Unraveling the Mechanisms of Manual Therapy: Modeling an Approach

Abstract

Synopsis Manual therapy interventions are popular among individual health care providers and their patients; however, systematic reviews do not strongly support their effectiveness. Small treatment effect sizes of manual therapy interventions may result from a "one-size-fits-all" approach to treatment. Mechanistic-based treatment approaches to manual therapy offer an intriguing alternative for identifying patients likely to respond to manual therapy. However, the current lack of knowledge of the mechanisms through which manual therapy interventions inhibit pain limits such an approach. The nature of manual therapy interventions further confounds such an approach, as the related mechanisms are likely a complex interaction of factors related to the patient, the provider, and the environment in which the intervention occurs. Therefore, a model to guide both study design and the interpretation of findings is necessary. We have previously proposed a model suggesting that the mechanical force from a manual therapy intervention results in systemic neurophysiological responses leading to pain inhibition. In this clinical commentary, we provide a narrative appraisal of the model and recommendations to advance the study of manual therapy mechanisms. J Orthop Sports Phys Ther 2018;48(1):8-18. doi:10.2519/jospt.2018.7476.

We need to debate the value of manipulative therapy and recognize that we do not always understand from what to attribute our success

“…A not so subtle reality continued at the American Academy of Orthopaedic Manual Physical Therapist (AAOMPT) 2017 annual conference where less than a third of the presentations were specific to manual therapy. Given the trends in emerging evidence that question the reliability, validity and clinical effectiveness of manual therapy as a standalone intervention, perhaps a good whack on the back of our collective hands was appropriate [2][3][4].…”

Manual therapists – Have you lost that loving feeling?!

“…A recent editorial by Reid et al [11] suggested ' …we, as advocates of a specific treatment specialization, have not done an adequate job in providing sufficient and sound evidence that orthopedic manual physical therapy demonstrates high clinical utility…In other words, we have failed to tell our story. ' Traditional paradigms of how manual therapy works have been questioned [12][13][14]. At the time, clinical benefits observed from manual therapy were believed to be from local changes in tissue, joint mobility, and alignment [15].…”

“…At the time, clinical benefits observed from manual therapy were believed to be from local changes in tissue, joint mobility, and alignment [15]. New evidence suggests that many manual therapy theories and paradigms are outdated and invalid, and yet we still cling to them at our own peril [12,13,16,17].…”

“…Current best evidence suggests that any benefit seen from manual therapy likely arises from a complex interplay between neurophysiological effects, placebo, patient expectation, and therapeutic alliance [12,13]. In clinical research, it is very difficult to control for all possible confounding variables, and, once you strip away these 'non-specific' factors [12,13,16,[18][19][20][21], manual therapy as a stand-alone treatment is of questionable efficacy.…”

“…In clinical research, it is very difficult to control for all possible confounding variables, and, once you strip away these 'non-specific' factors [12,13,16,[18][19][20][21], manual therapy as a stand-alone treatment is of questionable efficacy. Systematic reviews suggest that manual therapy for musculoskeletal conditions may have significant short-term effects on pain, but the longterm effects on disability, function, health care costs, and quality of life remain questionable [4][5][6]8,22].…”