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Manual therapy is a “hands on” approach to assessment and treatment of musculoskeletal disorders whereby a practitioner manipulates the soft tissue, muscles, tendons, joints and/or bones of a relatively passive patient.1

Somatic Dysfunction: an osteopathic term defined as the impairment or altered function of components of the somatic system: skeletal, arthrodial, and myofascial structures, and their related vascular, lymphatic and neural elements.2


Common manual therapies include osteopathic manipulative treatment (OMT), chiropractic, massage, reflexology, acupressure as well as manual physiotherapies such as those developed by Rolfe, Cyriax, Mennell and others.  Osteopathic and chiropractic techniques dominate this field of treatment in the United States.3

Epidemiology including risk factors and primary prevention

Numerous musculoskeletal injuries respond to manual medicine treatments. Back 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.


  • The therapeutic principles of Osteopathic 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
  • In the osteopathic model,2 structural or functional abnormalities of the musculoskeletal system include:
    • asymmetry of related parts;
    • impaired range of motion (hyper- or hypomobility);
    • abnormal texture of soft tissue.
  • Chiropractic focuses on the spine, crediting vertebral malalignment as causing pressure on nerves which may affect visceral function and lead to disease4
  • Different musculoskeletal manual therapies engage different neurophysiologic principles, including hyperactive gamma motor neurons associated with spasms, Golgi tendon organ reflexes, reciprocal innervation reflexes and elastic stretch reflexes2

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  • Practitioners of manual medicine view the musculoskeletal system as an “integral and interrelated part of the total human organism.”2Unresolved somatic dysfunction often leads to postural abnormalities and asymmetries. Areas of tightness persist and inhibit muscle function, causing areas of noted weakness. These asymmetries then increase the risk of further musculoskeletal injury and pain.
  • 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.6
  • 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.7

Specific secondary or associated conditions and complications

  • Unresolved acute pain carries the risk of becoming chronic. Persistent chronic pain causes disability, worsens the sedentary condition, and worsens psychological pathologies.
  • Complications from manual medicine are rare but incidents of peripheral nerve damage, myelopathy and death have been described.
  • Case reports and case series have shown that chiropractic manipulation of the cervical spine with hyperextension and contralateral rotation of the head significantly reduced VA circulation, which may injure the vessels of the head and neck, most frequently the upper cervical segments of the vertebral artery though the intracranial VA and carotid arteries may also be negatively affected.  This may lead to vertebral basilar artery dissection, stroke and potentially even death.8



The most common presenting complaint is pain or lack of motion.  Areas at risk for repetitive strain or postural dysfunction are especially affected, such as 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, ranging of the patient’s joints, and gait analysis can help 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.2

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. Plain film X-rays and 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.9

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.10


The environment can influence the outcome of any musculoskeletal treatment including manual techniques. Initial skepticism bias for manual treatment may reduce efficacy. A challenging work environment can cause a higher rate of pain recurrences.

Professional Issues

Patients must give consent for treatment with manual techniques. Cases of neurological impairment resulting from manipulation are rare but have been described as in the Specific secondary or associated conditions and complications section.

Initial bias against manual treatments may need to be overcome.


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.
  2. In osteopathy, Principles of Manual Medicine is considered the authoritative textbook.2
  3. In 2007 the Academy for Chiropractic Education published updates to their guidelines, entitled Manual Medicine Guidelines for Musculoskeletal Injuries (updated in 2009).11

At different disease stages

  1. Acute: Interventions at this stage may be limited by severe pain, because “guarding” may limit the techniques available. In such situations, other modalities such as medications, modality applications or injections can be utilized to reduce pain acutely and as the patient becomes more relaxed, the muscles can better benefit from manipulation techniques.
  2. Subacute
    • Rehabilitation in the form of stretching and strengthening exercises must be employed in this stage.
    • Manipulation at this stage may be used to correct dysfunctions and for symptom relief and may result in the use of less pain medication or injections.
    • 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
    • The chronic/stable patient can benefit not only from manual medicine treatments, but also from a multidisciplinary rehabilitation approach.
    • Attention to “re-activation” must occur and restore the patient to a better functioning state despite the pain they may have.
    • 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: The use of manipulation in cancer patients remains controversal. Depending on the individual, manipulation may be utilized to ease pain and suffering.  Historical concern for massage in cancer patients existed, however a comprehensive review by Corbin12 found there has been no significant evidence that massage therapy can spread cancer, though direct pressure over a tumor is nonetheless usually discouraged.  Massage in cancer may lower pain, anxiety, depression and nausea and improve sleep; gentle effleurage may increase NK cells, improving immunity.12

Patient & family education

Manual medicine may be met with skepticism and/or 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.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  1. New techniques in manual medicine are continually being developed and are available to practitioners through various Continuing Medical Education (CME) courses


Cutting edge concepts and practice

  • Videofluoroscopy is being used in research to attempt to quantify the underlying mechanisms of manual therapy13
  • The American Journal of Obstetrics and Gynecology published the PROMOTE (Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects) study which showed Osteopathic manipulation was both safe in pregnant woman and provided significant treatment effects for pain and back-related functioning14


Gaps in the evidence-based knowledge

  • Despite numerous positive case series, a lack of randomized, double-blind, placebo controlled studies exists for manual therapies due to inherent difficulties with blinded or sham manipulation.
  • The use of manipulation in cancer patients remains controversial (possibly safe, possibility for tumor spread).


  1. Wainapel SF, Fast A.  Alternative Medicine in Rehabilitation: a Guide for practitioners. New York: Demos Publishing; 2001.
  2. Greenman, P. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins. 1996.
  3. Pettman, E.  A History of Manipulative Therapy. J Man Manip Ther. 2007;15(3):165–174.
  4. Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Arch Intern Med. 1998;158(20):2215–24.
  5. 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.
  6. 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.
  7. 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.
  8. Albuquerque FC, Hu YC, Dashti SR, Abla AA, Clark JC, Alkire B, Theodore N, McDougall CG. Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011 Dec;115(6):1197-205.
  9. 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.
  10. Licciardone JC, Stoll ST, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine 2003;28(13):1355-1362.
  11. 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.
  12. Corbin L. Safety and efficacy of massage therapy for patients with cancer. Cancer Control. 2005 Jul;12(3):158-64.
  13. Taylor AL, Wilken JM, Deyle GD, Gill NW. Knee extension and stiffness in osteoarthritic and normal knees: a videofluoroscopic analysis of the effect of a single session of manual therapy. J Orthop Sports Phys Ther. 2014 Apr;44(4):273-82.
  14. Hensel KL, Buchanan S, Brown SK, Rodriguez M, Cruser dA. Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects: the PROMOTE study. Am J Obstet Gynecol. 2015 Jan;212(1):108.

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

Original Version of the Topic:

Andrew Sherman, MD. Role of Manual Therapies in Musculoskeletal Disorders. Publication Date: 2011/11/11.

Author Disclosures

Stephanie E. Rand, MD
Nothing to Disclose