eMedicine Specialties > Physical Medicine and Rehabilitation > Therapeutic Modalities

Massage, Traction, and Manipulation

Author: J Michael Wieting, DO, MEd, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Principles and Practices, Director of Sports Medicine, Associate Director of Physician Assistant Training Program, Department of Osteopathic Principles and Practice, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
Coauthor(s): Adam P Cugalj, DO, Clinical Instructor, Staff Physician, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine, Fellow in Spine, Sports and Musculoskeletal Medicine, Buffalo Spine and Sports Institute, PC, Buffalo, New York
Contributor Information and Disclosures

Updated: Oct 2, 2008

Massage

Various forms of massage, traction, and manipulation have been used in medicine throughout the world for several thousand years. Each modality represents an approach to treatment of the musculoskeletal and other systems sought by a steadily increasing number of people.  While research on each of these modalities continues, a long-standing variable, the concept of touch, unites them all.

In the 1940s, Rene A. Spitz reported on foundling home infants who, otherwise healthy and well taken care of, failed to thrive and often died in the absence of being held or touched.  Kunz and Krieger additionally defined and taught the principles behind the related concepts of healing touch and therapeutic touch in the 1970s.  While there is no consensus on the complete physiology of massage, traction, or manipulation, it is generally accepted that there is more to these treatment approaches than just the interaction of mechanical forces and human anatomy.  There is a long history of touch as a natural, essential component to healing and health maintenance.
 
Throughout history, massage has been woven into the cultural context of medicine. Massage may be the earliest and most primitive tool to treat pain.¹ Massage consists of  Eastern and Western variants. In the West, the practice and popularity of massage has varied over time. In recent years, a previous decline in popularity of massage, probably related to technological advancements in medicine, has been reversed into a resurgence of interest. In the US, approximately $2-4 billion is spent annually on visits to massage therapists, which accounted for approximately 26% of the $11.7 billion spent on nontraditional healthcare in the 1990s.
 
The American people are pursuing massage in increasing numbers for various reasons (eg, relief of pain, relaxation, conditioning). While little doubt exists that massage is beneficial for certain conditions, additional research is needed to establish its profile of efficacy.
 
Definition of basic massage concepts

Massage is a therapeutic manipulation of the soft tissues of the body with the goal of achieving normalization of those tissues. Massage can have mechanical, neurological, psychological, and reflexive effects. Massage can be used to reduce pain or adhesions, promote sedation, mobilize fluids, increase muscular relaxation, and facilitate vasodilation. Massage easily can be a preliminary treatment to manipulation; however, it clearly targets the health of soft tissues, while manipulation largely targets joint segments.
 
Massage consists primarily of hand movements, some of which may be traction based. Traction is defined as the act of drawing or pulling or as the application of a pulling force. Traction sometimes involves equipment but also can be applied manually. In addition, traction affects changes in the spinal column itself, with soft tissues only secondarily changed. Effects of massage, like those of traction, tend to be fairly nonspecific.
 
Types of massage 
Western
 
Western massage is the chief type of massage practiced in the United States today. Among the most common types of massage therapy are acupressure (Shiatsu), Rolfing, Swedish massage, reflexology, and myofascial release.¹  Western massage organizes variations of soft-tissue manual therapy into several categories. Pare of France introduced the basic terminology for Western massage to the United States. The essence of Western massage is use of the hands to apply mechanical forces to the skeletal muscles and skin, although the intent may be to affect either the more superficial tissues or the deeper ones. Types of basic Western massage are characterized by whether (1) the focus of pressure is moved by the hands gliding over the skin (ie, effleurage), (2) soft tissue is compressed between the hands or fingers and thumb (ie, pétrissage), (3) the skin or muscle is impacted with repetitive, compressive blows (ie, tapotement), or (4) shearing stresses are created at tissue interfaces below the skin (ie, deep friction massage). Forms of Western massage include the following:
 

• Effleurage
• In this approach, the practitioner's hands glide across the skin overlying the skeletal muscle being treated.
• Oil or powder is incorporated to reduce friction; hand-to-skin contact is maintained throughout the massage strokes.
• Effleurage can be superficial or deep.
• Light strokes energize cutaneous receptors and act by neuroreflexive or vascular reflexive mechanisms, whereas deep stroke techniques mechanically mobilize fluids in the deeper soft-tissue structures.
• Deep stroking massage is performed in the direction of venous or lymphatic flow, whereas light stroking can be in any direction desired.
• Effleurage may be used to gain initial relaxation and patient confidence, occasionally to diagnose muscle spasm and tightness, and to provide contact of the practitioner's hands from one area of the body to another.
• The main mechanical effect of effleurage is to apply sequential pressure over contiguous soft tissues so that fluid is displaced ahead of the hands as tissue compression is accomplished.
• Pétrissage
• Pétrissage involves compression of underlying skin and muscle between the fingers and thumb of 1 hand or between the 2 hands.
• Tissue is squeezed gently as the hands move in a circular motion perpendicular to the direction of compression.
• The main mechanical effects are compression and subsequent release of soft tissues, reactive blood flow, and neuroreflexive response to flow.
• Lymphatic pump is a type of pétrissage done to the chest and rib cage of persons with respiratory compromise in order to draw lymph into the thoracic duct and venous circulation as a result of an alternating increase and decrease of pressure on the chest cavity.
• Tapotement
• This percussion-oriented massage involves striking soft tissue with repetitive blows, using both hands in a rhythmic, gentle, and rapid fashion.
• Numerous variations can be defined by the part of the hands making an impact with the body.
• The therapeutic effect of tapotement may result from compression of trapped air that occurs on impact.
• The overall effect of tapotement may be stimulatory; therefore, healthy persons with increased tolerance for this approach are more likely to find this type of massage useful.
• Deep friction
• Pressure is applied with the ball of the practitioner's thumb or fingers to the patient's skin and muscle.
• The main effect of deep friction massage is to apply shear forces to underlying tissues, particularly at the interface between 2 tissue types (eg, dermis-fascia, fascia-muscle, muscle-bone).
• Deep pressure keeps superficial tissues from shearing so that shear and force are directed at the deeper tissue surface interface.
• Deep friction massage frequently is used to prevent or slow adhesions of scar tissue

 
Eastern massage
 
Over the centuries, Eastern massage systems have been an integral part of the cultures where they are practiced. Systems for evaluation, diagnosis, and treatment generally are not grounded in conventional Western neurophysiology. Eastern massage includes, among other approaches, Shiatsu, a Japanese system based on traditional Chinese meridian theory with principles of Western science. The theory of Shiatsu is based upon the system of the 12 traditional Chinese meridians (ie, major channels) of the body in which the energy, life force, or Chi, circulates. Acupressure pressure points, situated along the course of channels, allow access to these channels. Acupressure applies massage forces, largely through digital pressure, to the same points treated with acupuncture needles. Imbalances of energy along the meridians are believed to cause disease and can be rectified by localized finger pressure.

Reflexology and auriculotherapy

• These systems of massage share the meridian concept with Shiatsu.
• In these approaches, the meridians are believed to have whole body representations on the extremities (similar to the homunculus of the brain).
• The feet (in reflexology) and the ear (in auriculotherapy) have been mapped in detail.

Decongestive Lymphatic Therapy
 
Decongestive lymphatic therapy is the complex massage approach that includes manual lymphatic drainage (MLD) in addition to compressive bandages, exercises, and skin care. Manual lymphatic drainage consists of gentle massage in the treatment of lymphedema. Proximal areas are treated first to prevent a damming effect; the treatment is thought to stretch the lymphatic collectors and to stimulate the drainage system. The massage is followed by the application of compressive bandages and is incorporated into a complete self-care program.
 
Massage technique

The practitioner controls several variables of massage, including milieu. Actual application of treatment includes rhythm, rate, pressure, direction, and duration.
 
Most massage approaches involve a friction-reducing medium, so that the hands of the practitioner move along the patient's skin with minimal friction. Powders or oils often are used. Massage strokes also should be regular and cyclic. The rate of application for massage varies with the type of technique. In some approaches (eg, tapotement, percussion), the rate is several times per second, while in others it is much slower.
 
The amount of pressure depends upon technique and desired results. Light pressure may produce relaxation and relative sedation and may decrease spasm; breakdown of adhesions and intervention at a deeper tissue level may require heavier pressure. Treatment of edema and stretching of connective tissue generally requires intermediate amounts of pressure. Direction of massage often is centripetal to provide better mobilization of fluids toward the central circulation. The sequence of tissues treated often is performed in a centripetal fashion.
 
When muscles are treated, motions generally are kept parallel to muscle fibers. If the treatment goal is to reduce adhesions, shearing forces are circular or at least include cross-fiber components. The area to be treated with massage depends upon the condition being treated and may vary from a well-circumscribed area to treatment of contiguous areas.
 
Duration of treatment depends upon the area being treated, desired therapeutic goals, and patient tolerance. Wide variation exists regarding treatment duration, which often is guided by changes occurring to tissue during massage application. If massage is performed before other treatments, duration may be determined by the result needed in order to optimize the next treatment step. Duration of a massage therapy program can range from 1 week to months and depends upon verifiable therapeutic goals. Patients must be reexamined from time to time, depending upon diagnosis and therapeutic goals, to insure satisfactory progress.

Massage Effects, Indications, Contraindications, and Research

Physiologic effects of massage
 
Massage produces some mechanical effects on the body. Mechanical pressure on soft tissue displaces fluids. Fluid moves in the direction of lower resistance under the static forces of the practitioner's hands, but a moving locus of pressure creates a pressure gradient. Assuming no significant resistance, pressure is lower proximal to the practitioner's advancing hand. Once mobilized fluid leaves the soft tissues, it enters the venous or lymphatic low-pressure systems. The amount of fluid mobilized in any single treatment is likely to be quite small; however, the physiatrist needs to be aware of this physiologic effect in patients with significantly compromised cardiovascular or renal function. When treating lymphedema, massage is performed more proximally and then moves distally, based upon the premise that proximal blockage in the lymph channels must be opened first to allow for subsequent distal mobilization of fluid and protein.
 
Kneading and stroking massage decreases edema; compression converts nonpitting to pitting edema. In addition to strictly mechanical effects, these massage approaches release histamine, causing superficial vasodilation to assist in washing out metabolic waste products. Venous return increases, which subsequently increases stroke volume.
 
Some evidence suggests that massage increases blood flow contralaterally; however, the mechanism of this postulated action has not been well established. These effects on mobilization of fluids are more important in flaccid or inactivated limbs, because normal compression supplied by skeletal muscle contraction usually is not present in those cases. Studies suggest that massage may decrease blood viscosity and hematocrit and increase circulating fibrinolytic compounds. Preliminary data suggest an explanation for the success of massage in decreasing deep vein thrombosis (DVT). Massage may be contraindicated in the presence of existing thrombosis.
 
Other blood compounds that show massage-related increases include myoglobin, creatine kinase, lactate dehydrogenase, and glutamic oxaloacetic transaminase. Temporary increases in these substances represent local muscle cell leakage from applied pressure. Lactate decreases in massaged muscles as well. Massage may decrease muscle spasm and increase force of contraction of skeletal muscle. Decreased spasm and increased endurance may result from wash out of metabolic waste products by fluid mobilization and increased blood flow. Decreased muscle soreness probably results from metabolic wash out.
 
Reflexive changes
 
Massage can stimulate cutaneous receptors, spindle receptors, and superficial skeletal muscle as well. These structures produce impulses that reach the spinal cord, producing various effects, including moderation of the facilitated segment. Somatovisceral reflex changes to the viscera are possible in this model.
 
Psychological effects of massage
 
Massage generally increases feelings of relaxation and well-being in patients. Whether this is from placebo effect or the result of some previously undiscovered reflex is not fully understood.  Practitioners often incorporate a variety of psychophysical techniques, such as guided imagery, into massage treatment.  A prospective, nonrandomized trial of massage therapy at a major US cancer center sought to examine massage therapy outcome in a large group of patients.  Over a 3-year period, 1290 patients were treated with regular ("Swedish"), light touch, or foot massage, based on the request of the patient.  The patients filled out symptom cards before and after a 20-minute (average) massage session. Symptom scores were reduced by approximately 50%, with outpatients demonstrating about 10% greater benefit than did inpatients. Anxiety, nausea, depression and pain demonstrated the greatest improvement in symptom score.
 
Several studies have investigated the role and potential benefits of massage during pregnancy.  A study by Field and colleagues found such a benefit not only in the recipient of the massage, but also in the patient's spouse.²  In this study, self-reported leg pain, back pain, depression, anxiety, and anger were reduced to a greater extent in pregnant women who underwent massage than in women in the control group. In addition, the women's partners, who performed the massages, reported feeling less depression, anxiety, and anger over the course of the massage therapy period than did partners in the control group. Moreover, the pregnant women and their partners showed improved scores on a relationship questionnaire. The data support the positive psychological effects of massage and reinforce the therapeutic concept of touch, as previously discussed.
 
 
Therapeutic goals and indications for massage therapy
 
Massage may be used as primary therapeutic intervention or as an adjunct to other therapeutic techniques. Uses can include, but are not limited to, (1) mobilization of intertissue fluids, (2) reduction or modification of edema, (3) increase of local blood flow, (4) decrease of muscle soreness and stiffness, (5) moderation of pain, (6) facilitation of relaxation, and (7) prevention or elimination of adhesions. Massage may be used to alter pathophysiology of a primary condition (eg, contracture) or to prevent or modify deleterious effects of a previously used treatment modality.
 
Many studies have focused on the utility of massage to treat low back pain. The authors of one literature review concluded that strong evidence exists for the efficacy of massage in relieving chronic, nonspecific low back pain; they also found "moderate evidence that massage provides short- and longer-term follow-up relief of symptoms." Moreover, the authors determined there to be "moderate evidence that acupressure may be better than Swedish massage" for chronic low back pain, "especially if combined with exercise."
 
Hospitalized patients who receive massage express improvements in mood, body image, self-esteem, and perceived levels of anxiety. This phenomenon is facilitated by reduction in physical symptoms and distress and may be accompanied by decreased tension, anxiety, and pain perception.
 
Another therapeutic effect derived from massage is muscle relaxation. Massage appears to reduce tone and enhance circulation to the area. Muscle relaxation also may result from increased sensory stimulation caused directly by massage. This increased sensory input to the spinal cord may result in changes in reflex pathways, leading to central modulatory decreases of muscle tone.
 
Other effects of massage are enkephalin release, endorphin production, promotion or absorption of fibrous tissue, restoration of connective tissue pliability, improvement of lymphatic flow (in some studies, up to 7-9 times), and increased levels of natural killer (NK) cells.  Tanabe and Nakayama provided animal data that suggest that mechanical stimuli, such as massage, to adipocytes may inhibit expression of adipogenic transcription factor peroxisome proliferator-activated receptor, which is independent of systemic energy consumption.³ They postulate that such stimuli can assist in reducing the body's fat stores, and may help to decrease obesity.
 
Contraindications for massage
 
Massage is contraindicated when it could cause worsening of a particular condition, unwanted tissue destruction, or spread of disease. Malignancy, thrombi, atherosclerotic plaques, and infected tissue could be spread by massage. Absolute contraindications to massage include (1) DVT, because increased blood flow in a limb could cause a thrombus to detach from the vessel wall, creating an embolism; (2) acute infection; (3) bleeding; and (4) a new open wound. Relative contraindications include (1) incompletely healed scar tissue, (2) fragile skin, (3) calcified soft tissue, (4) skin grafts, (5) atrophic skin, (6) inflamed tissue, (7) malignancy, (8) inflammatory muscle disease, and (9) pregnancy. The physiatrist should be aware that massage must be used very carefully in chronic pain patients.

The direct, hands-on nature of massage may potentiate strong psychophysical effects and may cause unintentional reliance on passive treatment modalities. In all patients, it is necessary to establish treatment end points at the beginning of the treatment period and to terminate treatment when those end points have been achieved. A 2003 review by Ernst that examined the safety of massage found that the majority of adverse effects of massage therapy came about as a consequence of performance by lay practitioners or as a result of using "exotic" massage practices, other than Swedish-style massage.⁴  He further concluded that while massage therapy is not entirely risk-free, reports of serious adverse events appear to be rare.  It would be beneficial for the physiatrist, or other prescribing physician, to be aware of the training and experience of the massage therapist to which he or she is referring the patient.
 
Research in massage
 
While many studies have been conducted on the clinical utility of massage, the quality of these efforts has been somewhat variable. A number of studies have investigated the use of therapeutic massage in conjunction with exercise, acupuncture, or manipulation, particularly in athletic performance, and the reduction of postexercise or delayed-onset muscle soreness. A Cochrane review article from 2006 included 19 trials (1395 participants) and assessed whether massage alone or in combination with other treatments could help reduce neck pain and improve function. The authors concluded that overall, the quality of the studies was poor and the number of participants in most trials was small. Most studies lacked a definition, description, or rationale for massage and/or the massage technique.⁵

Similar conclusions were reported for numerous other studies, with a common consensus being the need for additional studies on the benefits of therapeutic massage. Research studies evaluating massage have had significant variations in sample size and constitution and have suffered from absence of adequate controls, methodologic errors, and other limitations. The long-term efficacy of massage has not been validated.

Future inquiry must establish the long-term efficacy of massage in a more rigorous, scientific fashion. Studies are needed that, using a valid experimental design, allow pretesting and posttesting; these investigations also need to employ appropriate sample sizes and statistical analysis methods, include reliable and valid measurement tools, and provide some degree of standardization of duration and frequency of treatment. It is also argued that some attempt to control for the so-called placebo effect (as well as touch) must be included in future studies. Additional research may examine the effectiveness of massage when it is used in conjunction with 1 or more other treatments, such as manipulation, exercise, or medications.

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Traction

Traction is the act of drawing or pulling and relates to forces applied to the body to stretch a given part or to separate 2 or more parts. Currently, traction is used effectively in treatment of fractures. In physiatric practice, use of traction often is limited to the cervical or lumbar spine with the goal of relieving pain in, or originating from, those areas.
 
Since the days of Hippocrates, correction of scoliosis also has involved traction. There are various types of traction currently in clinical use. The most common are mechanical, hydraulic or motorized, manual, and autotraction.  Mechanical forms of traction use a hydraulic or motorized pulley system with weights, along with a harness or sling device to attach to the patient's body.  Manual traction involves the therapist using his or her hands on the patient's body, with the body weight of the therapist providing the tractive force.  Autotraction is controlled by the patient pulling on bars or handles at the head of the table, without direct involvement of a therapist.  Gravitational traction with a tilt table and underwater variations of traction are also in clinical and home use but are less frequently employed than the other forms described.  
 
Physiologic effects of traction
 
In the cervical spine, the most reproducible result of traction is elongation. In a classic study, Cyriax reported applying force of 300 pounds manually, with a resultant 1 cm increase in cumulative lumbar spine interspace distance.⁶ Studies have shown that optimum weight for cervical traction to accomplish vertebral separation is 25 pounds. Additionally, 2-20 mm elongation of the cervical spine has been shown to be achievable with 25 or more pounds of tractive force. Studies have demonstrated that anterior intervertebral space shows the most increase in cervical flexion of 30°. Traction in the extended position generally is not recommended, because it is often painful and may increase risk of complications from vertebral basilar insufficiency or spinal instability.
 
Once friction is overcome in the lumbar spine, the major physiologic effect of traction is elongation. Investigators have reported widening of lumbar interspaces requiring between 70-300 pounds of pull. This widening averaged up to slightly more than 3 mm at one intervertebral level. The length of time that the separation persists remains indeterminate, with studies documenting distraction durations of 10-30 minutes after treatment.
 
Data on dimensional and pressure changes of lumbar disks caused by traction are not conclusive. Decreases in interdiskal pressure with 50-100 pounds of traction have been documented, but evidence exists that some applications actually cause an increase in interdiskal pressure. Therefore, evidence is inconclusive, with much information favoring at least temporary reduction of the herniated component of an abnormal lumbar disk with concomitant traction. 
 
Some theories on the physiologic effects of traction suggest that stimulation of proprioceptive receptors in the vertebral ligaments and monosegmental muscles may alter or inhibit abnormal neural input from those structures. As with other theories to explain the physiology of traction, there is little to no empirical evidence to fully support it.⁷
 
Outcome studies related to traction
 
Very few scientifically rigorous studies exist that allow the effect of traction to be distinguished from the natural history of pathology (eg, radiculopathy). Criteria have been suggested that would allow the true effects of traction to be delineated. These criteria include (1) randomized controlled trials, (2) blind outcome assessments, (3) equivalent co-interventions, (4) monitored compliance, (5) minimal contamination and attrition, (6) adequate statistical power and description of study design and interventions, and (7) relevant, functionally oriented outcomes. No traction outcome study to date has incorporated these criteria. Despite inadequacies in the literature, randomized, controlled trials that meet some of these criteria do provide some insight into the efficacy of traction as a treatment modality. A review of randomized, controlled trials of traction analyzed English language studies done between 1966 and 2001. The only conclusion that could be drawn, based on this review, was that there exists poor evidence to support the effectiveness of traction for back pain relief.⁸ A subsequent review, by Graham and colleagues, arrived at 2 clinical conclusions; one conclusion favors the use of intermittent traction over a continuous protocol, and the other does not support the use of continuous traction.⁹   The reviewers felt there was inconclusive evidence overall for either form of traction, based upon the methodologic quality of the numerous studies reviewed.

A systematic literature review by Clarke and colleagues further supported the aforementioned conclusions regarding traction for low back pain.⁷  Through an examination of randomized clinical trials, the authors determined that the evidence did not support the intermittent or continuous use of traction alone to treat low back pain in mixed groups of patients suffering from this condition, whether or not sciatica was present. Owing to inconsistent results and methodologic problems in most of the studies involved, the authors also did not recommend traction for patients with sciatica. Clarke and his coauthors also said that because the available research was insufficient, they could not comment on the use of traction in combination with other therapies.

What can be reasonably derived from these studies is that more work needs to be done to be able to make evidence-based recommendations on the application of traction for back pain. Additional evidence is also needed to evaluate the optimal type and position of the tractive forces for various clinical conditions, as well as to assess the use of traction as a component of a patient's treatment, rather than as an isolated modality.  
 
Lumbar traction
 
The Agency for Health Care Policy and Research (AHCPR) review of the literature on traction resulted in a conclusion that "spinal traction is not recommended in the treatment of acute low back problems." In addition, the 1996 and 1999 guidelines published by the UK Royal College of General Practitioners (RCGP) stated that "there is little evidence to support the continued use of traction in the management of acute low back pain (LBP)."  Despite these recommendations, the widespread use of lumbar traction remains relatively high, with up to 20% of patients in the United States and 30% of those with low back pain and sciatica receiving traction as a treatment. 
 
Studies that claim improvement after traction report modest and very short-term improvements, with limited or no improvement in overall function. Additionally, these studies have significant design flaws. While a particular group of patients may benefit from a particular type of traction for either short-term or long-term improvement in functional outcome, the literature currently does not identify this patient population. In addition, it is important to note that although high quality evidence supporting the use of traction for the treatment of low back pain is currently scarce, there is likewise insufficient data in the literature to show that traction is not effective for this problem.⁷
 
Cervical traction
 
Few randomized, controlled trials address patient outcomes after cervical traction. While many studies have produced statistically significant findings, the actual clinical significance of those findings is not clear.  Some studies have been published on new protocols for cervical traction, as well as on new devices for traction application. The evidence for the efficacy of these devices and methods appears to need further study before widespread application can be made or recommended.
 
Techniques for applying traction
 
Cervical traction generally is accomplished with a free-weight–and–pulley system or an electrical, motorized device. Adequate pull is achieved by using a head or chin sling attached to a system that can provide pull in a cephalad direction. Motorized devices are applied easily but require the patient to be attended. Free-weight–and–pulley systems often are used in the home with 20 or more pounds of water or sand and a pulley system attached to a door. If a tractive force of only 20 pounds is possible, the system is likely to fail to achieve therapeutic results. Advise patients not to attempt cervical traction at home alone, because they may find themselves in uncomfortable positions and may need assistance doffing the traction devices.
 
Most home traction systems are difficult for patients to set up without assistance. Home cervical traction may cause increase in pain or may fail to produce significant pain relief unless professionally monitored on a periodic basis. At the initiation of home traction, the patient should be required to demonstrate proper use of equipment to the satisfaction of the prescribing physician or therapist.
 
In the lumbar spine, adequate pull with weights and pulleys or motorized devices to achieve vertebral distraction usually can be obtained with the proper apparatus. Generally, a harness is attached around the pelvis (to deliver a caudal pull), and the upper body is stabilized by a chest harness or voluntary arm force (for the cephalad pull). Motorized units have the advantage of allowing intermittent traction with less practitioner intervention. If the goal of tractive force is to distract lumbar vertebrae, 70-150 pounds of pull usually are needed. Friction between the treatment table and patient's body usually requires tractive force of 26% of the total body weight before effective traction to the lumbar spine is possible. Many traction devices use a split table that eliminates the lower body segment friction.
 
Body weight theoretically should provide enough pull to distract lumbar vertebrae and eliminate mechanical devices. Gravity traction is applied almost exclusively in the lumbar region. After 10 minutes of inversion traction, documented increases in intervertebral separation are noted; however, side effects also are frequently reported, including increased blood pressure, periorbital petechiae, headaches, blurred vision, and contact lens discomfort. 
 
A study from Hungary re-analyzed an old method of applying traction in the treatment of patients with lumbar or cervical diskopathy.¹⁰  Patients were vertically suspended by a special harness in a warm-water bath, with a specified amount of weight applied to the lower limbs. One harness allowed for traction on the lumbar spine, while the other focused on the cervical region. The study participants had land-based physical therapy exercises and the weightbath therapy, while a control group only had the exercises. Therapeutic benefit was perceived to be greater by patients treated with a combination of the weightbath and exercise than it was by patients in the control group, according to result following treatment and at 3-month follow-up.

The treatments were well tolerated, and no adverse effects were reported. Although the study concluded that this form of traction treatment "is a relatively straightforward, non-invasive, and low-cost intervention that can be implemented anywhere," further research may be needed to corroborate the findings of this pilot study. Such investigation may need to be supplemented with cost and feasibility data before widespread implementation is initiated. 
 
Other traction technique considerations
 
In cervical traction, determining sitting versus supine position is based upon the patient's comfort and ability to relax. Maximal distraction generally occurs between 20-30° of flexion without rotation or side bending.
 
Studies have shown that, in the cervical spine, larger improvement in range of motion (ROM) with less accompanying pain was noted in patients subjected to intermittent traction of 20 pounds peak (10 seconds on, 10 seconds off, for a total of 15 minutes of treatment time) than in patients subjected to 15 minutes of manual or static traction of 25 pounds.  Constant cervical distraction forces of 30 pounds generate maximum vertebral separation in 7 seconds or less, and no further separation is gained by applications of up to 60 seconds.
 
Supine position is chosen most commonly for lumbar traction since the sitting position may result in outcome-limiting discomfort from the harness. Hip flexion of 15-70° routinely is incorporated to cause relative lumbar spine flexion; this may facilitate optimal vertebral separation.
 
Studies, in addition to patient preference, suggest that some relative advantage exists to an intermittent versus continuous protocol of cervical traction. Some studies report that continuous traction is necessary in the lumbar spine to fatigue muscles and allow strain to fall on joints; however, no statistical difference has been observed with either continuous traction of 100 pounds for 5 minutes or intermittent traction of 100 pounds, peaking for 15 minutes. As in traction on the cervical spine, improved patient tolerance favors an intermittent protocol.
 
In the sitting position, application of approximately 10 pounds is required to counterbalance the patient's head in cervical traction. Traction of 30 pounds applied to a neck flexed up to 24° can cause vertebral separation, but an increase of force to 50 pounds has been found to produce no clear-cut additional separation. In the lumbar spine, a pull, which equals approximately 50% of the weight of the body part, is needed to overcome friction. As previously noted for the lower body, this amounts to approximately 26% of total body weight.
 
In 2006, Akbino and colleagues published a study examining what the most beneficial amount of total body weight (TBW) would be for cervical traction.¹¹  Trials were done with patients randomly assigned to 1 of 3 groups, with each group receiving traction of 7.5%, 10%, or 15% of the patient's TBW. The patients in the treatment group using 10% of their TBW demonstrated the highest therapeutic efficacy with the fewest side effects, compared with the 7.5% and 15% TBW groups. 
 
The optimal duration of traction has not been demonstrated clearly. Studies have revealed recommendations varying from 2 minutes to 24 hours in the cervical spine. Duration of approximately 15-25 minutes commonly is prescribed. Cervical traction generally is prescribed at a frequency of daily for the first week and then every other day (ie, 3 times per week) for total treatment duration of approximately 3-4 weeks.  In the lumbar spine, treatment generally is recommended in the 8-40 minute range per session, daily for the first week and then every other day (ie, 3 times per week) for a total of 3-4 weeks. In cervical and lumbar traction, goals of treatment determine the time course, as well as the end point of treatment. Possible treatment end points may include pain relief, achievement of normal ROM, return to work or other desired activity, lack of improvement in symptoms, and inability of the patient to cooperate with treatment.
 
Indications for traction
 
The literature does not give clear indications what types of neck or low back pain may improve from traction. Studies strongly suggest that traction does not produce significant influence on long-term outcome of neck pain or low back pain. Practitioners who rely on sound scientific advice may use traction rarely. Practitioners who are receptive to empirical treatments may be amenable to the concept that traction may separate vertebrae and decrease the size of herniated disks, thereby benefiting radiculopathy; however, no consensus has been reached among clinicians or researchers in this area.
 
In a 2008 review investigating the use of lumbar traction for patients with chronic low back pain, Gay and Brault found only 10 randomized, controlled trials addressing this treatment.¹²  As a group, the studies contained more evidence against the use of traction than they did for it. The authors broke the information into subcategories based on whether the data covered patients with back and lower limb pain or with low back pain alone. They also looked at sustained and intermittent traction in these patient groups.

The results indicated a lack of benefit in the use of sustained traction for chronic low back pain, with or without lower limb symptoms. Motorized, intermittent traction, which has been aggressively marketed (eg, VAX-D, DRX9000), likewise did not seem to differ in efficacy from simple intermittent axial traction. Gay and Brault cautioned against fully extrapolating the results of the available randomized, controlled trials to the distraction-manipulation therapies at present, until further research can be completed specifically assessing their effects. At this time, there are at least 2 trials of these devices underway.
 
Contraindications to traction
 
No scientific reports clearly delineate contraindications for traction. The practitioner must rely on empirical information and opinion. Old age has been cited as a relative contraindication. Most practitioners agree that contraindications to cervical or lumbar traction include, but may not be limited to, the following: (1) ligamentous instability, (2) osteomyelitis, (3) diskitis, (4) primary or metastatic tumor, (5) spinal cord tumor, (6) severe osteoporosis, (7) clinical signs of myelopathy, (8) severe anxiety, and (9) untreated hypertension.
 
In the cervical spine, the practitioner also must take into account the fact that patients with vertebral basilar artery insufficiency may be more susceptible to cerebrovascular complications. Furthermore, patients with advanced rheumatoid arthritis or connective tissue disorders may be at risk for atlantoaxial instability.
 
Other relative contraindications to traction in the cervical or lumbar spine include (1) midline herniated nucleus pulposus, (2) acute torticollis, (3) restrictive lung disease, (4) active peptic ulcer, (5) hernia, (6) aortic aneurysm, and (7) pregnancy.
 
Akbino and colleagues monitored systolic and diastolic blood pressure, heart rate, rate pressure product, and electrocardiogram (ECG) at 5-, 10-, and 15-minute intervals during administration of cervical traction of 7.5%, 10%, or 15% of the patient's TBW.¹¹  Compared with the patient's premeasured baseline for these values, there was a decrease in the systolic and diastolic blood pressure and rate pressure product for all subjects in each of the 3 groups. Although the change was not statistically significant in the group receiving traction at 7.5% of TBW, it was (p < 0.05) for the 10% and 15% TBW groups. There was no significant difference in heart rate or ECG variables in any group. The authors of this study recommended monitoring these values before and immediately following application of cervical traction, especially in at-risk patients, or those with known blood pressure or cardiac problems.
 
Referral considerations
 
The physiatrist who refers patients for traction must write a detailed and specific prescription that includes at least the following patient information: (1) age, (2) sex, (3) diagnosis, (4) underlying medical conditions, (5) precautions needed, and (6) recommended follow-up. Traction should not be a single treatment approach but rather should be 1 part of a comprehensive rehabilitation treatment program. The most effective use of traction is likely to improve the patient's activity level, mobility, and overall function.
 
Specific items to outline in traction referrals also should include the following information: (1) position (of the body, neck, or hip and knee), (2) mode of application (continuous or intermittent), (3) weight to be applied, (4) concurrent modalities (eg, heat), (5) frequency and duration of treatment, (6) reevaluation guidelines and time frames, (7) guidelines for discontinuation, and (8) therapeutic goals.
 
The future of traction
 
Traction has enjoyed a long history of clinical acceptance based upon very little scientific understanding of its mechanism of action or efficacy. Two 2005 surveys examined the use of traction by physical therapists. One, by Haarte and colleagues¹³ contains data from the United Kingdom, while the second, by Poitras and coauthors,¹⁴  was performed in Quebec, Canada. Both surveys reported widespread use of traction by physical therapists for the treatment of low back pain. Significant questions exist regarding duration of symptom relief and other benefits derived. Given the difficulty of objective documentation of the benefits of traction, it is not surprising that there has been a reduction in its use.

Related eMedicine topics:
Atlantoaxial Injury and Dysfunction
Atlantoaxial Instability
Disk Herniation
Lumbar Disc Disease
Lumbar Disk Problems in the Athlete
Lumbosacral Disc Injuries

Related Medscape topics:
Resource Center Rheumatoid Arthritis
Resource Center Spinal Disorders

Manipulation

Therapeutic manipulation has been practiced in almost all countries of the world since at least the time of Hippocrates; early references have also been found in Egyptian hieroglyphics and early Chinese medical literature. Recent times have seen rapid growth of manipulation and manual therapy and an increase in its public use. Some healthcare professionals' opposition to the use of manipulation is explained by the fact that manipulation requires skills significantly different than those acquired in allopathic medical schools. This difference separates practitioners who possess manipulation skills from those who do not. The techniques used in manipulation also fall outside of the mainstream of allopathic medicine.
 
Manipulation procedures are used in many ways by a variety of practitioners. The most common goal of a manipulative treatment is to increase the mobility of a particular area or region of the musculoskeletal system where restrictions are encountered. While some practitioners focus on pain relief as a main outcome measure, others seek enhanced mobility or reduction in restriction of vascular or lymphatic congestion as it relates to the rest of the body.
 
Most of the 90 million annual manipulations performed in the United States by physicians and other practitioners are for complaints of musculoskeletal back and neck pain. Manipulation generally is directed at restoration of normal motion and elimination of pain secondary to disturbed biomechanics. The majority of the research on the use of manipulation focuses on its application to the cervical and lumbar spine, as well as on treating painful conditions in these areas with either mobilization or thrust-type maneuvers. It is important to realize that there are many other types of manipulative techniques, and which one is chosen should be based on a thorough examination of the patient and on the particular musculoskeletal lesion to be treated. 
 
Definition
 
A consensus definition of manipulation is "the use of the hands applied to the patient incorporating the use of instructions and maneuvers to achieve maximal painless movement and posture of the musculoskeletal system."  Most common types of manipulation involve passive mechanical forces applied to specific vertebral segments, regions, or other joint segments of the musculoskeletal system, with a primary goal of restoration of diminished ROM.

Techniques of Manipulation

Introductions to the most common techniques of manipulation presently used in the United States are presented in the below text. This list is limited to techniques that physicians are most likely to encounter.
 
A brief discussion of direct versus indirect treatment is germane to the understanding of the rationale for choosing a particular technique.  Once an area of restriction, or somatic dysfunction, is palpated, the means of correction must be chosen.  One can elect to treat in the direction of restriction, or into what is commonly called the "ease of motion," that is, away from the restricted motion.  A direct technique engages the motion barrier; this means that the practitioner directs forces into and through the motion barrier.  On the other hand, an indirect technique allows the body's inherent neurologic or intrinsic forces to release the restriction, as the practitioner positions the area to be treated opposite the direction of a restriction.  For example, if pain and reduced motion is elicited by actively rotating a patient's neck to the patient's right side, it can be deduced that the patient's restriction is on the right.  Thereby, if the treatment selected takes the patient's neck further to the right, ie, into the restriction or barrier, this is a direct treatment.  Conversely, if the patient's neck is rotated to the left, or away from the barrier, it is considered an indirect method of treatment.
 
Direct thrust
 
Direct-thrust (eg, high-velocity/low-amplitude) techniques, including European mobilization with impulse, involve diagnosis of dysfunction of a vertebral segment by identifying position or motion abnormalities or related tissue-texture changes, including tenderness to (1) palpation or (2) induced motion. The practitioner then rotates, side bends, and either flexes or extends the adjacent vertebral segments, locking the facet so that further motion is limited to the segment in question. The vertebral segment is then moved passively to its limit of motion (or barrier) in order to remove slack motion, and a small force, localized to the specifically identified joint, is applied to hold that position. Brief, controlled thrust is applied in the direction perceived as limited, and a small motion in the desired direction occurs as the vertebra crosses its barrier. Forces, duration of actions, acceleration, and displacement values for direct thrusting techniques have been measured. These forces peak in the range of 100-400 Newtons over a period of approximately 150 milliseconds. Direct manipulative techniques featuring forces applied over transverse or spinous processes are short-lever techniques. If force is applied distant to the vertebrae through the locked column, the procedure is considered a long-lever technique. All direct-thrust techniques must have forces well localized and specifically directed, and structural diagnosis must be adequate before their application.
 
Articulatory technique
 
Articulatory technique, also referred to as low velocity, high amplitude, involves passive movement of a vertebral joint within reduced ROM (defined by its resting position and dysfunctional limitation of motion). Extent of motion at its end point may vary, but the ultimate end point and dysfunctional barrier become the same, with the barrier becoming attenuated with repeated motion. The quality or feel of induced motion, in addition to the quantity of force and excursion, are normalized by this procedure. A small amount of additional force occasionally may take the vertebra through its barrier or restriction.
 
Indirect positional techniques
 
Indirect positional techniques (eg, counterstrain and functional techniques) are based on the underlying principle that somatic dysfunction or hypomobility is caused by an inappropriately firing muscle group, rather than by shortened, passive tissue, such as joint capsule, ligament, or fascia. Thrust, articulation, and muscle energy techniques employ forces that could be expected to lengthen shortened, passive tissues, whereas these positional techniques change an inappropriate engram of muscle behavior.
 
Counterstrain
 
Developed by Jones, counterstrain is an indirect myofascial technique that shares with functional technique an emphasis on relative positioning of a joint or body part as an essential component of treatment.^15,16 Counterstrain treatment involves placing a joint or body part into position of maximal ease or comfort, thereby relaxing ligamentous and myofascial soft tissue. This relaxation allows inappropriately shortened muscles to reset their spindles, which then normalizes proprioceptive input into the spinal cord. The restricting muscle generally is shortened excessively by this positioning (eg, counterstrained), and its antagonist muscle is overstretched (eg, strained) gently in the process.  The optimal treatment position is found by minimizing pain associated with palpatory pressure over a tender point and, once this position of maximum ease is found, it is held for approximately 90-120 seconds, with concurrent tender-point monitoring. During this time, tenderness should fade to no more than 20-30% of its initial value. Occasional small, fine-tuning, passive positioning movements with verbal feedback from the patient may be needed. Tenderness is part of this feedback system; therefore, the patient must respond to the practitioner's questions.  The patient is slowly returned to a neutral position in 1 plane of motion at a time to prevent recurrence of inappropriate muscle firing.
 
Counterstrain is considered an indirect technique, because positioning is always in a direction away from the restricted motion. If multiple tender points are encountered, they are treated in order of decreasing tenderness. The areas of the highest accumulation of tender points (first proximally, and then distally) are then addressed.
 
Tender points are found beneath the skin through palpatory examination over shortened and restricted muscles or over related anatomic structures (eg, tendons, muscles, ligaments). Tender points generally do not coincide with trigger points or points associated with fibromyalgia. Counterstrain tender points usually are small, fibrotic, discrete areas thought to be manifestations of distal somatic dysfunction and are not associated with other signs of fibromyalgia, nor are they paired. Counterstrain tender points are distributed widely in generally reproducible locations, depending on the nature and location of associated somatic dysfunctions. Those associations are not based on known neurophysiologic or neuroanatomic referral patterns.
 
Counterstrain is considered safe, effective, gentle, and atraumatic, so it is a very useful technique for the older, hospitalized, or immune-compromised patient, as well as for apprehensive patients and children. Counterstrain techniques are easy to perform, forgiving for the novice learner, and easily incorporated by the patient into a prescribed home exercise program.
 
Functional techniques
 
Functional techniques, as well as counterstrain, have a methodologic approach oriented to resetting inappropriate afferent impulses from nociceptors and mechanoreceptors, resulting in efferent alpha motor activity to the skeletal muscle, by placing the joint or body part into a position of maximum ease. Unlike counterstrain, however, the position is found and monitored by the practitioner, sensing either increased resistance to trials of small, induced motions or increased tissue tension of the nearby tissue when motion is induced. The most relaxed position is held in this balanced state.
 
Functional technique practitioners feel that inherent body motions (eg, respiration) allow the firing pattern of the afferent muscles to reset so that they are normalized in a neutral position. This approach, also unlike counterstrain, does not make use of tender points and may be somewhat more objective, because practitioner's palpatory findings determine positions of balance.
 
The practitioner puts the patient through a sequence of positions, with the goal of progressing toward anatomic neutral as the position of maximum ease or balance. Functional techniques are useful in acute and chronic conditions, because they focus on the quality, rather than the quantity, of motion, with restoration of normal function implying normal quality and ROM. Functional techniques require significant experience on the part of the practitioner.
 
Muscle energy
 
Muscle energy is a direct, non-thrusting technique (also known in the United States as isometrics and in Europe as mobilization) and has a strong relationship to proprioceptive neuromuscular facilitation. The physician positions the patient and removes slack as in direct thrust procedures and subsequently prevents active motion of the affected vertebral segment away from its barrier. The patient then exerts minimal to moderate isometric force against resistance offered by the physician for approximately 5-10 seconds and subsequently relaxes. The physician then finds that the barrier has been displaced and that the affected segment moves beyond its original barrier. This procedure is repeated 2-3 times, with diminishing gains and increased ROM.
 
Soft-tissue technique
 
Soft-tissue technique uses mechanical stretch of skin, muscle, and fascia to increase motion. Lateral and linear stretch and deep inhibitory pressure are the most common procedures used. Soft-tissue techniques are useful in virtually all patients and may function as the first step in manipulative treatment involving multiple techniques. Soft-tissue techniques are very valuable in encouraging circulation and enhancing venous and lymphatic flow. The overall purpose of soft-tissue techniques is to relieve fascial and superficial muscle tension. Soft-tissue techniques are easily learned and can be incorporated into clinical practice with virtually no difficulty.
 
Myofascial release
 
Myofascial release techniques are directed at vertebral, segmental, or generalized hypomobility. Myofascial release can be indirect (ie, when a restricted area is placed into a position of little resistance until subsequent relaxation occurs) or direct (ie, when the affected area is placed against a restrictive barrier with constant force until fascial release occurs). All the myofascia of the body are interconnected, and when one area is tight or restricted, diminished movement occurs not only locally but (potentially) in distant, related areas.
 
Myofascial release practitioners palpate to assess tissue response and adjust applied forces of stretch, pressure, twist, or traction until affected tissues change toward normal. This progression may occur over a short period of time and is referred to as release. The mechanism of release may be biomechanical or neuroreflexive; however, fascial resistance to forces applied should be symmetric, and the tissue should be relatively mobile and responsive to force being applied. In myofascial release, the mechanical approaches of direct thrust, articulatory technique, and muscle energy are combined with the neuroreflexive approaches of counterstrain, functional technique, and soft-tissue technique. Effective use of myofascial release requires considerable palpatory skill and experience, and training time is relatively long compared with that for other manipulative approaches.
 
Craniosacral
 
Craniosacral manipulation is based on the concept of a primary respiratory mechanism (ie, a cyclic, palpable, rhythmic wave of inherent motion appreciated most easily in the cranial and sacral areas). This wave may represent a continuous state of flux in the cerebrospinal fluid (CSF). This primary mechanism may entail inherent mobility of the central nervous system (CNS), CSF fluctuation, cranial bone articular mobility, involuntary motion between the sacrum and ilia, and mobility of interspinal and intercranial membranes.
 
The craniosacral practitioner palpates the head and/or sacrum to feel pulsations of the wave motion, occurring in the range of 8-12 pulses per minute, as well as to evaluate symmetry, regularity, frequency, and amplitude of the wave. When abnormalities are found, general pressure is applied to the skull and sacral areas to restore the wave to normal symmetry rhythm and amplitude.
 
While this technique is considered somewhat controversial among nonpractitioners, its largest subset of potential patients may be infants with failure to thrive, birth defects, or head injuries, as well as adults with neurologic or CNS pathology. The growth in popularity of this manipulative approach requires physicians to have at least passing familiarity with it. Proficiency with craniosacral manipulation requires considerable training and experience.

Manipulation Risks, Benefits, and Patient Selection

Risks and benefits of manipulation
 
Few risks are involved in manipulative care. Complications from isometric or articulatory treatments have not been reported. The number of reports of complications from direct-thrust manipulation actually is quite small, considering the number of manipulations performed annually. Most potential complications of manipulative care are avoidable.
 
Evidence for the benefits of manipulation is mounting. Proponents report excellent results in treating acute, as well as chronic, musculoskeletal problems. Empirically, these outcomes are comparable to those achieved with more conventional treatments, many of which carry no proof of efficacy. Manipulative care has been shown to decrease use of medication and physical therapy, to be superior to conventional treatment and placebo manual care, and to be most efficacious in persons with noncomplicated acute low back pain. Manipulation results in less disability and faster recovery, as well as in greater improvement in pain and activity tolerance, and is a valuable adjunct to an ongoing exercise program. Manipulation has been shown to be useful in the treatment of upper, middle, and perirespiratory infections, as well as advanced cardiopulmonary disease, headache, and neck pain.
 
Manipulative care in physiatric practice
 
The physiatrist usually is able to identify, through focused musculoskeletal examination, patients who are most likely to benefit from manipulative care. Although some manipulation techniques have applicability to hospitalized patients, most persons for whom manipulation is considered appropriate are encountered in the outpatient setting. This constituency includes patients with structural problems (eg, vertebral rotations, pelvic asymmetries, sacral torsions, other entities in which diagnosis relies on palpatory skill). 
 
Selection of patients
 
Perform a general physiatric examination on each patient. Identify and treat any underlying pathology, including fractures, herniated disks, sprains, strains, hematomas, joint injuries, and peripheral and central neurologic injuries. Use additional diagnostic studies as needed. The physiatrist contemplating manipulative intervention performs a focused, detailed history and structural examination in areas suggested by symptoms or by the general examination. This involves observation, active gross- and fine-motion assessment, and general palpatory/motion examination. Success of manipulative therapy often depends upon accurate palpatory diagnosis. Palpatory and segmental autonomic changes may be significant components of structural diagnosis.
 
Generally included in the evaluation of vertebral or segmental levels are: (1) bony structure asymmetry; (2) restricted vertebral motion relative to adjacent vertebrae in flexion, extension, side bending, and rotation; (3) tissue-texture changes; (4) local tolerance to palpation or induced motion; and (5) tenderness elicited over vertebral processes or by induced motion. Evaluate passive motion for range, symmetry, and amount of force needed to achieve full range, which is assessed in terms of quality or end field of motion. Evaluate combinations of vertebral motion as well (eg, flexion, rotation).
 
Springing of the vertebrae and examination of tenderness or local pressure on interspinous ligaments often are useful techniques in determining musculoskeletal function and loss of joint mobility. Subcutaneous tissue-texture changes, such as edema or fibrosis, may be noted by palpation and may indicate musculoskeletal pathology with associated segmental autonomic changes. Include an examination of the ribs, occiput, and pelvis in the structural examination. Hypermobile musculoskeletal segments may not be amenable to manipulative intervention but may indicate the presence of hypomobile segments in other locations and, if nontender, may be amenable to successful manipulation to resolve distant hypermobility.
 
Thorough structural examinations, as described, may add 5-10 minutes to an initial visit and less than 5 minutes to subsequent patient examinations. Taking the time to perform a thorough structural examination will usually allow the physician to most appropriately focus his or her treatment on the area of most need. By localizing the main area of restriction, the treating physician often can minimize the dose and frequency of the manipulative intervention. The physiatrist choosing manipulation should possess a relatively high degree of basic palpatory skills so that referral to another physician or manipulative practitioner includes specific identification of structural dysfunction. Additionally, palpatory examination allows the physiatrist to determine which areas need manipulative treatment and to establish a potential end point of manual care.

Related Medscape topic:
CME/CE Spinal Manipulation May Not Be Helpful for Low Back Pain

Manipulation Methods, Indications, and Contraindications

The availability of manipulation care varies significantly, depending upon geographic location and regional practice patterns. Physiatrists who wish to use manipulation but who do not wish to provide it themselves generally refer patients either to a physician or to a licensed nonphysician practitioner. Referral to another physician practitioner often works well, but potential problems exist, especially regarding patient referral. This issue may be addressed through a specific referral that states the exact nature and scope of the evaluation and treatment requested, that encourages discussion with the referring physician, and that makes clear the intention of the physiatrist to resume the remainder of the patient's care. If the referral is to a licensed nonphysician practitioner, first diagnose the appropriate problem and write a specific prescription for manipulation. 
Manipulative care can be provided as part of a comprehensive therapy program; however, the physiatrist should write a detailed prescription for the specific area to be treated and identify the diminished motion to be restored, as well as the frequency and length of treatment. This enables the physiatrist to monitor patient progress objectively and determine the end point and benefit of manipulative treatment.

The 3 main obstacles for the physiatrist interested in performing manipulation are acquisition of skills, maintenance of skills, and economic considerations. Manipulative techniques are learned best on colleagues and fellow learners under close supervision. Studies suggest that the minimum learning time required might vary from 3-12 months, depending upon the modality being learned. This extended period of time has significant ramifications for the practitioner. Because of enhanced safety and the small potential for harm, sufficient skill can be acquired by most practitioners in 1-2 weeks of formal training in each of the types of manipulation, including isometric/muscle energy, counterstrain, myofascial release, and articulatory techniques. Training time for these approaches is shorter, because inappropriate or nonindicated indirect technique, unless repeated frequently or over a prolonged period of time, rarely causes detrimental effects.
 
Postdoctoral training programs, such as those approved or offered by the AmericanAcademy of Physical Medicine and Rehabilitation, the American Association of Colleges of Osteopathic Medicine, and other organizations, may provide a means by which the physiatrist can become acquainted with the skills necessary to begin manipulative care. Interest among physiatric residents in acquiring manipulative skills is high, and this fact has expanded training opportunities for physicians. Many residency programs now include required and/or optional training in manipulative skills.
 
Maintenance of manipulative skills is fairly easy for a full-time practitioner; however, it may be more difficult for the physiatrist whose practice does not feature a high volume of manipulative care. Infrequent use of manipulative skills results in decreased competence, but the actual minimum frequency of use needed to maintain competence or excellence varies considerably among practitioners. Manipulation, if performed appropriately, can be time efficient and financially viable.

Indications for manipulation
 
Manipulation is appropriate for a variety of musculoskeletal problems, especially those of the thorax, rib cage, upper and lower extremities, back, pelvis, and neck. It is also useful when loss of motion or function is encountered or when localized tenderness or pain is noted on induced motion. Some clinical situations (eg, acute fractures, disk herniations with neurologic signs, tumors, acute inflammation, joint disease) may not respond to manipulative care because of local conditions that may constitute contraindications or hypermobility. Remember also to exclude systemic or visceral pathologic conditions, or at least to put them under concurrent care of the practitioner. Some physicians use manipulation for treatment, while others provide it in a more prophylactic manner. 
 
Side effects of manipulation
 
The most commonly reported side effect of manipulation is a transient increase in discomfort lasting approximately 6-72 hours. Minor, temporary autonomic effects (eg, early or increased menses, increased perspiration, vasomotor changes) have been reported.
 
Duration of manipulative care
 
Direct techniques (such as high-velocity, low-amplitude thrust) usually have immediate effect, and improvement is seen within a week. Indirect techniques may take longer for the effect to be seen. Caution must be used to avoid unnecessary continuation of treatment when pain relief does not correlate with biomechanical improvement. If the patient's condition does not improve objectively within 2-4 weeks, reevaluation of the structural diagnosis, manipulative approach, or other therapeutic plan is indicated. Determine the duration of each course of therapy on a case-by-case basis.
 
Contraindications for manipulation
 
Different manipulative approaches vary as to the degree of invasiveness. Because of higher forces involved, direct techniques are the most invasive and, therefore, are more likely to be contraindicated.
 
Absolute contraindications for manipulative care, especially indirect techniques, are very rare. Few relative contraindications exist. Manipulative care should be performed only for hypomobile vertebral segments or other structural dysfunctions deemed amenable to manipulation. Accurate structural diagnosis is critical. Inadequate practitioner skill is a major contraindication for all types of manipulative care.

Articulatory techniques are contraindicated for patients with vertebral malignancy, infection or inflammation, myelopathy, multiple adjacent radiculopathies, cauda equina syndrome, vertebral bone disease, bony joint instability, and cervical rheumatoid disease. Direct manipulation (eg, high-velocity/low-amplitude) is contraindicated in those cases and, additionally, in the presence of (1) spinal deformity, (2) systemic anticoagulation treatment, (3) severe diabetes or atherosclerotic disease, (4) degenerative joint disease, (5) vertebral basilar disease or insufficiency, (6) spondyloarthropathies, (7) ligamentous joint instability or congenital joint laxity, (8) aseptic necrosis, (9) local aneurysm, (10) osteoporosis, (11) acute disk herniation, and (12) osteomalacia.
 
Haldeman and colleagues performed a retrospective review of patients in whom the occurrence of stroke was temporally associated with cervical spine manipulation.¹⁷  It was concluded that no known mechanism exists to predict who is at risk for such an event and that stroke is an inherent and idiosyncratic risk associated with this type of treatment, as well as an exceedingly rare complication.
 
Patients with a tendency toward somatoform fixation in painful anatomic areas, as well as those with obsessional neurosis, are poor candidates for direct manipulative techniques. Pregnancy and known threat of miscarriage are absolute contraindications only for direct manipulative techniques. Conservative indirect techniques are considered safe (as long as they are performed by a competent practitioner) into the latter stages of pregnancy.
 
Objective radicular signs are a contraindication for direct-thrust techniques of all kinds. Active myositis or infection may constitute a contraindication for isometric care because of the need to provide active muscular contractions. Functional techniques, counterstrain, or other indirect approaches may be applied safely in these conditions. No contraindications have been documented for functional or counterstrain techniques.
 
Complications of manipulation
 
Complications of manipulation generally arise because of poorly skilled/trained practitioners or due to the performance of contraindicated procedures. No documented or anecdotal reports of complications resulting from articular, isometric, counterstrain, functional, soft-tissue, or myofascial release exist. Most reported complications involve direct (eg, high-velocity/low-amplitude) thrusting techniques that generally have been done in the cervical region and, in almost all cases, the neck was extended inappropriately during the procedure. Extremely serious consequences may occur with very low frequency, estimated to be approximately 1 case in 1-1.5 million manipulations. The Back Letter states that, "As to whether or not healthy patients should be concerned with the risk of cervical manipulation, the risk appears to be quite small."¹⁸  
 
Risk to the patient is minimized by proper positioning of the individual, with avoidance of extreme positions of flexion, extension, side bending, and rotation. Careful evaluation and treatment of patients with known or suspected osteoporosis or spinal disease also is important.
 
Manipulation, specifically its application to the cervical spine, has been mentioned in the lay press. Associations have been made between cervical, high-velocity thrust techniques and vertebrobasilar artery strokes and strokelike symptoms. Given the number of such manipulative treatments performed in the US and Canada alone on an annual basis (estimated conservatively in the tens of millions) and the number of reported cases of such events per year (estimated to be in the single digits), cervical spinal manipulation is a relatively safe procedure.

However, a thorough physical examination, including a neurologic examination and an assessment of the patient's comorbid conditions and risk factors, needs to be conducted before such manipulation is performed. If a thrusting technique is chosen, the force used should be the minimal necessary to achieve the correction and should be localized as precisely as possible to the restricted segment. Extremes of motion in any direction, but especially cervical extension, should be avoided, because these end ranges have been shown to be the ones most often associated with poor treatment outcomes.

A study by Cassidy and colleagues that specifically investigated the possible link between the risk of vertebrobasilar artery stroke and chiropractic manipulation did not rule out a potential connection between these "rare events" and cervical manipulation; the authors found such an association in study patients under age 45 years.¹⁹  The results, according to the report, "suggest that the association between chiropractic care and [vertebrobasilar] stroke found in previous studies is likely explained by presenting symptoms attributable to vertebral artery dissection. It might also be possible that chiropractic manipulation, or even simple range-of-motion examination by any practitioner, could result in a thromboembolic event in a patient with a preexisting vertebral dissection." It should also be remembered that this reference does not apply to manipulation performed by a fully trained and licensed physician, nor does it apply to any type of manipulation other than high-velocity, low-amplitude thrust in the cervical spine.
 
Manipulation may be used to treat infants and children, as well as adults. Particular care must be taken in the application of manipulative treatments to children, especially with regard to thrust techniques. Some of the serious adverse events in this population that have been documented include death, subarachnoid hemorrhage and tetraplegia.

A systematic review study of manipulation-associated adverse events in children, which included information culled from many case reports, found that all such events involved children under age 13 years and that these events were associated with diagnoses that did not appear to be those commonly addressed by manipulation.²⁰ The authors of this review performed literature searches using multiple electronic databases for articles published from 1900-2005. Given the large number of patients who were treated with spinal manipulation during this time period, they felt that it was reasonable to conclude that "adverse events resulting from spinal manipulation are either remarkably rare or underreported."

According to the report, a number of risk factors may predispose a child to an adverse event as a result of spinal manipulative procedures, including "immaturity of the spine, rotational manipulation of the cervical spine, and high-velocity thrust techniques."  Five of the serious adverse-event reports in this study did not specify the type of spinal manipulation used. Two of the 4 that reported such events specified that the practitioner used "rapid and/or strong rotational maneuvers."

It can be inferred from reviews such as this that rotational manipulation of the cervical spine should be used with extreme caution in the pediatric population, and that young patient age may be a relative contraindication for thrusting, especially rotational, maneuvers.  Additional attention to accurate diagnosis and a thorough history and physical examination may prevent such catastrophic outcomes in the pediatric population.

Related eMedicine topic:
Vertebrobasilar Stroke

Hypothesis of the Etiology of Somatic Dysfunction

Manipulation is a mechanical intervention. Hypotheses that explain somatic dysfunction usually involve position and treatment of vertebral bodies, muscle, fascial segments, or other body parts, as well as soft tissue. Acute pathologies (eg, fractures, ligamentous tears, tumors, avulsions, joint inflammation) are not considered amenable to manipulation as a primary mode of treatment. Some pattern of neuromuscular behavior resulting in early localization of hypomobility may respond to manipulative care. Pain and edema may cause immobility, leading to contracture or an abnormal neuromuscular pattern. Precipitating pathology of somatic dysfunction may be largely resolved by the time diagnosis is made; however, pain also may arise from dysfunction and, along with impaired mobility, may be related directly to it. Pain and somatic dysfunction can create a self-perpetuating syndrome. 
 
The musculoskeletal manifestation of restricted movement and impaired mobility of a body segment is known as somatic dysfunction. The condition has also been called an osteopathic lesion, a chiropractic subluxation, a joint blockage, and a loss of joint play, among other terms.
 
Barrier models have been suggested to explain palpable findings. Normal joints possess an active and a larger, passive ROM. A barrier or motion restriction produced by abnormal muscle contraction, ligamentous, or capsular shortening forms in 1 or more directions between the neutral position and normal limits so that patients are not able to achieve normal range. The manipulation practitioner then applies additional force to achieve normal passive ROM.
 
The facilitated segment model assumes that a vertebral body, chronically malpositioned by contracture, overly active muscle, or other somatic dysfunction, floods the segmentally related area of the spinal cord with inappropriate, nonfatiguing proprioceptive impulses. These impulses, in turn, spill over and facilitate outgoing motor neurons and autonomics in the same vertebral segment of the spinal cord. Pathways are then present for interaction between soma and viscera at related segments, and the palpatory diagnosis of visceral disease and the determination of influence on the viscera are possible. This phenomenon allows asymptomatic, abnormal segmental areas to develop symptoms from general illness, distant disease, or emotional stress. Physiatrists familiar with autonomic hyperreflexia and similar phenomena can relate easily to the concepts of somatovisceral reflexes and segmental spillover.
 
The mechanical model of altered joint play is distinct from the neurophysiologic hypothesis of somatic dysfunction. All normal voluntary joint motion is accompanied by a wiggling motion in a direction perpendicular or, possibly, tangential to the plane of that motion. This joint play exists because joint surfaces are not perfectly congruent. Loss of joint play because of soft-tissue restriction may inhibit voluntary motion from absence of the involuntary component. Passive intervention is needed to normalize function because lost joint play is in an involuntary direction. Pain arises, therefore, from poor mechanical function.
 
The concept of "ease and bind", central to functional and other indirect techniques, uses a model of vertebral motion around a symmetry point where motion in any direction encounters equal tissue resistance. In a dysfunctional vertebra or other musculoskeletal tissue, the balance point is not the anatomic neutral, so that movement in one direction of motion is met by more resistance (bind) than another (ease). The maintenance of asymmetry arises in proprioceptive and gamma motor spindle sensors, and treatment usually involves passive motion to and maintenance of the ease position so that the spindles can reset their output. The strain-counterstrain method suggests that the aberrant activity of the spindles can trigger reflex patterns and tender points, which can be used to monitor the positional resetting of the spindle output.²¹
 
Hypothesis of action of manipulation
 
The overriding mechanism by which manipulative techniques relieve pain is not fully understood. A simple categorization separates treatments into those that mechanically lengthen tight soft tissues from those that alter the firing rate of inappropriately shortened muscles to achieve relaxation or ease. Either of these treatment techniques eliminates hypomobility of an offending segment if soft tissue is lengthened or the muscle is relaxed sufficiently. Functional, muscle energy, (most) myofascial release, and counterstrain techniques, using small forces, can work only on neuroreflexive alteration of muscle activity. Direct-thrust and articulatory techniques involve larger forces and, presumably, are able to stretch and elongate tissue.
 
Restricted motion arises from abnormal muscle contraction and shortened or stiffened soft tissues. All forms of manipulation interfere with abnormal muscular contraction, either by producing afferent stimuli that attenuate hyperexcitable, gamma-efferent systems or by elimination of proprioceptive input that stimulates the gamma-efferent system. Thrust and, possibly, articulatory and isometric techniques stimulate Golgi tendon organ input. Articulatory and isometric techniques may elicit permanent lengthening of collagenous tissue by inducing a permanent set with repeated stretching. Direct-thrust techniques result in high stress levels and probably in high strain levels in soft tissues over a short period of time. Nonuniform distribution of strain may develop, leading to localized tissue injury and subsequent healing with permanent elongation, with the net result being that vertebrae regain normal motion play; the forces needed to produce motion then are normalized.
 
Facet malposition or malfunction can be influenced directly with manipulation by passive joint motion. A bulging disk may be reduced or normalized by manipulation. The change in proprioceptive input to the spinal cord may close the gate on pain or remove abnormal, facilitating proprioceptive input.
 
Use of manipulation by physiatrists

The goals of manipulation are to restore or optimize biomechanical function by improving motion, thereby facilitating mobility, minimizing pain, and increasing the patient's overall level of wellness. Scientific evidence for the efficacy of manipulation has been mounting. General acceptance of the utility of manipulation in acute low back pain and other forms of musculoskeletal pathology has resulted in recommendations that manipulation be directed toward restoration of normal motion, reduction of pain, and overall increase of physical activity. There is also increasing evidence to support the use of manipulation in combination with other modalities to optimize the return of function.

A study by Childs and colleagues compared the use of exercise as a stand-alone therapy with the employment of spinal manipulation in combination with an exercise program, in patients suffering from low back pain.²²  Improvements in disability and pain were, to a statistically significant degree, greater in the patients who received both therapies than in those in the low-stress aerobic and lumbar spine–stabilizing exercise group.

Subsequent literature reviews examining the use of manipulation in treating pain in the cervical and lumbar regions have also supported its use.  Bronfort and colleagues found moderate evidence to support the use of spinal manipulation and mobilization in the treatment of chronic low back pain, stating that such treatment is "at least as effective as other efficacious and commonly used interventions."²³

Hurwitz and colleagues performed a comprehensive literature review of nonsurgical interventions for the treatment of patients with whiplash associated disorder (WAD) and for other neck disorders with or without trauma.²⁴ The authors found that among the patients studied, treatment with mobilization and exercises seemed to be more effective than did treatment with the usual types of care or physical modalities.
 
The study also found evidence that for non-WAD neck disorders, in the absence of radicular signs or symptoms, it was more beneficial to treat patients with manual (manipulation or mobilization) and exercise interventions, low-level laser therapy, and perhaps acupuncture than it was to provide them with either sham or alternative treatments, or with no intervention at all. However, among the more successful "active" treatments, none was found to have a clear benefit over the others on either a short- or long-term basis. According to the report, for "WAD and neck disorders without trauma, the evidence favors supervised exercise sessions with or without manual therapy over usual or no care. Of the manual therapies, manipulation and mobilization yield comparable clinical outcomes."
 
Prescription of manipulation

Referral of a patient to another practitioner for manipulation requires a prescription, the contents of which may be communicated through conversation between the practitioners. Manipulative care also may be included as a portion of a general strengthening, conditioning, and musculoskeletal educational program. The specific region to be manipulated, potentially suggested techniques, and discussion of any medical issues, considerations, or side effects also must be a part of the prescription. Include patient age, precautions, diagnosis, treatment recommendations, frequency, duration, and other comments in all prescriptions for manipulation. Follow-up patient examination is essential. If treatment has been unsuccessful, consider reformulation of the diagnosis or of the therapeutic manipulative approach. If manipulation procedures are producing discomfort lasting more than 8 hours, consider changing to a less invasive, or possibly an indirect, technique.
 
The manipulative technique used in any intervention is determined by the time course of the problem and the patient's age and general physical condition, as well as past medical history, the presence of any contraindications, and the practitioner's expertise and training. These considerations underscore the need for a careful history and physical examination, structural examination, and functional diagnosis. A musculoskeletal problem amenable to manipulation must be identified in order for this approach to be effective. The identification of the source of pain is particularly important for patients with subacute or chronic pain. Note also that complete eradication of pain is rare. This fact may lead patients to become dependent on manipulation. Having well-defined biomechanical end points of treatment (eg, normal ROM and tissue texture) helps to formulate an effective end to treatment. Especially in the patient with chronic pain, manipulation should be directed toward obtaining an optimal biomechanical musculoskeletal condition as quickly as possible.
 
Research relating to manipulation

Numerous clinical trials of spinal manipulative treatment have been summarized in the literature. Further, manipulative treatment has been the subject of multiple international consensus meetings. Trials have attempted to improve knowledge by comparing thrust with nonthrust (ie, direct with indirect) techniques and joint-specific with nonjoint-specific manual therapies, by varying the frequency and intensity of interventions and by comparing different types of joint-specific manipulation techniques. Studies in the literature have varied in terms of research design, criteria for improvement, time of evaluation, and techniques examined. The wide variations among studies have made blinded reviews and objective meta-analysis very difficult.
 
Anatomy and physics of manipulation

Understanding of the biomechanics of direct-thrust manipulation has significantly advanced. Indirect (ie, nonthrust) manipulation has been studied less. The external mechanical forces involved, the duration of the application of those forces, and the gross anterior/posterior displacements have been measured in human subjects, and relative displacements have been measured in cadaver studies. Study of internal forces and relative displacements of vertebral bodies resulting from applied forces still has not been performed. Some research has been conducted on the neurologic and neuromuscular responses to direct-thrusting procedures; however, little has been done to study other types of manipulative therapies in terms of biomechanical parameters or physiologic responses to them.
 
What has been learned about pain and mechanoreceptors, spinal cord physiology, and normal spinal biomechanics since the late 20th century has allowed this information to be applied and has facilitated contributions to the understanding of manual medicine and the treatment of somatic dysfunction. Knowledge about small tissue strains now is being accumulated and assimilated into manual medicine thinking. Two primary areas of research development and scholarly inquiry that relate to manual medicine at this time are the objective measurement of somatic dysfunction in patients and the examination of the association of somatic dysfunction with acute and chronic pain. Further inquiry also is warranted into questions concerning mechanism and (in the current era of health care – cost containment) efficacy.

Conclusions

Massage, traction and manipulation are among the oldest medical treatments known and continue to be widely practiced throughout the world. There are an ever-growing number of patients utilizing these methods of care despite a relative dearth of quality, evidence-based research supporting their isolated use.

Each of these treatments has some scientific support to back its use in certain cases or conditions, and from a logical perspective, one can assume that some middle ground exists for the application of massage, traction, or manipulation in a cautious and controlled manner within the medical paradigm. Each of these treatments also carries some risk, but given the estimates of use worldwide and the reports of direct or indirect side effects related to these therapies, the risks appear to be minimal, with the treatments offering potential benefits for patients.

From an osteopathic perspective, manipulation is not intended to be a stand-alone treatment; rather, it is meant to be a component of the treatment strategy for a given patient. Indeed, current research on manipulation seems to support this use, and further research must be done on a variety of conditions to determine the best combinations to effectively and safely aid the patient’s recovery. The same concept should be applied to the investigation of massage and traction to determine how to best use these treatments in the complete care of a patient.  Because physiatry has embraced the “team approach” since its inception, combining the administration of a thorough physical examination with the use of a variety of practitioners, modalities, and treatments is not a new concept, and the strategy tends to be well-accepted.

Keywords

massage, traction, manipulation, massage therapy, pregnancy massage, medical massage, back pain, low back pain, lower back pain, cervical traction, neck traction, traction device, lumbar traction, healing touch, Eastern massage, Western massage, therapeutic manipulation, soft-tissue manual therapy, effleurage, petrissage, pétrissage, tapotement, deep friction massage, percussion message, deep pressure, Shiatsu, acupressure, reflexology, auriculotherapy

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