accessed May 5, 2013.

Author Disclosure

Adam P. Cugalj, DO
Nothing to Disclose

Kathleen McManus, DC
Nothing to Disclose

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