The Evidenced-Base Practice of Joint Manipulation/Manual Therapy
What is manual therapy?
Manual therapy is defined as the skilled passive movement of joints (joint mobilization/manipulation) and soft tissues (soft tissue mobilization/specific localized massage). Physicians focus mostly on osteokinematics, or gross motions of a limb (i.e. How far can this patient bend his/her knee?). Manual physical therapists are concerned with normalizing arthrokinematics, or specific motions that take place between joint surfaces that allow for normal joint mobility (i.e. Why can't this patient bend his/her knee? What specific joint movements or soft tissue restrictions are present?). Manual therapists use specific hand placements and the precise application of forces to restore normal movement to joints and soft tissues. Manual therapy is used in conjunction with other physical therapy techniques, exercises and modalities.
Who performs manual therapy/joint manipulation?
Roughly 80% of entry-level physical therapists have received at least some basic education in manual therapy while in physical therapy school. Beyond that, therapists may attend post-graduate training to become certified in manual therapy. There are several schools of thought within manual therapy, each with their own treatment approach; however, the basic concept is to restore normal joint and soft tissue mobility.
Jeff Lewandowski, DPT, ATC, MTC, SCS and Allison Smith, DPT, ATC, MTC of SportsCare Physical Therapy completed 235 hours of post-graduate training and testing, along with a 2-week residency in joint manipulation through the University of St. Augustine to receive their certification in manual therapy. They are the only two certified manual therapists in the John's Creek area.
How does manual therapy work?
There are four main effects of manipulation that have been proposed: mechanical, neurophysiological, biochemical, and psychological. Mechanically, passive movement of a joint stretches the surrounding muscles, ligaments and the joint capsule; it may also break adhesions or realign scar tissue, which leads to increased range of motion. These improvements are supported and maintained by having the patient perform specific exercises. Neurophysiological mechanisms have been suggested in research literature. It is believed that manual therapy can have an inhibitory effect on pain systems in the spinal cord as well as at the site of injury. Biochemically, joint manipulation has also been shown to activate the endogenous opiate system, which can lead to a "natural high." Psychologically, hands-on treatment leaves patients confident in achieving positive outcomes from manual therapy; touching and manipulating injured tissues helps to validate the patient's complaints of pain.
Which patients should receive manual therapy?
Any patient with a painful or hypomobile joint meets the criteria to receive manual therapy. There are no absolute contraindications to manual therapy; however there are numerous precautions. These include the presence of disease, hemarthrosis, muscle holding, hypermobile joints, and joint replacements that the patient has not actively moved yet.
Which joints can be treated with manual therapy?
There are no limitations to which joints can be manipulated or mobilized. Manual therapy is most known for its use on the spine. However, all joints may be treated, including the shoulder, elbow, wrist and hand, sacroiliac joint, hip, knee, ankle, and toes. Manual therapy also includes a wide variety of muscle energy techniques and specific exercises that reduce muscle spasm and guarding, and subsequently increase joint mobility.
What is the efficacy of manual therapy?
Manual therapy has been shown to decrease pain and increase functional outcomes. Joint manipulation has been well-researched, and its efficacy published in numerous peer-reviewed journal articles, including Spine, Annals of Internal Medicine, Physical Therapy, Journal of Orthopaedic and Sports Physical Therapy,, Cochrane Systematic Review, and many more. A small selection of recent articles is included below.
SPINE
Joint manipulation to the spine has been used in the clinical setting for years, and research shows that this type of treatment may be more effective than traditional exercise therapy for specific subgroups of patients. Current research focuses on clinical prediction rules to determine which patients are most likely to benefit from spinal manipulation, based on findings in the patient's history and physical examination.
LUMBAR
1. FlynnT, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, et al. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement with Spinal Manipulation. Spine 2002; 27: 2835-43.
The purpose of this prospective, cohort study was to identify patients with low back pain who are likely to benefit from spinal manipulation. This study was conducted on 71 patients with LBP with or without numbness in the lumbar spine, buttock and/or lower extremity. Treatment success was defined by a >50% change in Oswestry disability rating scores over 3 treatment sessions. Four of the following five baseline variables raise the probability of successful treatment with spinal manipulation from 45% to 95%: duration of LBP <16 days, ≥1 hip with >35º of internal rotation, ≥1 hypomobile lumbar segment upon spring testing, FABQ work score <19, and no symptoms distal to the knee.
2. Childs J, Fritz J, Flynn T, et al. A Clinical Prediction Rule to Identify Patients with Low Back Pain Most Likely to Benefit from Spinal Manipulation: A Validation Study. Annals of Internal Medicine 2004; 141: 920-928.
This study was conducted to validate the aforementioned manipulation clinical prediction rule. One hundred thirty one patients with low back pain were randomly assigned to receive the manipulation and exercise or exercise alone. Patients were examined according to the criteria set forth by Flynn, et al. and disability and pain were assessed at 1 week, 4 weeks, and 6 months. Treatment effects are greatest, with a 92% chance of a successful outcome, in patients who are positive on the clinical prediction rule and receive the spinal manipulation along with exercise.
3. Aure O, Hoel Nilsen J, Vasseljen O. Manual Therapy and Exercise Therapy in Patients with Chronic Low Back Pain: A Randomized Controlled Trial with 1-Year Follow-up. Spine 2003; 28: 525-531.
Forty nine patients with chronic low back pain (>8 weeks) listed on sick leave at least 8 weeks and up to 6 months were randomized to a manual therapy or exercise therapy group for 16 treatments over 2 months. Pain, disability, general health and return-to-work time were assessed at baseline, immediately post-treatment, at 4 weeks, 6 months, and 12 months. Although both groups showed significant improvement from baseline through the 1-year mark, the manual therapy group demonstrated twice the reduction in pain, and was more than two times as likely to have returned to work.
4. Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren K, Sarna S, Hurri H. A Randomized Trial of Combined Manipulation, Stabilizing Exercises, and Physician Consultation Compared to Physician Consultation Alone for Chronic Low Back Pain. Spine 2003; 28: 2185-91.
Two hundred four chronic low back pain patients were randomly assigned to either a manipulation or consultation group. The manipulation group received four treatments consisting of manipulation and stabilization exercises for the lumbar spine and pelvis. All subjects completed questionnaires regarding pain intensity, self-rated disability, depression, health-related quality of life, health care costs, and lost-work costs. At baseline, 58% of patients in the manipulation group and 62% of those in the consultation group experienced daily LBP. The manipulation group showed more significant improvements in pain intensity and self-rated disability than the consultation group at the 5 and 12 month follow-ups.
5. Fritz J, Whitman J, Childs J. Lumbar Spine Segmental Mobility Assessment: An Examination of Validity for Determining Intervention Strategies in Patients with Low Back Pain. Archives of Physical Medicine & Rehabilitation 2005; 86: 1745-1752.
This randomized controlled trial included 131 patients with LBP for an average of 27 days. Lumbar spinal motion was assessed using posterior-anterior (P-A) mobility testing, and subjects were classified as hypomobile or hypermobile, and treated for 4 weeks. Regardless of classification, patients were randomly assigned to either a manipulation or stabilization treatment group. Outcome measures included the Fear-Avoidance Beliefs Questionnaire, the modified Oswestry Distability Questionnaire, and a numerical pain rating scale. Measurements were collected at baseline and at 4 weeks. Significant improvements were made in hypomobile patients who received manipulation, and hypermobile patients who underwent a stabilization exercise program. Of all the subjects in the study, 50.4% experienced at least a 50% improvement in their ODQ scores.
6. Flynn T, Fritz J, Wainner R, Whitman J. The Audible Pop is Not Necessary for Successful Spinal High-Velocity Thrust Manipulation in Individuals with Low Back Pain. Archives of Physical Medicine & Rehabilitation 2003; 84: 1057-60.
This prospective cohort study identified 71 patients with nonradicular LBP who received standard spinal manipulation, and aimed to determine if the presence of an audible pop altered the effectiveness of the manipulation. Outcome measures included spinal ROM, pain rating scale scores, and modified Oswestry Disability Questionnaire scores 48 hours after treatment. There is no relationship between an audible pop upon spinal manipulation and ROM, pain, or disability improvements in patients with nonradicular LBP.
CERVICAL
1. Gross A, Hoving J, Haines T, Goldsmith C, Kay T, Aker P, Bronfort G. A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Disorders. Spine 2004; 29: 1541-48.
A systematic review of randomized controlled trials was completed to assess whether manipulation and mobilization on adults with mechanical neck disorders (MND) improve patient-reported pain levels, function/disability, patient satisfaction, and global perceived effect. Thirty three randomized trials in 52 publications were selected from 528 initial articles. Articles written by March 2002 were included in the review. The findings of this review indicate that single or multiple treatment sessions including manipulation and/or mobilization, either alone or with superficial modalities (i.e., electrical stimulation, ice, traction), were not effective in short-term improvement of pain and function. However, strong evidence exists for long-term benefits of multimodal care, defined as mobilization and/or manipulation plus exercise, in terms of pain relief, improved function, and global perceived effect.
2. Coppieters M, Stappaerts K, Wouters L, Janssens K. The Immediate Effects of a Cervical Lateral Glide Treatment Technique in Patients with Neurogenic Cervicobrachial Pain. Journal of Orthopaedic & Sports Physical Therapy 2003; 33: 369-378.
Restricted cervical motion segments may be a possible cause of neurogenic cervicobrachial pain.
Twenty patients with subacute peripheral neurogenic cervicobrachial pain were randomly assigned to either a cervical mobilization or therapeutic ultrasound group. The mobilization group received a lateral glide to the contralateral cervical spine in attempt to free ≥ 1 restricted motion segments. Outcome measures included elbow extension ROM, distribution of symptoms, and pain intensity during neural provocation testing. Significant differences were observed for all outcome measures between the two groups (p≤.0306). The mobilization group's mean elbow extension ROM increased from 137.3º to 156.7º, the area of symptom distribution decreased by 43.4%, and pain intensity dropped from 7.3 to 5.8 (p≤.0003). No significant improvements were found in the ultrasound group.
EXTREMITIES
Joint manipulation is usually associated with the spine. However, it has been proven to effectively treat the extremities as well.
KNEE
1. Deyle G, Henderson N, Matekel R, Ryder M, Garber M, Allison S. Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee: A Randomized, Controlled Trial. Annals of Internal Medicine 2000; 132: 173-181.
In an effort to determine the effectiveness of manual therapy on osteoarthritis of the knee, 83 patients with osteoarthritis of the knee were randomly assigned to receive treatment or a placebo. The treatment group received manual physical therapy, which consisted of accessory joint movement, muscle stretching and soft tissue mobilization of the knee, as well as to the lumbar spine, hip or ankle if needed. This group also performed a supervised exercise program while at the physical therapy clinic, as well as a modified home exercise program. The placebo group received subtherapeutic ultrasound to the site of knee pain. Variables measured included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and distance covered in a 6-minute walk test (6-MWT). The WOMAC is a valid, reliable and responsive outcome measure commonly used in patients with hip or knee osteoarthritis; the 6-MWT is also a reliable measure of functional exercise capacity. Measurements were taken at baseline, 4 weeks, 8 weeks, and 1 year. In the treatment group, the average distance covered in the 6-minute walk test increased by 12.3% at 4 weeks and 13.1% at 8 weeks (p<0.05); there was no significant change in the placebo group. The average WOMAC scores were 51.8% and 55.8% lower in the treatment group at 4 and 8 weeks, respectively. Again, no significant change occurred in the placebo group. At 1 year, the treatment group maintained the improved performance in the 6-MWT, and the WOMAC scores were still above baseline. Finally, those in the treatment group were less likely to receive knee replacement surgeries at 1 year.
2. Deyle G, Allison S, Matekel R, Ryder M, Stang J, Gohdes D, Hutton J, Henderson N, Garber M. Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program. Physical Therapy 2005; 85: 1301-1317.
This randomized controlled trial compared manual therapy with exercise (clinic treatment group) to a home exercise program (home group) in 134 subjects with knee osteoarthritis. Subjects in the clinic treatment group received manual therapy, supervised exercise, and a home exercise program for a 4-week period. The home exercise group was given the same home exercise program which was reviewed in the clinic at a follow-up visit 2 weeks later. After completion of the 4-week treatment, both groups continued to perform an identical home exercise program for one year. Outcome measures included WOMAC scores and distance covered in a 6-minute walk test. Both groups showed statistically significant improvements over baseline in both outcome measures at 4 and 8 weeks. At week 4, the clinic treatment group experienced a 52% improvement in WOMAC scores, while the home group's scores improved by 26%. Distance covered in the 6-minute walk test increased ~10% in both groups. At 1 year, both groups were equally improved over baseline, yet the clinic group was less likely to be taking medication for arthritis, and these subjects were more satisfied with their rehabilitation outcome.
3. Zipple T, Hammer R, Loubert P. Treatment of Fabella Syndrome with Manual Therapy: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2003; 33: 33-39.
A 44-year old, physically active male reported to physical therapy with a 10-year history of left posterolateral knee pain during athletics and activities of daily living, and predominately upon knee flexion. A thorough history and examination revealed no alternative diagnosis aside from fabella syndrome, which was confirmed with radiographic images. The therapist palpated a fabella in the lateral head of the left gastrocnemius muscle. With the patient positioned prone, the therapist applied soft tissue mobilization of the lateral gastrocnemius and common fibular nerve, as well as medial, lateral, and inferior fabellar glides. The patient noted immediate pain reduction and displayed increased active knee flexion by 30º. The patient reported being symptom-free both at 4 weeks and 16 months post-treatment, and was able to resume his usual activities.
FOOT / ANKLE
1. Green T, Refshauge K, Crosbie J, Adams R. A Randomized Controlled Trial of a Passive Accessory Joint Mobilization on Acute Ankle Inversion Sprains. Physical Therapy 2001; 81: 984-994.
When comparing the dorsiflexion range of motion of an injured and uninjured ankle, the two may appear grossly equivalent. However, in an injured ankle, posterior glide of the talus is often restricted, and patients may present with a tight posterior capsule, muscular imbalances, and altered kinematics, all of which may lead to pain, gait abnormalities, and/or anterior capsule impingement. A randomized controlled trial evaluated the effects of an anteroposterior (A-P) glide of the talus on restoring pain-free ankle dorsiflexion ROM, stride speed, step length, and single limb support time in persons with acute ankle inversion sprain (< 72 hours). Forty one patients were randomly assigned to an experimental group, which received A-P talar mobilizations as well as rest, ice, compression, and elevation (RICE) of the ankle, or a control group which received only the RICE protocol. The experimental group required fewer sessions to achieve full pain-free dorsiflexion (p<.01), had greater improvements in ROM before (p<.02) and after (p<.01) each of the first three sessions, and made greater improvements in stride speed in the first and third sessions (p<.05) as compared to the control group. Step length symmetry and single limb support time improvements were similar between both groups.
2. Shamus J, Shamus E, Gugel R, Brucker B, Skaruppa C. The Effect of Sesamoid Mobilization, Flexor Hallucis Strengthening, and Gait Training on Reducing Pain and Restoring Function in Individuals with Hallux Limitus: A Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy 2004; 34: 368-376.
Hallux limitus is a common condition that affects the great toe, and may include first metatarsophalangeal joint (MPJ) sprains or limitations in mobility. Twenty adults with subacute or chronic first MPJ pain, decreased range of motion, and weakness were enrolled in this study. Each patient received a routine treatment for first MPJ sprains, including whirlpool, ultrasound, first MPJ mobilizations, hamstring and calf stretches, marble pick-up exercises, electrical stimulation and cold packs. Ten of these adults were placed in an experimental group, which received sesamoid mobilizations, flexor hallucis strengthening, and gait training in addition to the above treatment. All patients received therapy 3 times per week for 4 weeks. Objective measures were first MPJ extension ROM, flexor hallucis strength, and subjective pain levels at baseline and at the last treatment session. Upon discharge, the experimental group made greater improvement in first MPJ extension ROM, strength, and reported lower subjective pain levels than the control group (p<.001).
3. Jennings J, Davies G. Treatment of Cuboid Syndrome Secondary to Lateral Ankle Sprains: A Case Series. Journal of Orthopaedic & Sports Physical Therapy 2005; 35: 409-415.
A cluster of signs and symptoms are required to identify cuboid syndrome, a condition which may result from a plantar flexion / inversion ankle injury, and lead to lateral ankle and/or midfoot pain. It is reported that cuboid syndrome presents in up to 4% of athletes with foot problems, and in up to 17% of professional ballet dancers. Seven patients identified with cuboid syndrome by 2 independent examiners entered physical therapy treatment, and received "cuboid whip" manipulation 1 to 8 weeks after sustaining a lateral ankle sprain. All participants returned to athletics after 1 to 2 sessions involving the cuboid manipulation, and were symptom-free both immediately upon return to sport, and throughout the rest of the season (avg. 5.7 months).
SHOULDER
1. Bang M, Deyle G. Comparison of Supervised Exercisewith and without Manual Physical Therapyfor Patientswith Shoulder Impingement Syndrome. Journal of Orthopaedic & Sports Physical Therapy 2000; 30: 126-137.
Fifty two subjects with shoulder impingement syndrome were randomly assigned to either a manual therapy group or an exercise therapy group. The exercise therapy group was supervised by a physical therapist in flexibility and strengthening exercises, while the manual therapy group received the same treatment with the addition of manual therapy to the shoulder, shoulder girdle, cervical spine, or thoracic spine. All groups attended 6 half-hour sessions across 3-4 weeks. The testers were blinded to group assignment, and measured strength, pain, and function before initiation of the study and roughly 2 months later, after the 6 therapy visits. Although both groups achieved significant decreases in pain and increases in function, the manual therapy group made more significant improvement. Also, only the manual therapy group made significant increases in strength.
2. Vermeulen HM, Rozing PM, Obermann WR, et al. Comparison of High-Grade and Low-Grade Mobilization Techniques in the Management of Adhesive Capsulitis of the Shoulder: Randomized Controlled Trial. Physical Therapy 2006; 86: 355-368.
One hundred subjects with unilateral adhesive capsulitis with symptoms ≥ 3 months and ≥ 50% reduction in passive ROM were randomly assigned to either a high-grade (HGMT) or a low-grade (LGMT) mobilization group. The HGMT group received passive mobilization to end-range glenohumeral joint positions, while the LGMT group received mobilizations within a pain-free range. Both groups were treated for a maximum of 12 weeks, or 24 sessions. Outcome measures included active and passive ROM and shoulder disability questionnaire scores. Greater statistically significant changes were made by the HGMT group for passive shoulder abduction (at 3 and 12 months), and for active and passive external rotation (at 12 months). The HGMT group showed a statistically significant greater difference in trend over the entire 12 month follow-up for passive external rotation and shoulder disability questionnaire scores.
3. Roubal P, Dobritt D, Placzek J. Glenohumeral Gliding Manipulation Following Brachial Plexus Block in Patients with Adhesive Capsulitis. Journal of Orthopaedic & Sports Physical Therapy 1996; 24: 66-77.
The purpose of this multiple case report was to propose an alternative method of nonconservative treatment of adhesive capsulitis involving glide manipulation under interscalene plexus block. Eight patients with symptoms of adhesive capsulitis underwent posterior and inferior glide manipulation by a physical therapist until tearing of the capsule was heard and felt. Immediately post-manipulation, average increases in passive flexion, abduction, external rotation and internal rotation ranges of motion were 68º, 77º, 49º, and 45º respectively. Patients continued traditional physical therapy for an average of 4 weeks. Upon discharge, average increases in passive/active range of motion were 76/67º, 82/73º, 50/44º, and 49/40º respectively.
ELBOW
1. Cleland J, Whitman J, Fritz J. Effectiveness of Manual Physical Therapy to the Cervical Spine in the Management of Lateral Epicondylalgia: A Retrospective Analysis. Journal of Orthopaedic & Sports Physical Therapy 2004; 34: 713-22.
The etiology of lateral epicondylitis has been proposed to be an overuse injury to the common extensor tendon, although there is little consensus amongst experts. Several additional mechanisms have been proposed, including entrapment of the radial nerve, somatosympathetic dysfunction, and referred pain from cervical spine articulations. Therefore, this retrospective review was conducted of 112 patient charts to analyze self-reported outcomes in patients with lateral epicondylalgia who received local elbow treatment or local treatment plus manual therapy of the cervical spine. Seventy five percent of patients in the local treatment group and 80% of patients in the local treatment plus manual therapy group reported successful long-term outcomes via telephone follow-up. Patients in the manual therapy group were able to achieve these outcomes in a fewer number of visits (p<.01).
2. Struijs PAA, Damen PJ, Bakker EWP, et al. Manipulation of the Wrist for Management of Lateral Epicondylitis: A Randomized Pilot Study. Physical Therapy 2003; 83: 608-616.
Another proposed etiology of lateral epicondylitis involves decreased ventral scaphoid mobility upon wrist extension. According to this theory, if scaphoid motion is restricted, the wrist extensors have to exert more force to extend the wrist, leading to overuse injury of the common extensor tendon. Thirty one subjects with lateral epicondylitis were randomly assigned to two treatment groups: a wrist manipulation group (ventral scaphoid mobilizations during wrist extension), or a group that received ultrasound, cross friction massage, as well as strengthening and stretching exercises. Follow-up global measures of improvement were measured at 3 and 6 weeks for the 28 subjects who completed the study. Global improvement at 3 weeks (p=.05) and pain rating at 6 weeks (p=.03) indicate that the manipulation was superior to the other treatments. Global improvement measures between groups were not statistically significant at week 6.
3. Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and Sympathoexcitatory Effects of Mobilization with Movement for Lateral Epicondylalgia. Physical Therapy 2003; 83: 374-383.
Mobilization with movement (MWM) has been proposed to induce similar physiological effects as some spinal manipulations. Twenty four participants with chronic lateral epicondylalgia were included in this placebo, control, repeated-measures study to determine if mobilization with movement stimulates hypoalgesia and sympathoexcitation. The results indicate that hypoalgesic effects occur, and decreased pain lead to increased grip force and pain thresholds. Excitation of the sympathetic nervous system was shown by heart rate, blood pressure, and cutaneous sudomotor and vasomotor function alterations that are consistent with some spinal manipulations.
WRIST / HAND
1. Backstrom K. Mobilization with Movement as an Adjunct Intervention in a Patient with Complicated De Quervain's Tenosynovitis: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2002; 32: 86-97.
This case study describes the use of mobilization with movement (MWM) techniques in combination with traditional physical therapy for an individual with de Quervain's tenosynovitis. This 61 year old female patient had limited range of motion in all directions at the wrist as well as at the first carpometacarpal joint. The patient received 12 sessions of traditional physical therapy along with a MWM technique combining active motion of the thumb and wrist with passive radial glide of the proximal row of carpals. This patient experienced complete resolution of impairments and functional limitations, which suggests that traditional therapy plus novel MWM techniques may correct joint malalignments of the wrist better than conventional treatment alone.
HIP
1. Cibulka M, Delitto A. A Comparison of Two Different Methods to Treat Hip Pain in Runners. Journal of Orthopaedic & Sports Physical Therapy 1993; 17: 172-176.
Mobilization, specifically long axis distraction, is thought to reduce hip joint pain and restore mobility via afferent nerve stimulation and increased joint lubrication. It is thought that sacroiliac dysfunction coexists with hip pain. However, little research has been conducted on the treatment of hip pain in a physical therapy context. In this study, 20 physically active patients with acute (<3 weeks) anterior or lateral hip pain were randomly assigned to either a hip mobilization group or a sacroiliac thrust manipulation group. Outcome measures included patient-perceived hip pain on a 0-10 scale, pain upon FABER testing, and hip internal rotation range of motion. Roughly 3 days after the physical therapy session, the sacroiliac manipulation group significantly improved over baseline in terms of pain scores (p<.016) and FABER testing (p<.02).
