Musculoskeletal Manipulation

Aka: Musculoskeletal Manipulation, Osteopathic Manipulative Treatment, Manipulative Therapy, Manipulation Procedure, Chiropractic Manipulation, Spinal Manipulation, Muscle Energy Technique, Muscle Energy Therapy, Counter Strain Therapy

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II. Types

  1. Counter Strain Therapy
    1. Passive shortening of a Muscle until its associated Tender Point softens while being palpated
    2. Joints and Muscles are manipulated away from a restrictive barrier (taut Muscle) toward a less restrictive position
    3. Once Trigger Point pain decreases, position is held for 90 seconds, and then returned to a neutral position
  2. Muscle Energy Technique
    1. Stretches tight Muscles and fascia
    2. Examiner applies counter force against a patient's isometric contraction of involved Muscles
    3. Patient holds each contraction for 3-5 seconds and repeats the maneuver 3-5 times
  3. Soft Tissue Therapy
    1. Fascial tissue is lengthened through manual force
  4. Spinal Manipulation
    1. Manual force applied to spinal joint, moving it at it's end range of motion

III. Indications

  1. Acute Low Back Pain
    1. May offer short term benefit, but no longterm benefit compared with other Low Back Pain Management
    2. Assendelft (2003) Ann Intern Med 138(11): 871-81 [PubMed]
    3. Rubinstein (2012) Cochrane Database Syst Rev (9): CD008880 [PubMed]
    4. Paige (2017) JAMA 317(14): 1451-60 [PubMed]
  2. Chronic Low Back Pain
    1. Offers some benefit in the longterm, but no better than other conservative therapy
      1. Assendelft (2004) Cochrane database Syst Rev (1): CD000447 [PubMed]
  3. Neck Pain
    1. Cervical manipulation or mobilization appears effective in reducing pain in acute and chronic Neck Pain
    2. There are risks to neck manipulation including rare but catastrophic effects (e.g. Vertebrobasilar Dissection)
    3. Gross (2015) Cochrane Database Syst Rev (2): CD004249 [PubMed]
    4. Gross (2010) Cochrane Database Syst Rev (1): CD004249 [PubMed]
    5. Gross (2004) Cochrane Database Syst Rev (1): CD004249 [PubMed]
  4. Chronic cervicogenic Headache or Tension Headache
    1. May be effective, but studies of efficacy to date are small
    2. Cerritelli (2017) J Pain Res 10:601-11 [PubMed]
    3. Bronfort (2004) Cochrane Database Syst Rev (3):CD001878 [PubMed]

IV. Precautions

  1. Chiropractic Manipulation is common in infants and children (2.5 Million in 2007)
    1. Has been used for various complaints beyond musculoskeletal, including respiratory conditions, colic, allergies
    2. Evidence of benefit is poor in this population, and it is not generally recommended
    3. Posadzki (2013) Pediatrics 132(1):140-52 [PubMed]

V. Adverse Effects: Serious or Life Threatening

  1. Vertebrobasilar Dissection (<1 in 20,000)
  2. Lumbar Disk Herniation (<1 in 2 million)
  3. Cauda Equina Syndrome (<1 in 3 million)
  4. Death (<1 in 3 million)
  5. Nielsen (2017) Syst Rev 6(1): 64 [PubMed]
  6. Stevinson (2002) Am J Med 112(7): 566-71 [PubMed]
  7. Vohra (2007) Pediatrics 119(1): e275-83 [PubMed]

VI. References

  1. Smith (2019) Am Fam Physician 99(4): 248-52 [PubMed]

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