Background
-
Techniques for treatment are commonly described as manipulation, mostly as a thrust (impulse) with high velocity and low amplitude (HVLA technique); mobilization, as passive, mostly repeated movement by traction and/or rotation, e.g. joint mobilization; soft tissue techniques or muscle energy techniques, as massage-like techniques, e.g. “strain–counter strain” and others.
-
The specific path and level of training and skills of the acting people, i.e. physicians, physical therapists, osteopaths, chiropractors, laymen.
-
The spectrum of diagnosed and treated complaints and disorders:
-
Pain: low back pain (LBP), neck pain (NP), headache, muscle or joint pain.
-
Restricted spine or joint movement (hypomobility), hypermobility, elevated muscle tone.
-
Methods
-
First category, manipulation: spinal manipulation OR manipulation thrust OR HVLA OR high-velocity low-amplitude OR HVT OR high-velocity thrust OR OMT OR osteopathic manipulative treatment OR manipulation with impulse OR musculoskeletal manipulation.
-
Second category, mobilization: (mobilization OR mobilization) AND (manual OR joint OR spine OR extremity)
-
Third category, functional/musculoskeletal: (“manual medicine” OR “manual therapy”) and (functional OR musculoskeletal OR disorder)
-
Fourth category, fascia: (“manual medicine” OR “manual therapy”) AND (fascia OR myofascial OR neurofascial)
Results
Search results
Low back pain
Author | Target/treatment | Assessment | Studies included/comments | Outcome |
---|---|---|---|---|
Dal Farra F et al. [14] | To assess effectiveness of osteopathic interventions in the management of NS-CLBP for pain and functional status. OMT, myofascial release, craniosacral treatment | All the included trials assessed pain levels and functional status, considered as the primary outcomes in the current review; VAS, Oswestry, mobility | N = 12 studies (1055 participants) – 6 studies osteopathic manipulative treatment | Osteopathic intervention effects results statistically significant in six trials. Results confirms and strengthen evidence that osteopathy improves pain levels and functional status in patients with NS-CLBP over a short-term period. MFR approach reported better levels of evidence for pain improvement if compared to other osteopathic modalities |
Furlan AD et al. (2012) [18] | To evaluate the efficacy, harms and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation and mobilization) for neck/low-back pain | VAS, Pain Disability Index, Oswestry Index, von Korf, Roland–Morris Disability Score | – 81 included in LBP (31 manipul/mob) – 52 included in NP (19 manipul/mob) – 13 studies manipulation alone | In older subjects with mixed LBP duration, spinal manipulation was significantly better than medical care or exercise in reducing disability at intermediate- and long-term follow-up. Spinal manipulation in addition to general practitioner care was relatively cost effective |
Gianola S et al. (2022) [20] | To assess the effectiveness of interventions for acute and subacute non-specific LBP | Pain and disability outcomes | N = 46 for pain; 31 for disability 12 of them MT MT = e.g. spinal manipulation, mobilization, trigger points or any other technique | With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate term |
Goertz CM et al. [21] | To evaluate patient-centred outcomes following a specific type of commonly used SM, high-velocity low-amplitude (HVLA), in patients with LBP | VAS, NRS, Roland-Morris, Oswestry The majority of studies included both pain and function as primary and/or secondary outcomes | N = 38 studies – 20 were evaluated for quality in one or more other reviews | Spinal manipulation for LBP shows a small but consistent treatment effect at least as large as that seen in other conservative methods of care |
Gomes-Neto M et al. (2017) [22] | To examine the efficacy of stabilization exercises versus general exercises or manual therapy in patients with low back pain | VAS, NRS, disability and function assessed by any questionnaire | N = 11 studies (478 patients) Treatments 1–3/week 20–60 min, duration 4–36 weeks | MT was as efficacious as stabilization exercises in decreasing pain and disability and should be part of musculoskeletal rehabilitation for LBP |
Hall H et al. [26] | To critically appraise and synthesize the best available evidence regarding the effectiveness of MT for managing pregnancy-related LBP and pelvic pain | LBP or pelvic girth pain intensity. Secondary outcomes included pain-related disability, quality of life, medication, acceptance and safety of women and children | N = 10 studies (1198 pregnant women) | Limited evidence to support the use of complementary manual therapies regarding pain intensity when compared to usual care and relaxation as an option for managing low back and pelvic pain during pregnancy; No difference to sham therapy |
Kolber MR et al. [33] | To assess the benefit and harms of pharmacologic and nonpharmacologic therapies used in the management of chronic radicular or non-radicular LBP | Not reported | N = 18 RCTs (2561 patients followed for 6 to 52 weeks) SMT: 5 RCTs with 686 patients followed for 2 to 12 weeks were included Rubefacients (capsaicin only): 3 RCTs with 611 patients Acupuncture: 8 RCTs with 4618 patients followed for 4 to 24 weeks | SMT: low evidence, one trial did not find sustained benefit 42 weeks after SMT completion |
Kovacs FM et al. [34] | To review the evidence on the effectiveness and safety of any form of surgery vs. conservative treatment for symptomatic lumbar spinal stenosis | Oswestry, SF-36 | N = 11 studies (918 patients) 1–2–3–6 months Each care provider decided the form of conservative or surgical treatment | In all the studies, surgery showed better results for pain, disability and quality of life, although not for walking ability (more effective than continued conservative treatment when the latter has failed for 3–6 months) |
Lascurain-Aguirrebena I et al. [38] | To review evidence for mechanisms of action of spinal mobilizations | Surface EMG, muscle cross-sectional area, endurance and strength, ROM, stiffness, pressure and thermal pain threshold, posture sway index, pain at rest | N = 24 studies; (> 500 patients) First systematic review with a full analysis of the evidence for the mechanisms of action of spinal mobilizations | Evidence suggests that spinal mobilizations cause neurophysiological effects: hypoalgesia, sympathoexcitation and improved muscle function. Three of four studies reported reduction in spinal stiffness |
Lavazza C et al. [39] | To assess effects and reliability of sham procedures in MT: hand contact sham treatment compared with MT (physiotherapy, chiropractic, osteopathy, massage, kinesiology and reflexology) in lumbar and cervical region | Primary outcomes were pain intensity | N = 24 (19 qualitative/2019 participants) SM/chiropractic: n = 7 studies (567 participants) Osteopathy (5 trials, 645 participants) Kinesiology (1 trial, 58 participants) Articular mobilizations (6 trials, 445 participants) Muscular release (5 trials, 304 participants) Symptom duration not reported | Very low evidence quality suggests clinically insignificant pain improvement in favour of MT compared with ST; similar effects were found with no treatment. The heterogeneousness of sham MT studies and the very low quality of evidence render uncertain these review findings. When blinding was ensured the effects of sham therapy and MT were larger |
Namnaqani FI et al. [48] | To assess the effectiveness of the McKenzie method compared to manual therapy in the management of patients with chronic LBP | VAS, Oswestry, Roland–Morris, after 3, 6, 12 months | N = 5, no meta-analysis | In patients with CLBP, many pain measures showed that the McKenzie method is a successful treatment to decrease pain in the short term, while the disability measures determined that the McKenzie method is better in enhancing function in the long term |
Nim CG et al. (2021) [50] | To explore whether SMT applied at a candidate site is superior to SMT applied at a non-candidate site in relation to the clinical outcome. Cervical pain (n = 6) Lumbar pain (n = 4) | Pain intensity or disability. Secondary outcomes included objective measurements, e.g. pressure pain detection threshold (PPT) and range of motion | N = 9 + 1 (944 patients); 4 reported funding SMT at the candidate site compared to SMT to the opposite side of the indication (i.e. at the same spinal level but on the contralateral side—“same level”) SMT at the candidate site compared to SMT elsewhere in the same spinal region (i.e. cervical, thoracic or lumbar—“same region”) SMT at the candidate site compared to SMT to a distant spinal region | None of these nine studies detected any statistically significant differences in the outcome measurements for the two treatment approaches: SMT given at a clinician-determined “correct” vertebral level did not have better outcomes than treatment given more haphazardly. Not retested if patients recognized that SMT was applied at the non-candidate site. Reasons for findings: The candidate site is a subjective concept The manipulation is not specific A neuromuscular or biomechanical mechanism might explain the positive results of SMT Some positive effects of SMT may be due to non-specific mechanisms |
Paige NM et al. [52] | Is the use of SMT in the management of acute (≤ 6 weeks) LBP associated with improvements in pain or function? SMT was given alone or as part of a package of therapies | VAS, NRS Roland–Morris, Oswestry | N = 15 RCT (1711 patients) Heterogeneity was not explained | SMT treatments for acute LBP were associated with statistically significant benefit in pain and function at up to 6 weeks, which was, on average, clinically modest |
Rubinstein SM et al. [59] | To assess the effects of SMT for chronic low-back pain; HVLA | VAS, NRS, Roland–Morris, Oswestry, SF-36, functional state, return to work | N = 26 RCTs (total participants = 6070), 9 of which had a low risk of bias Approximately two thirds of the included studies (N = 18) were not evaluated in the previous review | In general, there is high-quality evidence that SMT has a statistically significant short-term effect on pain relief and functional status in comparison with other interventions. Evidence suggests that SMT causes neurophysiological effects (local hypoalgesia, sympathoexcitation, improved muscle function) |
Thornton JS et al. (2021) [65] | To summarise the evidence for non-pharmacological management of LBP in athletes; spinal manipulation means mobilization (!) | VAS, SF-36, Oswestry, Roland–Morris, others including muscle strength | n = 14, 4 in meta-analysis 5 with MT (157 patients) | There were short-term beneficial effects of massage and spinal manipulation Acute LBP: spinal manipulations combined with icing and stretching improved pain by an average of 2 points (VAS 0–10) 24 h after one treatment |
Weiss CA (1) et al. [71] | To assess effectiveness of chiropractic care options commonly used for pregnancy-related LBP, pelvic girdle pain (PGP) Osteopathic manipulative treatment | Self-reported changes in pain or disability | N = 50 studies, pregnancy Postpartum n = 16 studies 2 SRs of high and acceptable quality with 1 RCT each that examined OMT as part of a plan of management for managing LBP or PGP | Both SRs reported improvements in pain and disability with OMT as a treatment modality. Moderate, favourable evidence for electrotherapy and osteopathic manipulative therapy |
Weiss CA (2) et al. [72] | To assess the effectiveness of specific chiropractic care options commonly used for postpartum LBP, pelvic girdle pain (PGP), or combination | Self-reported changes in pain or disability self-reported outcomes | N = 16; 5 SR, 10 RCT, 1 cohort study | No treatment option was identified as having sufficient evidence to make a clear recommendation |
Neck pain
Author | Target/treatment | Assessment | Studies included/comments | Outcome |
---|---|---|---|---|
Cross KM et al. [11] | To assess effects of thoracic spine thrust manipulation (supine or seated thrust) on pain, ROM and self-reported function in patients with mechanical neck pain | VAS, faces pain scale; NDI, NPQ, NPRS, ROM | N = 6 reviews (limited number of RCTs) | Results indicate that thoracic spine thrust manipulation can provide a positive treatment effect immediately following thrust manipulation for up to 6 months |
Cumplido-Trasmonte C et al. (2021) [12] | To determine the effectiveness of manual and non-invasive therapies in the treatment of patients only with tension-type headache; MT, global manipulation soft tissue technics | HIT‑6, HDI, VAS, CROM, headache diary | N = 10 (19–42 patients) 4 studies MT; dose of MT was very heterogeneous | All the studies analysed show positive results in patients receiving physiotherapy with MT on pain intensity, pain frequency, disability, overall impact, quality of life, and craniocervical ROM in adults with tension-type headache. No clear evidence that any technique is superior to another |
Fernandez M et al. [16] | To evaluate the effectiveness of SMT for CGHA | VAS, NRS, NDI, Headache Impact Test (HIT-6), mean headache hours per day, per week | N = 7 (> 600 patients) | Low-quality evidence showing a significant, small effect favouring SMT over other MT for pain intensity and disability; moderate-quality evidence for pain frequency. At long-term follow-up: low-quality evidence showing a non-significant difference between SMT and other MT for pain intensity (2 studies) |
Gross A et al. [25] | To assess if manipulation or mobilization improves pain, function/disability, patient satisfaction and quality of life in adults experiencing NP with or without headache | Pain relief, function, disability and patient satisfaction; pain relief, and global perceived effect | N = 17 for meta-analysis | Moderate-quality evidence showed cervical manipulation and mobilization produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low-quality evidence suggested cervical manipulation may provide greater short-term pain relief than a control |
Hidalgo B et al. [28] | To update the evidence for different forms of manual therapy and exercise for patients with different stages of non-specific neck pain. HVLA, mobilization, combination of both, other treatment | VAS, NPRS, NDI, CROM, overall health and quality of life; for short, intermediate-term, long-term (1 year) | N = 23 RCT (680 patients acute NP; 929 patients chronic NP) | HVLA with statistically significant and clinically relevant improvements for pain and disability from 1 week to 6 months. Moderate to strong evidence in favour of HVLA or combined HVLA and mobilization combined with exercise for improvement in pain, function and satisfaction; mobilization need not be applied at the symptomatic levels |
Jin X et al. (2021) [30] | To evaluate the evidence pertaining to the efficiency and safety of using MT to treat patients with cervicogenic cephalic syndrome; MR, MT, acupuncture, exercise | VAS, Dizziness Handicap Inventory (DHI), NDI, ROM | 8 RCTs (395 patients) meta-analysis No serious adverse effects | Significantly reduced scores of VAS, DHI and NDI. and improved ROM of the cervical spine |
Kroll LS et al. (2021) [36] | To review the evidence for manual joint mobilization techniques (MR, MT), supervised physical activity, psychological treatment, acupuncture and patient education as treatments for TTH on the effect of headache frequency and quality of life | Headache frequency and intensity | N = 13 RCTs, 6 joint mobilization (MR technique, MT, osteopathic MT, suboccipital muscle manipulation) | Some positive effects were shown on headache frequency, quality of life, pain intensity and stress symptoms. Weak recommendation for joint mobilization |
Lystad RP et al. [42] | To evaluate the evidence for MT in conjunction with or without vestibular rehabilitation in the management of cervicogenic dizziness | Dizziness frequency, dizziness intensity, posturography, VAS | N = 15 (5 RCTs), (592 patients) | 12, including all five RCTs, reported improvements in dizziness and associated symptoms (e.g. neck pain) following MT. The remaining study measured skull spatial offset repositioning ability and found a significant improvement following soft tissue manipulation |
Miller J et al. [47] | To assess if MT, including manipulation or mobilization, combined with exercise improves pain, function, disability, quality of life, global perceived effect and patient satisfaction for adults with NP with or without CGHA or radiculopathy | VAS, Northwick Park NP Questionnaire, Function and disability, quality of life, costs | N = 17 RCT multimodal treatment of neck pain: acute, subacute, chronic and mixed duration (5 whiplash associated, 1 degenerative changes, 5 cervicogenic headache, 3 radicular singes) 7 manipulation 5 mobilization 5 man & mob combination | Results favoured manipulation, mobilization and exercise over exercise alone, also for long-term pain reduction Moderate evidence favouring reduced costs consisting of MT and exercise Serious adverse events such as stokes or serious neurological deficit could not be established Various combinations of MT and exercise emerged to treat neck pain |
Schroeder J et al. [61] | To compare manipulation or mobilization of the cervical spine to physical therapy or exercise for symptom improvement in patients with neck pain Cervical SM (chiropractic therapy), cervical spinal mobilization (MT) | ROM, VAS, disability SF-36, patient-rated treatment improvement, treatment satisfaction, health status | N = 6 studies (> 500 patients) No studies were performed in patients with chronic pain | Subjects who underwent mobilization therapy compared with physical therapy reported a greater improvement in general health at 7 weeks No differences in SF-36 between SM and home exercise at 12 or 52 weeks Low evidence in acute pain and functional improvement for SMT vs. exercise |
Young JL et al. [75] | To evaluate the effectiveness of thoracic manipulation versus mobilization in patients with mechanical neck pain | VAS, CROM, disability scales | N = 14 studies (250 subjects in experimental group) | Significant amount of evidence, although of varied quality, for the short-term benefits of thoracic manipulation in treating patients with mechanical neck pain |
Zhu L et al. (2016) [76] | To assess effects of cervical manipulation compared with no treatment, placebo or conventional therapies on pain measurement in patients with degenerative cervical radiculopathy | VAS, syndromes in TCM | N = 3 trials (502 participants) Each systematic review included a variety of conservative interventions or complex interventions | Above all, cervical SM showed significant immediate effects in improving pain scores compared with cervical computer traction. Long-term effects of cervical rotational manipulation were not observed |
Temporomandibular disorder
Author | Target/treatment | Assessment | Studies included/comments | Outcome |
---|---|---|---|---|
Armijo-Olivo S et al. (2016) [3] | To summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions in TMD | VAS, MMO, PPT | N = 48 studies (n = 40–130 treated persons/study) Unclear or high risk of bias | MT alone or in combination with exercises shows promising effects. MT targeted to the cervical spine decreased pain and increased mouth ROM in patients with myogenous TMD |
Calixtre LB et al. [6] | To synthesize evidence regarding the isolated effect of MT in improving TMJ function, considering MMO and pain as main outcomes | Pain VAS, MMO, PPT | N = 8 studies (n = 374 patients) Most of the RCTs included were high methodological-quality studies | MT showed greater MMO (high evidence), pain (moderate evidence) and PPT compared to a usual care group |
De Melo LA et al. (2020) [46] | To evaluate the effectiveness of MT in the treatment of myofascial pain related to TMD; several types of MT | Perception of subjective pain | N = 5 studies, (279 total patients) 156 were treated with MT only or MT with counselling | MT was better than no treatment in one study and better than counselling in another study; however, MT combined with counselling was not statistically better than counselling alone; MT alone was not better than botulinum toxin. MT combined with home therapy was better than home therapy alone in one study |
Galindez-Ibarbengoetxea G et al. [19] | To describe the effects of cervical HVLA manipulation techniques on range of motion, strength, and cardiovascular performance | Perception of subjective pain | N = 11 studies (553 patients) | Cervical HVLA manipulation results in improvements in mobility as well as in the cardiovascular system. A large effect size was found in CROM improvement, especially for patients with neck pain. Rotation was the most clearly improved movement. In addition, mouth opening without pain was improved after upper cervical HVLA manipulation, mainly in patients with neck pain |
Homem MA et al. [29] | To determine the existence of scientific evidence demonstrating the effectiveness of OMT as an adjuvant to orthodontic treatment in individuals with orofacial disorders | Functional parameters, Payne test, homogeneity test, cephalometric analysis, ultrasound of masseter | N = 4 RCT (212 patients) All papers had a high risk of bias; results quite particular to specific conditions: anterior open bite, orofacial dyskinesia, masseter thickness | Scientific evidence of orofacial MT in correcting dentofacial deformities when combined with orthodontic treatment |
La Touche R et al. [37] | To assess the effectiveness of cervical MT on patients with TMD and to compare cervicocraniomandibular MT vs. cervical MT | VAS, MMO, pain pressure test, NDI | N = 6 studies; 5 for meta-analysis; (252 patients) | Cervical MT vs. other nonmanual therapy: all four included studies showed significant improvements in pain intensity Cervical MT vs. cervicocraniomandibular MT: significant reductions in pain intensity at 3 months of follow-up |
Martins WR et al. [43] | To assess the effectiveness of a musculoskeletal manual approach in temporomandibular joint disorder patients | Active and passive MMO, mandibular movement, VAS, PPT, EMG on masseter muscle | N = 8 studies, (n = 160 patients) | Significant large effect on active mouth opening and on pain during active mouth opening in favour of musculoskeletal MT techniques when compared to other conservative treatments; beneficial effects with cervicogenic headaches |
Van der Meer HA et al. [69] | To evaluate the literature on the effectiveness of physical therapy (exercise, orofacial MT, cervical MT) on concomitant headache pain intensity in patients with TMD | VAS | N = 5 studies, (107 patients) | Very low certainty that there is an effect of physical therapy for TMD on concomitant headache intensity |
Upper and lower extremities
Author | Target/treatment | Assessment | Studies included/comments | Outcome |
---|---|---|---|---|
Aoyagi M et al. [2] | To assess the effectiveness of SM in patients with upper limb pain as part of the concept of regional interdependence | ROM, NPRS, PPT, HPT (hot pain threshold), CPT (cold pain threshold) | N = 6 studies (201 patients), 3 for meta-analysis | Meta-analysis results suggested there were no statistical differences between SM and other interventions in terms of effects on reducing upper limb pain. The overall quality of evidence was very low; no strong recommendations can be made for the use of SM in these patients |
Bertozzi L et al. (2015) [5] | To assess the effect of conservative interventions (exercise, MT) on pain and function in people with thumb carpometacarpal OA | Hand pain, hand physical function or other secondary measures of hand impairment such as grip or pinch strength, ROM or stiffness | N = 13 RCT, meta-analysis Follow-up to 12 months MT = 4 studies vs. control | Moderate-quality evidence that MT and therapeutic exercise combined with MT improve pain in thumb carpometacarpal OA at short- and intermediate-term follow-up |
Desjardins-Charbonneau A et al. [15] | To search for efficacy of MT for rotator cuff tendinopathy | Pain at rest, VAS, ROM, NPRS | N = 21 studies (n = 880) Only 5 studies had a moderate to low risk of bias | Small but statistically significant overall effect for pain reduction of MT (low- to moderate-quality evidence) compared with a placebo or in addition to another intervention |
Hernandez-Secorun M et al. [27] | To evaluate the effectiveness of conservative treatment (pharmacology, electrotherapy and MT) in patients with CTS regardless of the level of severity and the presence of systemic diseases | VAS, BCTQ (Boston Carpal Tunnel Questionnaire), BCTQ-SSS (BCTQ Symptom Severity Scale), BCTQ-FSS: (BCTQ Function Severity Scale), EMG-CMAP—several parameters | N = 29 studies (30–181 patients) | MT could be effective for severe CTS patients with a systemic condition in the short term The studies that compared MT and electrotherapy found significant differences in favour of the MT group |
Loudon JK et al. [41] | To summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains | VAS, ROM, gait parameter | N = 8 studies (144 patients) Immediate effects | For treatment of subacute/chronic lateral ankle sprains, some form of joint MT appears to help with ankle ROM, especially dorsiflexion and pain reduction |
Maxwell CM et al. [45] | To synthesize the effects of SMT on lower limb neurodynamics | Passive straight leg raise or slump test | N = 8 RCT 4 studies, SMT in thoracic and lumbar region | Limited evidence suggests SMT-improved range of motion and was more effective than some other interventions Comparisons of SMT to sham interventions were mixed |
Pieters L et al. (2020) [54] | To evaluate the effectiveness of interventions within the scope of physical therapy, including exercise, MT, electrotherapy, and combined or multimodal approaches to managing shoulder pain | No report | N = 16, 6 of them systematic reviews (100 to 10,000 patients) with moderate and low evidence for MT | A strong recommendation can be made for exercise therapy as the first-line treatment to improve pain, mobility and function in patients with subacromial shoulder pain. Manual therapy may be integrated, with a strong recommendation as additional therapy |
Pollack Y et al. [55] | To determine whether manual therapy, consisting of deep massage, myofascial release or joint mobilization is effective in treating plantar heel pain | VAS, PPT, SF-36 questionnaire: Physical function Bodily pain General health General health: Emotional role Vitality | N = 6 RCT (177 patients intervention group) Treatment duration: 4 weeks–12 months Outcomes relating to joint mobilizations are controversial | Five studies (from 6) showed a positive short-term effect after MT treatment, mostly soft tissue mobilizations, with or without stretching exercises for patients with plantar heel pain compared to other treatments. MT effectiveness is still under debate |
Salamh P et al. [60] | To determine the effectiveness and fidelity of studies using MT techniques in individuals with KOA | VAS, ROM, WOMAC, KOOS, PSFS, quadriceps muscle peak torque, 6 min walk test, KOOS Weeks to 9 months self-reported function | N = 12 studies (324 patients); meta-analysis MT techniques individualized based on examination findings | MT appears to be moderately effective for improved self-reported function, specifically as an adjunct to another treatment and versus comparators of no treatment or other treatments; support the clinical utility of MT for knee OA |
Tsokanos A et al. [67] | To evaluate the short- and long-term efficacy of MT in knee OA in terms of decreasing pain and improving knee ROM and functionality | VAS, ROM, WOMAC, muscle strength | N = 6 RCTs; (40–300 patients) Intervention 2 to 24 weeks Re-evaluation differed | MT can induce a short-term reduction in pain and an increase in knee ROM Regarding the long-term benefits of MT, the research findings were inadequate for making safe and reliable conclusions |
Xu Q, Chen B et al. (2017) [74] | To evaluate the effectiveness and adverse events of MT compared to other treatments for relieving pain, stiffness and physical dysfunction in patients with KOA | WOMAC, pain, stiffness, function | N = 14 studies (424 patients) Meta-analysis Evidence may be limited by potential bias and poor methodological quality of included studies | The meta-analysis showed favourable effects of MT on pain relief and superior effects on stiffness Preliminary evidence suggests that MT might be effective and safe for improving pain, stiffness and physical function in KOA patients and could be treated as complementary and alternative options (?) |
Additional effects of manual medicine treatment
Author | Target/Treatment | Assessment | Studies included/comments | Outcome |
---|---|---|---|---|
Abaraogu et al. [1] | Efficacy of manipulative therapy in women with primary dysmenorrhea | Pain relief (VAS, PPT, pain rating index) Quality of life (menstrual distress questionnaire) | n = 4 studies, 3 thereof for meta-analysis Spinal manipulative therapy Bilateral global pelvic manipulation technique Reflexology | Moderate methodological quality Significant evidence of pain reduction → manipulative therapy as adjunct therapy Lack of blinding and outcome concerning quality of life |
Arumugam et al. [4] | Effects of external pelvic compression (EPC) on form closure, force closure and neuromotor control of the lumbopelvic spine | Doppler imaging of vibrations Radiographic lumbopelvic angles and erector spinae muscle activity in standing, erect and slump sitting Active straight leg raise test EMG activity of abdominal and thoracic muscles Ultrasonography of pelvic floor movement Pain scale (VAS) Isometric measures, MVC | n = 18 studies 15 used a pelvic compression belt 2 used manual compression 1 used mechanical compression with device | Moderate evidence for EPC in decreasing laxity of SIJ, changing lumbopelvic kinematics, altering selective recruitment of stabilizing musculature and reducing pain Limited evidence for EPC on decreasing sacral mobility and affecting strength of muscles surrounding the SIJ Results might not necessarily apply to sustained application of EPC |
Chow et al. [8] | Assessment of studies evaluating spinal manipulative therapy (SMT) and infectious disease and immune system outcomes | Level of selected immunological biomarkers | n = 13 studies, 6 thereof RCTs | No clinical studies to support or refute the efficacy or effectiveness of SMT in preventing the development of infectious disease or improving disease-specific outcomes Preliminary data that SMT has short-term changes in selected immunological and endocrine biomarkers among asymptomatic participants |
Chung et al. [9] | The association between cervical spine manipulation and internal carotid artery (ICA) dissection—safety of cervical spine manipulation | n.a. | No studies were found measuring the incidence or association of cervical spine manipulation and ICA dissection | Incidence of ICA dissection and cervical manipulation is unknown Besides some case reports, there is no epidemiologic evidence for association to validate this hypothesis |
Coté et al. [10] | The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders | Asthma: peak expiratory flow Infantile colic: parents-perceived global improvement Hypertension: blood pressure, heart rate Dysmenorrhea: pain (VAS) Migraine: migraine days per month | n = 6 studies RCTs, all suitable for meta-analysis | Acceptable or high methodological quality SMT for management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine—not preventing the occurrence of non-musculoskeletal disorders RCTs with high of acceptable quality |
Da Silva et al. [13] | Manual therapy as treatment for chronic musculoskeletal pain in female breast cancer survivors | Pain (VAS), PPT (algometer) Shoulder ROM SF-36/DASH Breast cancer-specific quality of life Arm/breast symptoms Pain catastrophizing (PRSS) | n = 5 studies RCTs, all suitable for meta-analysis Myofascial induction/release/therapy Classic massage Ischemic compression of trigger points | Positive effect on upper limbs and thorax of female breast cancer survivors Manual therapy decreased chronic musculoskeletal pain intensity and increased pain pressure threshold No difference in quality of life 3 studies of good quality |
Fernández-López et al. [17] | Effects of manual therapy on the diaphragm in the musculoskeletal system | Ultrasonographic diaphragm mobility Spinal motion (cervical and lumbar ROM) Posterior chain mobility/flexibility: finger-to-floor test/hamstrings flexibility/sit-and-reach test/Schober-test Pain: VAS, PPT (C4 level) Abdominal and rib cage excursion (Th4-Level) Assessment pain and function/questionnaires | n = 9 studies (no meta-analysis) Focus on diaphragm muscle Stretching or myofascial release Lumbar manual techniques | Manual therapy to diaphragm is effective: immediate increase in diaphragmatic mobility and thoracoabdominal expansion Improvement in posterior muscle chain flexibility Improvement in lumbar and cervical ROM No long-term studies No symptomatic population Neurophysiologic mechanism is unknown 8 × high or very high quality, deficits in blinding |
Kamonseki et al. [31] | Effects of manual therapy on fear avoidance, kinesiophobia and pain catastrophizing in individuals with chronic musculoskeletal pain | Fear avoidance beliefs questionnaire Tampa scale of kinesiophobia Pain catastrophizing scale | n = 11 studies, all suitable for meta-analysis (1 not-RCT) Joint mobilization Soft tissue techniques/mobilization Myofascial release Longitudinal sliding Deep pressure massage (ischemic compression Massage Muscle energy Hold–relax techniques Functional techniques | Manual therapy not significantly different to no treatment/other treatment in reducing fear-avoidance, kinesiophobia or pain catastrophizing Low or very low level of evidence Small to moderate effect size, but not significantly different to no or other treatment |
Kendall et al. [32] | Effects of manual therapies on stability in people with musculoskeletal pain | Balance measures: Gait speed Timed up-and-go test (TUG) Step test Sit-to-stand test Balance Performance: Static balance Modified Schober’s test Force plate centre of pressure Postural stability Romberg’s test No measuring of falls | n = 26 studies (mostly lower limb osteoarthritis or low back pain), 8 studies thereof for meta-analysis | Significant improvement of gait speed and TUG Only short-term (not in the long-term follow-up) No clear association between pain reduction and measures of stability Except of performance bias, risk of bias was generally low or of unclear level |
Kovanur-Sampath et al. [35] | Changes in biochemical markers following spinal manipulation | Biochemical markers: neuropeptides, inflammatory and endocrine biomarkers from blood, urine or saliva Immediate (up to 30 min) and short-term (hours after intervention) | n = 8 studies (randomized controlled trials and clinical trials) Spinal manipulation as intervention (healthy and painful) | Moderate-quality evidence on influence on biochemical markers Moderate-quality evidence: significant difference in favour of spinal manipulation (cortisol level) Low-quality evidence: increasing substance‑P, neurotensin and oxytocin level; no influence on epinephrine or nor-epinephrine level Modulation of pain and inflammation possible No statement on clinical importance of change in biochemical markers |
Navarro-Santano et al. [49] | Effects of joint mobilization on clinical manifestations of sympathetic nervous system activity | Skin conductance Skin temperature | n = 18 studies, 17 thereof for meta-analysis Mobilization (cervical, thoracic, lumbar and upper limbs region) 7 RCT’s 14 of 18 studies on asymptomatic healthy subjects | Significant increase of skin conductance and a decrease in temperature after mobilization Risk of bias was generally low Moderate evidence on a sympathoexcitatory effect of joint mobilization Level of evidence downgraded by heterogenicity |
Rechberger et al. [57] | Effectiveness of an osteopathic treatment on the autonomic nervous system (ANS) | Cardiovascular: heart frequency, heart rate volume Sympathetic activity: cortisol level Pain intensity Skin conductance/temperature Upright stance stability | n = 23 studies 10 RCT’s, 1 clinical multicentre study, 1 CCT, 5 randomized cross-over studies, 5 randomized pilot studies, 1 single case study | Good level of evidence: 3 as high, 11 as moderate, 8 as low Methodological quality is moderate Significant change of ANS by HVLA Significant change in the treatment of suboccipital region There might be “responder” and non “non-responder” No statement – concerning cranial osteopathic techniques due to lack of quality; – concerning effectiveness of mobilization cervical and thoracic due to low evidence; – concerning whether change in ANS took place in the sympathetic or parasympathetic system |
Roura et al. [58] | Do manual therapies have a specific autonomic effect? | Autonomic markers (examples): Skin conductance Skin temperature Heart rate variability Heart rate Blood pressure Microneurography Spillover Pupil light reflexes Electrodermal activity Thermal infrared imaging Skin blood flow | n = 12 reviews, all included RCT’s, partly other study-designs Spinal mobilization (1 × cervical) Spinal manipulations Cranial techniques Myofascial techniques Peripheral mobilization | 5 rated as low risk of bias Manual therapies can have an effect on both sympathetic and parasympathetic system Inconsistent results due to differences in the methodology No discrimination depending on the body region Skin conductance demonstrated a consistent acute sympaticoexcitatory effect for spinal mobilizations Cardiovascular parasympathetic system activation seems to be elicited by manipulations to the upper neck and lumbar spine and by myofascial techniques Clinical relevance unclear: – Mostly healthy subjects – Only short-term effects – Very few correlations with patient-related-outcome-measures |
Schulze et al. [62] | Efficacy of manual therapy for pain, impact of disease and quality of life in the treatment of fibromyalgia | Pain (VAS) Disease impact (Fibromyalgia Impact Questionnaire, SF-36) | n = 7 studies, 4 thereof for meta-analysis Myofascial mobilization/release | Low to moderate evidence Heterogeneity of the included studies Only short-term results Myofascial release (IG) vs. lymphatic drainage (CG): higher pain intensity and FM impact for IG Myofascial release (IG) vs. sham magnetotherapy (CG): improvement in different quality of life subscales and pain intensity for IG Myofascial release (IG) vs. pilates (CG): higher pain intensity and FM impact for IG General osteopathic treatment (IG) vs. control (CG): reduced pain intensity and reduction in the impact of FM (slow mobilization of soft and articular tissues through wide, smooth, rhythmic, continuous movements) |
Slater et al. [63] | The effectiveness of subgroup-specific manual therapy for low back pain | Pain (VAS, NRS) Activity (Oswestry Low Back Pain Disability Questionnaire) | n = 7 studies 3 subgroups: Centralization of symptoms (CoS) with repeated lumbar extension CoS as well as symptom reproduction in three out of four provocative tests for SIJ pain A predetermined clinical prediction rule for spinal manipulation | Significant treatment effects found for pain and activity at short- and intermediate follow-up in favour if manual therapy (subgroup specific) Low quality |
Tramontano et al. [66] | Vertigo and balance disorders—the role of osteopathic manipulative treatment | e.g. dizziness handicap inventory (DHI) Stabilometric assessment Mini-BEST test Sensory organization test (SOT) | n = 5 studies Osteopathic manipulative treatment (soft tissue, articulatory and muscle energy techniques, myofascial release, HVLA to thoracic/lumbar spine, counterstrain, balanced ligamentous technique) | (Weak) positive outcome on balance disorders through different outcomes Encouraging the connection of conventional medicine and evidence-based complementary medicine Studies of higher evidence are required, limited generalizability |
Ughreja et al. [68] | Effectiveness of myofascial release on pain, sleep and quality of life in patients with fibromyalgia syndrome | Pain (VAS, McGill Pain Questionnaire, Nordic musculoskeletal questionnaire)/pressure pain threshold) Sleep (Pittsburgh sleep quality index) Quality of life (fibromyalgia impact questionnaire, SF-36) Anxiety Depression Tender points Fatigue Postural stability Clinical global impression severity Range of motion Sit-to-reach-test | n = 6 studies, two thereof for meta-analysis on pain 4 to 40 sessions and 50 to 90 min (myofascial release) | Large significant effect on pain post-treatment and moderate effect at 6 months post-treatment Compared to sham and no therapy Moderate evidence Studies of higher evidence are required |
Webb et al. [70] | Myofascial techniques—effects on joint range of motion (ROM) and pain | Joint range of motion (active mouth opening, interincisal opening, cervical ROM, tape measurement, digital inclinometer, goniometer) Pain (VAS, PPT) | n = 9 studies, 2 thereof for meta-analysis Randomized controlled trials Muscle energy technique Strain counterstrain Ischaemic compression Myofascial release Neuromuscular technique Positional release | Every single trial concluded the positive effect of myofascial techniques on range of motion and pain Moderate effect size for jaw opening with latent trigger points in masseter muscle High levels of data heterogeneity within the other trials Lack of power calculation, bias prevention, validated outcome measures, reporting between-group differences, effect sizes and confidence intervals |
Wong et al. [73] | Strain counterstrain (SCS) technique to decrease tender point palpation pain compared to control conditions | Palpation pain on visual analogue scale (VAS) or numeric rating scale (NRS) | n = 5 studies, 2 thereof for meta-analysis Randomized controlled trials with isolated SCS treatment 8 or more of the 12 methodological criteria were fulfilled | Pooled: significant reduction of tender point palpation pain Low evidence quality No statement on long-term pain, impairment or dysfunction |
Diversity of research objectives
Discussion
-
High quality of evidence: further research is unlikely to change our confidence in the estimate of effect. There are consistent findings among 75% of RCTs with a low risk of bias that can be generalized to the population in question. There are sufficient data, with narrow confidence intervals. There are no known or suspected reporting biases. (All of the domains are met).
-
Moderate quality of evidence: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. (One of the domains is not met).
-
Low quality of evidence: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. (Two of the domains are not met).
-
Very low quality of evidence: we are very uncertain about the estimate. (Three of the domains are not met).
Conclusion
-
Spinal manipulation and mobilization and MT were significantly more efficacious for neck/low back pain than no treatment, placebo, physical therapy or usual care in reducing pain.
-
SMT is a cost-effective treatment to manage spinal pain when used alone or in combination with general practitioner (GP) care or advice and exercise compared to GP care alone, exercise or any combination of these.
-
SMT has a statistically significant association with improvements in function and pain improvement in patients with acute low back pain.
-
Preliminary evidence that subgroup-specific manual therapy may produce a greater reduction in pain and increase in activity in people with LBP when compared with other treatments. Individual trials with a low risk of bias found large and significant effect sizes in favour of specific manual therapy.
-
Upper cervical manipulation or mobilization and protocols of mixed manual therapy techniques presented the strongest evidence for symptom control and improvement of maximum mouth opening.
-
Musculoskeletal manipulation approaches are effective for the treatment of temporomandibular joint disorders—here is a larger effect for musculoskeletal manual approaches/manipulations compared to other conservative treatments for temporomandibular joint disorder.
-
MM is helpful and facilitating in the management of several diseases, with an influence on range of motion, pain intensity, flexibility and parts of the autonomic nervous system.
-
Clear elaboration of questions.
-
Exact description of manual medicine practice/manual techniques.
-
Lowering the bias in patient inclusion.
-
To use evidence summaries in clinical practice.
-
To help develop and update selected systematic reviews or evidence-based guidelines in their area of expertise.
-
To enrol patients in studies of treatment, diagnosis and prognosis on which medical practice is based.