Author(s): ToQuynh Thuy Vu, DO, Justin S. Hong, MD
Originally published: November 11, 2011 Last updated: July 3, 2024
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Overview and Description

Manual therapy (MT) is a hands-on approach to assess and treat musculoskeletal (MSK) disorders through which practitioners apply passive, skilled movement to directly or indirectly target anatomical structures or systems in order to create beneficial change.1 The practice of using one’s hands for therapeutic purposes has existed for centuries, though it was not until the 19th century that manual treatments were incorporated into alternative health professions as a foundational service.2,3

The most common types of MT include osteopathic manipulative treatment (OMT), chiropractic, massage, and manual physiotherapies. Less common techniques that exist but will not be explored in this overview include structural integration, cupping, reflexology, and acupressure. Osteopathic and chiropractic techniques dominate the MT field in the United States.2 Massage therapy remains a popular modality for patients, but is rarely covered by health insurance.4

Table 1: Common manual therapies and their goals and focuses3

Manual TherapyFunctional GoalsPrimary Focus
Osteopathic manual therapy (OMT)Use MT as a part of a holistic approach to patient care. Osteopathic physicians are licensed to practice medicine in the United States.Whole-person approach
ChiropracticDiagnosis, treatment, and prevention of mechanical disorders of the MSK and nervous system. Chiropractors can order imaging and make diagnoses but are not licensed medical doctors in the United States.Spine adjustments, joints and soft tissue manipulation
Massage therapyRelieve or prevent physical dysfunction and pain to enhance well-being. Massage therapists are licensed health professions in the United States.Soft tissues
Physical therapy (PT)/PhysiotherapyUse MT and therapeutic exercises to manage neuromusculoskeletal conditions. Physical therapists are licensed to practice PT in the United States.Joints, nervous system structures, myofascial structures, ligaments/cartilage, lymphatic tissues

Patho-anatomy/physiology

Different musculoskeletal manual therapies engage different neurophysiologic principles.

Osteopathic medicine and manual physiotherapies focus on similar principles involving reflex mechanisms and neural transmission activities of the nervous system. Examples include5:

  • Muscle spindles: Intrafusal spindle fibers are sensitive to changes in muscle length. Incongruency between muscle action and spindle fibers can result in hypertonic muscle and muscle imbalance.
  • Golgi tendon organ reflexes: The Golgi tendon apparatus is sensitive to tension, providing afferent information to the spinal cord to inhibit alpha motor neuron output and cause muscle relaxation to avoid excessive tendon tension.  
  • Fascia: Fascia is intimately connected to muscle and participates in contraction and relaxation. The elastic nature of fascia allows it to retain a shape and respond to deformation. Muscle imbalance can cause tightness and weakness of the fascial system and further create asymmetry. Increased stimulation causes an agonist muscle to contract and become tight, while its antagonist muscle lengthens and becomes loose. The fascia surrounding the tight agonist muscle and loose antagonist muscle will also shorten and lengthen, respectively.

Chiropractic focuses on the spine, believing that vertebral malalignment impedes mobility, blood flow, muscle tone, and nerve conduction. These impairments can affect visceral function and lead to disease.6

Massage is thought to increase lymph flow, shift the autonomic response from sympathetic to parasympathetic for increased relaxation, prevention of fibrosis, increased clearance of lactate, and for some effects on immunity, cognition, and pain. It is also thought to increase blood flow to muscles, though there is no scientific evidence to suggest this with recent studies.7

Practitioners of manual medicine view the MSK system as an “integral and interrelated part of the total human organism.”5 Unresolved 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 MSK injury and pain. For example, a patient with upper cross syndrome has tight pectoralis muscles anteriorly and tight upper trapeziuses and levator scapulae posteriorly. This is associated with weak deep cervical flexors, middle and lower trapezius muscles, and rhomboids. This patient then has a forward head posture, increased cervical lordosis and thoracic kyphosis, and protracted shoulders. This hunched posture can cause both weakness and pain in the neck and upper back.

Relevance to Clinical Practice

MT should be considered as a treatment option for managing MSK disorders as there is some evidence for it to improve function with relatively few side effects. Practitioners should be aware of absolute and relative contraindications to MT (Table 2). Patients should be assessed and educated about benefits and risks of treatments before proceeding.

Physical examination

A physical exam, including a neurological exam, should first be completed to ensure that the patient is stable. Further assessment and MT should not be performed if a patient is hemodynamically unstable or has signs or symptoms requiring emergent evaluation and care.

The structural exam then attempts to identify areas of dysfunction5

  • Inspection – inspect the joint or area for overt deformities, skin changes, or asymmetry in appearance or position compared to the other side.
  • Palpation – hands-on assessment of the joint or tissue for warmth, hypertonicity, boggy edema, or elicited tenderness.
  • Range of motion (ROM) – assess passive and active ROM of the patient’s joints to identify areas of reduced ROM.

Functional assessment

Additional areas of focus include leg lengths, iliopsoas length (Thomas test), and sacroiliac excursion and obliquity5. Areas of spinal hyper- and/or hypomobility may also be identified. It can be useful to perform MSK special tests related to the areas of interest to identify etiologies of the dysfunction. Gait analysis can also further identify postural abnormalities, asymmetries, or pathologic gait. Function including basic activities of daily living, work, and leisure activities can be negatively affected depending upon the structural abnormality and its downstream effects. It is important to assess the treatment areas before and after performing MT to see if the treatment has yielded any improvement – for example, comparing pain scores before and after treatment, retesting ROM, looking for improvement in symmetry or alignment, etc.

Laboratory studies

There are no guidelines supporting routine laboratory workup prior to MT.

Imaging

There are no guidelines for routine imaging prior to MT. X-rays may be taken before chiropractic spine manipulation to assess spine alignment, but generally MT can be performed without pre-treatment radiographs in the absence of red flag conditions.8

Supplemental assessment tools

Tools such as goniometry (measuring specific joint or gross spine ROM) and pain rating scales can be used to measure effectiveness of interventions9, however there are no guidelines to support the use of supplemental assessment tools in performing MT.

Predictions of outcomes

Despite MT remaining popular with patients and practitioners, there is limited high quality evidence for its effectiveness.10 Separate studies and systematic reviews have shown low to moderate evidence that MT improves pain and function and may be equal to guided exercise for back pain,11,12,13 neck pain,14 and headaches,15 while the combination of MT and guided exercises together tends to be superior when compared to either alone.

Several studies have shown low to moderate evidence that MT improves pain and function in temporomandibular joint disorders16,17 and shoulder pain,18,19,20 although these have not been shown to be superior to standard treatments. It has also been shown that both patients who receive OMT and sham manipulation reported greater outcomes in reduction of back pain, satisfaction in care, and improvement of physical and mental health compared to control subjects who have had no interventions, suggesting efficacy in placebo effect from increased time spent with patients during encounters or effects from ROM and touch.21

MT has been shown to be efficacious in patients with chronic MSK conditions, but not in patients with acute conditions.22

Specific secondary or associated conditions and complications

Patients must give informed consent for treatment with MT. It is important to thoroughly assess the patient to identify factors that preclude the use of MT. Contraindications include, but are not limited to, those listed below.

Table 2: Contraindications of MT5,23

Absolute ContraindicationsRelative Contraindications
• Lack of patient consent
• Hemodynamic instability
• Acute neurologic conditions with progressive symptoms (e.g., cauda equina syndrome, acute intervertebral disc herniation)
• Acute intracranial pathology
• Atlanto-axial instability (e.g., in rheumatoid arthritis, Down syndrome) when considering cervical MT
• Connective tissue disorders that compromise tissue integrity
• Fractures or open wounds in the area of treatment
• Active infection		• Intervertebral disc herniation without acute symptoms (if trying to manipulate the spine)
• Metastatic cancer (risk of promoting hematologic or lymphatic spread of metastasis)
• Coagulopathies (risk of bleeding)

Complications from MT are rare but incidents have been described. The primary severe complication remains to be cervical arterial dysfunction in the setting of cervical manipulation, leading to cerebrovascular ischemic events.24 Case reports and case series have shown that chiropractic manipulation of the cervical spine with hyperextension and contralateral rotation of the head significantly reduces vertebral artery circulation, which may injure the vessels of the head and neck, most frequently the upper cervical segments of the vertebral artery through the intracranial vertebral artery and carotid arteries may also be negatively affected. This may lead to vertebral basilar artery dissection, stroke and potentially even death.25 Atlanto-axial instability, as seen potentially in rheumatoid arthritis and Down syndrome, is an absolute contraindication for many cervical MT techniques. Manipulation in these patients may cause neurologic damage.5,26 Other case reports have shown rare neurologic presentations following MT including nerve damage,27 myelopathy,28 and death.29 These risks, albeit rare, should still be discussed with the patient prior to performing MT.

Available or current treatment guidelines

Certain types of MT have developed their own treatment or practice guidelines, as listed below:

  • In osteopathic medicine, Principles of Manual Medicine is considered the authoritative textbook on OMT.2
  • In 2009, the Academy for Chiropractic Education published updates to their guidelines, entitled Manual Medicine Guidelines for Musculoskeletal Injuries.30

At different disease stages

There are no current guidelines for performing MT during acute, subacute, and chronic phases of MSK disorders. Literature and systematic reviews are limited and show mixed evidence for use of MT in certain MSK disorders.

Hidalgo et al showed moderate evidence for use of MT in combination with exercise or electro/thermal therapy when compared to usual medical care (education, reassurance, medication, ergonomic and activity advice) for pain relief and functional improvement acute and subacute neck pain.31 There is moderate evidence in favor of MT combined with exercise when compared to exercise or MT alone for pain, function, and care satisfaction for adults with chronic neck pain.

On the other hand, Young and Argáez found that MT was not significantly different from sham MT or no treatment in adults with chronic, non-cancer neck and back pain.32

de Ruvo et al found that MT combined with exercise was more effective than exercise alone in improving ankle range of motion, lower limb function, and pain in acute lateral ankle sprains.33

Bokarius and Bokarius found strong evidence supporting use of MT for treating chronic low back and knee pain, however there is also some lower level evidence against using MT in chronic low back pain.34 Evidence for other chronic MSK conditions was scarce due to many studies having limited statistical power to demonstrate significance in treatment effect or lack of randomized controlled trials.

The safety and efficacy of MT has been studied for use in certain special populations. For example:

  • Patients who are pregnant: The American Journal of Obstetrics and Gynecology published the PROMOTE (Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects) study which showed that OMT was safe in pregnant women and provided significant treatment effects for pain and back-related functioning.35
  • Patients with cancer: The use of OMT in cancer patients remains controversial. Depending on the individual, manipulation as part of complementary and alternative medicine techniques may be utilized on a case by case basis to relieve pain in terminally ill patients.36 Historical concern for massage causing cancer to spread existed, however there has been no significant evidence to support this, 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 Natural Killer cells and improve immunity.37

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. Informed consent with a thorough discussion of risks and benefits is necessary before providing any MT.

Cutting Edge/Emerging and Unique Concepts and Practice

There is increasing evidence to support incorporating integrative medicine, including MT, in the acute hospital setting for pain management and to address acute MSK dysfunction.38,39

Gaps in the Evidence-Based Knowledge

Despite numerous case series supporting MT, a lack of randomized, double-blind, placebo-controlled studies exists for MT.33,34 There is also great heterogeneity among studies involving MT, with variation in patients and comparison groups, types of MT used in interventions, outcome measures, study design and report of adverse events.31 All of these inherent difficulties limit how the efficacy of MT for MSK disorders can be analyzed in an evidence-based manner.

References

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  33. de Ruvo R, Russo G, Lena F, et al. The Effect of Manual Therapy Plus Exercise in Patients with Lateral Ankle Sprains: A Critically Appraised Topic with a Meta-Analysis. J Clin Med. 2022;11(16):4925. Published 2022 Aug 22. doi:10.3390/jcm11164925.
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  35. 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.
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  39. Vitek SM, Bhagra A, Erickson EE, Cutshall SM, Slack SM, Rodgers NJ, Smidt JM, Jordan MJ, Bauer BA, Chon TY. Optimizing delivery to meet demand for integrative medicine services in an academic hospital setting: A pilot study. Explore (NY). 2020 Mar 7 Epub ahead of print.

Original Version of the Topic

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

Previous Revision(s) of the Topic

Stephanie E. Rand, MD. Role of Manual Therapies in Musculoskeletal Disorders. 5/5/2016

Stephanie E. Rand, MD. Role of Manual Therapies in Musculoskeletal Disorders. 6/29/2021

Author Disclosures

ToQuynh Thuy Vu, DO
Nothing to Disclose

Justin S. Hong, MD
Nothing to Disclose