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Overview and Description

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

Common manual therapies include osteopathic manipulative treatment (OMT), chiropractic, massage, traction, reflexology, cupping, and acupressure as well as manual physiotherapies such as those developed by Rolfe, Cyriax, Mennell and others.  Osteopathic and chiropractic techniques dominate this field of medical treatment in the United States.2 Massage therapy remains a popular out-of-pocket modality for patients, but it is rarely covered by health insurance.3


  • 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 reflexes4
  • 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-heal4
  • 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 disease5

Practitioners of manual medicine view the musculoskeletal system as an “integral and interrelated part of the total human organism.”4 Unresolved somatic dysfunction often leads to postural abnormalities and asymmetries (providing an example using inter-related muscle groups will help provide context). 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.

Relevance to Clinical Practice

Separate studies and systematic reviews have shown low to moderate evidence that manual therapy improves pain and function,  and may be equal to guided exercise for back pain,6,7,8 neck pain9 and headaches10, while the combination of manual therapy and guided exercises together tends to be superior to either alone.

Several studies have shown low to moderate evidence that manual therapy improves pain and function in tempomandibular joint disorders11,12 and shoulder pain,13,14,15 although these have not shown to be superior to standard treatments.

Physical examination

  1. A full neurological exam is completed to “clear” the patient prior to proceeding with the remainder of the exam and treatment. As detailed below, the most common complications of manual therapies have been cervical arterial dysfunction.16
  2. The structural exam then follows the neuro exam and attempts to identify areas of asymmetry, abnormal range of motion and tissue texture abnormalities (hypertonicity, warmth, boggy edema) that would qualify as somatic dysfunction. “Hands on” inspection, palpation, ranging of the patient’s joints, and gait analysis can help identify functional deficits.4
  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.4

Functional assessment

  1. Function can be affected negatively by structural abnormalities, including basic activities of daily living, work and leisure activities.
  2. Comparison of passive and active range of motion (before and after treatment) can help elucidate functional deficits.

Laboratory studies

When warranted by clinical examination, blood work, both routine (such as CBC, ESR, CRP) and disease specific (such as ANA, RF, TSH and antibodies) can evaluate for systemic disorders or inflammatory conditions some malignancies, and help to facilitate the appropriate referral to a specialist.


  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.17

Supplemental assessment tools

  1. Goniometry to measure specific joint or gross spine range of motion can be used before and after treatments to attempt to objectively measure effectiveness, including but not limited to
    • shoulder range of motion before and after Spencer technique
    • cervical range of motion before and after muscle energy
  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.

Predictions of outcomes

Despite manual therapy remaining popular with patients and practitioners, there is limited high quality evidence for its effectiveness.18

Licciardone found that both patients who received osteopathic and sham 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. Proposed similarities have included placebo effect from increased time spent with patients during encounters or effects from range of motion and touch.19

Haas and colleagues showed efficacy in chronic patients, but not in acute patients.20

Specific secondary or associated conditions and complications

  • Patients must give consent for treatment with manual techniques. Complications from manual medicine 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.16
  • Case reports and case series have shown that chiropractic manipulation of the cervical spine with hyperextension and contralateral rotation of the head significantly reduced vertebral artery circulation, which may injure the vessels of the head and neck, most frequently the upper cervical segments of the vertebral artery though 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.21
  • Atlanto-axial instability (as seen potentially in Rheumatoid Arthritis and Down Syndrome) is an absolute contraindication for many cervical manual therapy techniques. Manipulation in these patients may cause neurologic damage4,22
  • Case reports have shown rare neurologic presentations following manual therapies including nerve damage,23 myelopathy24 and death25

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).26
  4. 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 functioning.27

At different disease stages

  1. Acute (up to 6 weeks): 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 (6 to 12 weeks)
    • 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 workstation, attempts to improve fitness, and risky behaviors such as poor lifting technique.
  3. Chronic/stable (greater than 12 weeks)
    • 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 controversial. Depending on the individual, manipulation may be utilized to ease pain and suffering.  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.28 Historical concern for massage in cancer patients existed, however a comprehensive review by Corbin29 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.29

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.

Initial skepticism bias for manual treatment may reduce efficacy.

Cutting Edge/ Emerging and Unique Concepts and Practice

  • To combat the rising opiate epidemic, JCAHO released new pain management standards for accredited organizations in 2018.30
  • There is increasing evidence to support incorporating integrative medicine, including manual therapies, in hospitalized inpatients. 31,32

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. Pettman, E.  A History of Manipulative Therapy. J Man Manip Ther. 2007;15(3):165–174.
  3. Medicare Coverage Massage Therapy. https://www.medicare.gov/coverage/massage-therapy. Accessed 4/14/2020.
  4. Greenman, P. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins. 1996.
  5. Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Arch Intern Med. 1998;158(20):2215–24.
  6. Gomes-Neto M, Lopes JM, Conceição CS, Araujo A, Brasileiro A, Sousa C, Carvalho VO, Arcanjo FL. Stabilization exercise compared to general exercises or manual therapy for the management of low back pain: A systematic review and meta-analysis. Phys Ther Sport. 2017 Jan; 23:136-142. doi: 10.1016/j.ptsp.2016.08.004. Epub 2016 Aug 18. PMID: 27707631.
  7. Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014 Aug 30; 15:286. doi: 10.1186/1471-2474-15-286. PMID: 25175885; PMCID: PMC4159549.
  8. Ulger O, Demirel A, Oz M, Tamer S. The effect of manual therapy and exercise in patients with chronic low back pain: Double blind randomized controlled trial. J Back Musculoskelet Rehabil. 2017 Nov 6;30(6):1303-1309. doi: 10.3233/BMR-169673. PMID: 28946522.
  9. Miller J, Gross A, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Manual therapy and exercise for neck pain: a systematic review. Man Ther. 2010 Aug;15(4):334-54. PMID: 20593537.
  10. Cerritelli F, Lacorte E, Ruffini N, Vanacore N. Osteopathy for primary headache patients: a systematic review. J Pain Res. 2017 Mar 14; 10:601-611. doi: 10.2147/JPR.S130501. PMID: 28352200; PMCID: PMC5359118.
  11. Calixtre LB, Moreira RF, Franchini GH, Alburquerque-Sendín F, Oliveira AB. Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials. J Oral Rehabil. 2015 Nov;42(11):847-61. doi: 10.1111/joor.12321. Epub 2015 Jun 7. PMID: 26059857.
  12. Cuccia AM, Caradonna C, Annunziata V, Caradonna D. Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: a randomized controlled trial. J Bodyw Mov Ther. 2010 Apr;14(2):179-84. doi: 10.1016/j.jbmt.2009.08.002. Epub 2009 Sep 20. PMID: 20226365.
  13. Schwerla F, Hinse T, Klosterkamp M, Schmitt T, Rütz M, Resch KL. Osteopathic treatment of patients with shoulder pain. A pragmatic randomized controlled trial. J Bodyw Mov Ther. 2020 Jul;24(3):21-28. doi: 10.1016/j.jbmt.2020.02.009. Epub 2020 Feb 22. PMID: 32825990.
  14. Camargo PR, Alburquerque-Sendín F, Avila MA, Haik MN, Vieira A, Salvini TF. Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2015 Dec;45(12):984-97. doi: 10.2519/jospt.2015.5939. Epub 2015 Oct 15. PMID: 26471852.
  15. Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014 Aug 26;(8):CD011275. doi: 10.1002/14651858.CD011275. PMID: 25157702.
  16. Kerry R, Taylor AJ, MitchellJ, McCarthy C. Cervical arterial dysfunction and manual therapy: A critical literature review to inform professional practice. Manual Therapy. August 2008; 13(4): 278-288.
  17. 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.
  18. Clar, C., Tsertsvadze, A., Court, R. et al. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report.Chiropr Man Therap 22, 12 (2014).
  19. Licciardone JC, Stoll ST, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine 2003;28(13):1355-1362.
  20. 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.
  21. 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.
  22. Ghanim MT, BergmannS, TurnerRD , Eskandari R,  Mahajerin A. Recurrent Stroke in a Child With AtlantoaxialInstability Following Chiropractic Manipulation. J Pediatr Hematol Oncol. 2020Aug;42(6): e518-e520.   
  23. Heffner JE. Diaphragmatic paralysis following chiropractic manipulation of the cervical spine. Arch Intern Med. 1985 Mar;145(3):562-4.
  24. Salame K, Grundshtein A, Regev G,Khashan M, Lador R, Lidar Z AcutePresentation of Cervical Myelopathy Following Manipulation Therapy. Isr Med Assoc J. 2019 Aug;21(8):542-545.  
  25. Ernst E. Deaths after chiropractic: a review of publishedcases. Int J Clin Pract.2010Jul;64(8):1162-5.  Ccc Heffner JE. Diaphragmatic paralysis following chiropractic manipulation ofthe cervical spine.Arch InternMed. 1985 Mar;145(3):562-4.
  26. 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.
  27. 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.
  28. 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.
  29. Corbin L. Safety and efficacy of massage therapy for patients with cancer. Cancer Control. 2005 Jul;12(3):158-64.
  30. Pain Management Standards for Accredited Organizations. https://www.jointcommission.org/resources/patient-safety-topics/pain-management-standards-for-accredited-organizations/. Accessed 4/14/2020.
  31. Clark SD, Bauer BA, Vitek S, Cutshall SM. Effect of Integrative Medicine Services on Pain for Hospitalized Patients at an Academic Health Center. Explore (NY). 2019 Jan/Feb;15(1):61-64.
  32. 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.

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. 11/11/2011

Previous Revision(s) of the Topic

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

Author Disclosures

Stephanie E. Rand, MD
Nothing to Disclose