Manual therapy, manipulation, mobilization, massage, fascia treatment, passive treatment, research evidence, side effects, mechanisms of action
For several years now, there has been a lot of talk in the field of physiotherapy about the evidence for different therapy methods, their benefits and risks, and their intended uses and effectiveness. As a result, many therapists have changed their approach, moving away from "hands-on" techniques in favor of non-manual methods. This is likely due in part to concerns that manual methods may have adverse effects and a belief that they may not be very effective, as there is conflicting research evidence on the matter.
As a consequence, manual therapy as a part of rehabilitation is becoming less common, and not all therapists use manual techniques as part of their treatment. Instead, other forms of therapy are favored, such as those that aim to change the patient's thoughts or behaviors, teach the patient about pain and pain neurophysiology, reduce pain-related fear and stress, or increase the patient's own activity. While these methods work well for certain types of pain, they do not necessarily provide relief in all cases.
In this article, I want to highlight some information about manual therapy and clarify when it should be used as part of a comprehensive treatment plan. I will discuss the benefits of manual therapy and what types of side effects can be expected when incorporating manual therapy into rehabilitation. Before diving in, let's briefly review some terminology so that we can speak the same language and avoid unnecessary misunderstandings.
Manual therapy - what is it?
Manual therapy techniques are "treatments" that are part of pain management, rehabilitation, general well-being, or disease prevention. Manual therapy refers to the application of mechanical force to the body with a therapeutic purpose.
Here are a few examples of manual therapy treatments:
Gentle therapeutic touch
Acupressure or trigger point therapy
Massage and fascia treatment
Joint manipulation therapy
Joint mobilization
Mobilization with movement
Needle techniques (acupuncture, dry needling)
Why is manual therapy often considered ineffective?
In research studies, changes are typically measured and compared to the changes achieved by a control group. The control group may receive a different treatment or a different dosage of the same treatment or medication, and the response to treatment is then compared between the groups. The goal is to find the most effective way to treat the condition among two or more groups or treatment methods.
On the other hand, the control group may receive a placebo treatment, where the participant is given a procedure or medication known to be ineffective, but he or she believes they are receiving proper treatment. This is difficult to implement with manual techniques, but it is a common way to determine the efficacy of an investigational drug in pharmaceutical research. In these cases, the investigational drug is often compared to either sugar or calcium tablets.
Alternatively, the control group may simply have to wait, without any treatment, or receive so-called standard care. Standard care typically involves resting the affected area and using over-the-counter painkillers. In this case, the efficacy of the investigational treatment is compared to the natural healing process or standard care that is available to everyone. This helps determine whether the investigational treatment improves prognosis or shortens recovery time compared to natural healing or standard care.
What results are typically monitored in research studies, and what do they say about manual therapy
In research studies, different variables are often measured, and the groups being compared are never identical, making it difficult to compare the effectiveness of different treatments. It is important to understand what exactly is being measured in a study and the characteristics of the study group, so we can compare the results of different studies.
For example, in one study, the focus may be on changes in internal mechanisms, while in another, it may be on clinical changes in the subjects being studied. In the former, the focus is on changes that occur internally, while in the latter, external factors or changes in mindset may also have an impact. Moreover, the study's baseline characteristics may also differ; for example, one group may consist of young athletes, while the other comprises less active seniors. Such differences make it impossible to compare the two groups, and any conclusions about the effectiveness of the treatment based on such comparisons would be flawed.
Here are a few commonly used variables in research studies and their definitions, along with the evidence for manual therapy:
Mechanisms
"Mechanisms" refer to the stages or processes through which an intervention (or an independent variable) actually develops and produces change. Mechanisms explain why and how a change occurs.
Examples of mechanisms in manual therapy include:
Reduced inflammation
Modulation of descending pain pathways
Reduced muscle tension
Improved muscle performance
Reduced cortisol secretion
Increased blood flow
Placebo effect
Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy, 14(5), 531-538.
Clinical changes
Clinical changes refer to measurable changes in a patient's condition before and after a treatment intervention. These changes reflect the effectiveness of the treatment.
Examples of clinical changes resulting from manual therapy include:
Reduction of pain
Increased range of motion
Decreased interference of pain with daily activities
Improvements in commonly used questionnaires
Evidence of cost-effectiveness in treatment.
Therapeutic effect
The therapeutic effects of manual therapy are typically measured by the treatment response that leads to a favorable clinical outcome. This is often quantified by the effect size, which can range from 0 to 2.0. A score of 0 indicates no discernible difference between groups, while a score of 2.0 indicates that one group is almost 100% better than the other. Most effect sizes for rehabilitation interventions are in the range of 0.2-0.4, which are relatively small. This means that, on average, 58-66% of participants in the control group had worse outcomes than those in the treatment group.
It is important to note that the results are highly dependent on what manual therapy is being compared to. When manual therapy is compared to waiting or standard care, it is generally considered effective. However, when it is compared to therapeutic exercise, the difference between the groups is negligible, suggesting that both treatments are equally beneficial. Manual therapy is often used as part of a comprehensive rehabilitation program to expedite pain relief and improve healing prognosis.
https://pubmed.ncbi.nlm.nih.gov/27860218/
https://pubmed.ncbi.nlm.nih.gov/30921975/
https://pubmed.ncbi.nlm.nih.gov/31401702/
https://pubmed.ncbi.nlm.nih.gov/31726927/
https://pubmed.ncbi.nlm.nih.gov/26701903/
https://pubmed.ncbi.nlm.nih.gov/30030035/
Contextual Factors
Contextual factors are a conscious and unconscious part of therapeutic encounters that can either form a collection of perceived effects or enhance the effects of interventions. The contribution of contextual factors to observed clinical changes can vary from small to significant, depending on the patient, practitioner, setting, and intervention characteristics.
Examples of contextual factors include:
Previous experiences
Patient expectations
Clinical atmosphere
Therapeutic relationship
Patient beliefs
Provider beliefs
Treatment-related ceremony
Pain
Pain is by far the most common reason for seeking treatment in cases of musculoskeletal problems. However, there are many different types of pain, and not all pain is treated in the same way. The underlying mechanisms of pain determine the effectiveness of treatment, and the response to a particular treatment can depend on the type of pain being experienced. Therefore, it is important to distinguish between different pain mechanisms and to choose a treatment modality based on the specific pain mechanism in order to achieve a favorable outcome for the prevailing pain condition. This article briefly covers the definition of pain by the International Association for the Study of Pain (IASP) and the three main categories of pain mechanisms, as well as how they relate to manual therapy.
Definition
According to the IASP, pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
The following statements further clarify the definition of pain:
Pain is always a personal experience, influenced by biological, psychological, and social factors to varying degrees.
Pain and nociception are distinct phenomena. Pain cannot be inferred solely from the activity of sensory neurons.
Life experience and previous pain shape the pain experience.
A person's pain experience should always be respected.
Although pain usually serves an adaptive function, it can have harmful effects on functioning, social and psychological well-being.
Verbal description is only one of many behavioral expressions of pain; the inability to communicate does not eliminate the possibility that a person or animal is experiencing pain.
Pain mechanisms
Pain mechanisms have a strong influence on pain experience, treatment principles, and treatment prognosis. The following is a brief description of the main types of pain mechanisms, their differentiation, and treatment principles.
Nociceptive pain
Pain that arises from the activation of pain-sensitive nerve endings, but not from actual or threatened damage to nerve tissue. Nociceptive pain is characterized as sharp, stabbing, dull, aching, or throbbing. The primary treatments for nociceptive pain are nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, but if the pain is severe, opioid therapy may also be considered.
Examples of nociceptive pain include:
Osteoarthritis
Post-sprain pain
Acute inflammatory reactions
Strains
Bruises
Tears
Contusions
Nociceptive pain responds well to manual therapy, and partial pain relief is often immediate. This is known as an "in-treatment change," which is a prognostically important factor when developing a treatment plan. If the pain relief from treatment persists until the next visit (usually within a week of the first visit), the prognosis for improvement is excellent, and incorporating manual therapy into the rehabilitation process is validated and important.
Neuropathic pain
Neuropathic pain is caused by damage or disease to the nervous system. It is characterized by a burning, stabbing, or throbbing sensation, often accompanied by altered sensations or numbness that follows the neuroanatomical distribution of the damaged nerve. Typically, more potent medications that affect the central nervous system are used to treat neuropathic pain, such as amitriptyline, gabapentin, pregabalin, duloxetine, or venlafaxine.
Examples of neuropathic pain include:
diabetic neuropathy
cervical radiculopathy
myelopathy-related pain
pain associated with multiple sclerosis
trigeminal neuralgia
Manual therapy can be effective in treating neuropathic pain, but the treatments used are often quite different from those used to treat nociceptive pain. In neuropathic pain, the aim is to reduce pressure on the nerve tissue or improve its sliding properties. Treatment is often much gentler compared to the treatment used for nociceptive pain.
Nociplastic pain
Nociplastic or central pain refers to pain that is experienced even in the absence of clear evidence of actual or impending tissue damage or somatosensory system disease or injury. Prolonged pain is often attributed to nociplastic pain, which is characterized by sharp or dull aches, often accompanied by tingling, numbness, or a pins-and-needles sensation. Nociplastic pain is considerably more vague than nociceptive pain.
Common medications used to treat nociplastic pain are the same as those used for neuropathic pain, such as amitriptyline, gabapentin, pregabalin, duloxetine, or venlafaxine.
Examples of nociplastic pain include:
fibromyalgia
migraine
irritable bowel syndrome (IBS)
chronic headache
complex regional pain syndrome (CRPS)
temporomandibular joint (TMJ) pain and dysfunction
pelvic pain syndromes
Nociplastic pain does not typically respond favorably to manual therapy. Manual therapy that is too intense or too close to the painful area often results in increased pain that worsens over time. Nevertheless, manual therapy can still be beneficial in this case, provided that gentle touch and less painful areas are targeted. This approach often aims to modulate descending pain pathways, promote muscle relaxation, reduce cortisol secretion, or decrease inflammation. The goal of the treatment is pain relief rather than biomechanical changes.
Adverse effects of manual therapy
All treatment methods have potential adverse effects, including manual therapy. What are these effects, how common are they, and how do they impact treatment outcomes?
The most common adverse effects of manual therapy include temporary muscle soreness, increased pain, and stiffness. Up to half of the subjects may experience these effects, but they usually improve on their own within a few days. When comparing the adverse effects of manual therapy to other treatment methods, it is found to produce fewer adverse effects than medication but slightly more than conventional treatment or waiting. On the other hand, these effects may also improve treatment response in the long run. In fact, mild to moderate adverse effects in men after manual therapy appear to be associated with better treatment outcomes. The risk of serious adverse effects from manual therapy is almost negligible.
Interpreting Research Results in Manual Therapy for Effective Treatment
The use of manual therapy as part of a comprehensive treatment plan is a topic of debate. Interpreting and comparing research results is a complex process, as there are many factors that can affect treatment outcomes and responses. Drawing conclusions from these comparisons can sometimes be impossible. However, despite these limitations, researchers continue to make these comparisons and draw conclusions in the direction they desire.
It is important to remember that there is often significant variability in treatment response within groups, even for treatments that have been shown to be effective. What works for one person may not work for another, and this variability can affect the outcomes of research studies.
Critics who dismiss manual therapy as ineffective may be comparing it to a treatment that has already been proven to work, leading to the false impression that manual therapy is also ineffective. It is crucial to consider what treatment manual therapy is being compared to when examining research studies. If manual therapy is being compared to a treatment that is known to be effective and no differences are found, it means that manual therapy is equally effective. However, if the control group did not receive any treatment or was given a placebo treatment and there are no differences between the groups, then it would be likely that manual therapy was ineffective, but studies claiming this are scarce or nonexistent.
When comparing manual therapy to rehabilitative exercise, there are few significant differences between the two treatments. Both are equally effective in treating musculoskeletal conditions. However, when comparing manual therapy to conventional treatment or no treatment at all, the group that received manual therapy showed greater improvement. Additionally, manual therapy can lead to faster pain relief and earlier therapeutic exercise, which can shorten the overall duration of rehabilitation.
https://pubmed.ncbi.nlm.nih.gov/30921975/
https://pubmed.ncbi.nlm.nih.gov/31401702/
https://pubmed.ncbi.nlm.nih.gov/31726927/
https://pubmed.ncbi.nlm.nih.gov/25808530/
Manual therapy has been shown to be effective and works for a large majority of people suffering from musculoskeletal disorders. Like any other treatment, it has side effects and is not suitable for everyone in all situations. Often, the best results are achieved by combining treatment methods and designing a rehabilitation plan tailored to the patient's background, symptoms, clinical findings, and goals. An individualized approach to the patient's problems and a comprehensive assessment seems to be the most effective way to treat musculoskeletal disorders, but this is often challenging to implement. Nevertheless, we should strive towards this approach.
In conclusion, while manual therapy may not be a one-size-fits-all solution for musculoskeletal pain problems, it has been shown to be an effective treatment for many individuals. By taking a personalized approach to treatment and combining various methods, the best possible outcomes can be achieved. So, if you're struggling with musculoskeletal pain, don't overlook the benefits of manual therapy - it just might be the missing piece in your road to recovery!
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