The Highs And Woes Of Manual Therapy

Manual therapy is not a specific treatment

The idea of specific manual treatment of individual joints achieved through specific and specialised handling methods is not supported by any credible evidence. In 2021, Nim et al., published a systematic review examining the effects of site-specific versus distal MT treatment on people presenting with spinal pain. They found no difference in pain or function either immediately post-treatment or in a follow-up period between treatments directed at the supposed area of irritation and those applied distally to the region, either on the contralateral side or distal vertebral segment. This has been consolidated in a meta-analysis published this year – an update for the one by Nim and colleagues – again reporting there is no difference between site of spinal mobilisation applied and improvement in pain when patients are followed up over a 12-month period (Sørensen et al., 2023).

This appears to hold true when applying different grades of pressure. One high-quality, sham-controlled RCT reported no difference in the improvement in pain between placebo versus high- or low-force posterior-anterior spinal mobilisations (Snodgrass et al., 2014). Backed by a more recent meta-analysis of 901 participants with persistent musculoskeletal pain, high-velocity low amplitude spinal mobilisations did not result in lower reported pain levels when compared to a sham-controlled technique (Aspinall et al., 2019) although the authors rated the overall body of evidence as being of low quality.

Importantly, they also highlighted the difficulty in deciphering whether the increase in PPT following spinal mobilisations was due to the treatment or environmental and contextual factors, even when only looking at high-quality studies.

Recent papers from prominent manual therapists have urged the need to abandon site-specific (structural) effects of manual therapy, instead presenting compelling evidence that all the effects on pain and function in the post-manipulation window can be attributed to neurophysiological changes. I would urge the reader to view the article by Bialosky et al., 2018 for a brilliant rundown of the different levels of the nervous system manipulations can influence. To sum it up in a sentence, the neurophysiological effects span from the level of the motor units all the way to the different processing areas in the brain like the rostral ventral medulla and periaqueductal grey region.

What is even more interesting is that as the method of scientific inquiry improves, our ability to measure different areas of the body (accurately) also gets better!

We are now beginning to see a plethora of research in animal models showing the neuroimmune response to manual therapy. These include reductions in markers of neuroinflammation and pro-inflammatory cytokines in the dorsal root ganglion along with increased nerve axon diameter and myelin sheath thickness (Schipholt et al., 2021). All these systemic responses that are now being observed support the widely found notion that manual therapy is NOT a specific treatment that must be applied in a specific area to gain a beneficial response.

We are all slightly wonky: the fallacy of accuracy in manual palpation

Everyone is built different. The morphological variations in skeletal make up and neurological anatomy are well documented. In a recent systematic review involving 43 practitioners and 364 patients, there was insufficient evidence that any single or combined technique was either reliable or accurate in the assessment of lumbo-pelvic landmarks when compared to imaging modalities (Alexander et al., 2021). The studies included reported accuracy ranged from 42 - 71% or a measurement error of 2.79mm to 4.60mm; propagation error was reported to be significant when moving over L5 to S2 further confounding the accuracy of manual methods (this is the effect of making an error, then making a further judgement of distance based on the current measurement, further conflating the error rate).

It would seem that doctors, chiropractors and physiotherapists have a really hard time targeting the vertebrae they believe they are prodding.

We all love to feel a stiff joint, give it a wiggle and get it going. Often the patient enjoys this too! Whilst this might work for peripheral joints like the knee, ankle or hip, believing we can feel a stiff spine is of questionable reliability. One recent paper reported that therapists were unable to determine differing levels of stiffness via digital palpation (Davidson et al., 2020) with another recent cross-sectional study surprisingly finding that individuals with low back pain reported higher levels of pressure pain thresholds (i.e. higher pressure before reporting an onset of pain) with increasing levels of spinal stiffness as assessed by a pressure inclinometer (Nimet al., 2021).

Other systematic reviews have highlighted problems in the poor reliability of passive physiological intervertebral movements and posterior anterior intervertebral movements (Stolz et al., 2020) highlighting that it is not possible to determine segmental stability independent of adjacent vertebrae due to interdependency of spinal segments.

So far, whilst hands on with a patient does appear to have meaningful benefits to the patient as we have seen above, our ability to be sure of the vertebrae with which we are treating is no better in many cases than flipping a coin!

The reliability of symptom modification procedures is poor!

In 2009 Jeremy Lewis introduced the shoulder symptom modification procedure to systematically address movement of the painful shoulder with a view to modifying movement to produce one that is not painful for the patient. They can then take this movement home with them and it forms their rehabilitation, over time the complexity and functionality of this can be adapted to the specific needs of the patient. Whether intentional or not, the SSMP has been applied in such a way that clinicians believe and patients are told, that the changes in pain are due to restorations or corrections of faulty or erroneous biomechanics.

Once again, reinforcing the structural view of pain! But there are two problems with this.

The first is that pain, as we are all aware is rarely due to faulty biomechanics. Pain also has high inter- and intra-person variability – this is a crucial point to the second argument of why this approach is questionable to use in practise. Let us say we have Joe Blogs who has had six months of insidious shoulder pain that is bloody irritable and he’s just about reached his wits end with it. You spend time in a session finding a movement that appears pain free, you stress that this must be pain free as we are addressing the underlying faulty movement pattern. He’s happy, you are happy. You send Joe home with the exercises to complete.

Life gets in the way, he doesn’t do them for a few days but then remembers he’s got these exercises he needs to do, so he does them. But they hurt… why? When he saw you they were fine, they didn’t hurt. But now they bloody do, he gets frustrated and irate as you have told him that the movement pattern had been altered to one that ‘fixed’ the faulty pattern that was causing his pain. He’s still got pain though, but the movement is different. The confusion sets in, then the despair. He is left feeling let down by the healthcare system – not to mention the confusion for you (the poor physio) who has got to rationalise in their own head why, when you next see him, the original pain free movement is now painful.

For a system that has been widely adopted there is comparatively little research on its validity and reliability!

But those that have looked at it show some real inconsistencies in the SSMP. The initial paper conducted by Jeremy Lewis in 2016 had a convenience sample of 11 participants – these participants were treated by Jeremy, the video consultations then used in the reliability analysis that involved 40 qualified physiotherapists who received either short (3 hour) or long (1 day) training on the SSMP. The paper reported that aside from internal rotation in flexion which had an α coefficient of 0.76, all other movements were ≥ 0.8, suggesting substantial reliability. This was later questioned by another research paper reporting that whilst inter-rater reliability was moderate (kappa = 0.47) the correlation with the SPADI tool from 1-week to 1 month against changes in SSMP scores was poor, of note the author stated that the threshold of 0.75 has been suggested for it to be of useful clinical utility in practise (Meakins et al., 2018).

Notwithstanding... these findings echo an earlier paper that found intra-rater reliability did not exceed 0.67 (kappa) and inter-rater ranged from 0.01-0.0.86 kappa, suggesting the tool is likely inappropriate for use in clinical practise if we accept the threshold of 0.75 previously suggested (Bahat et al., 2016).

Whilst one might be tempted to suggest the SSMP is not the same and push and poking on the spinous process of the L5 vertebrae, the underlying reasoning spouted is often the same – address the underlying “faulty tissue” or “stiff joint”. Prod it, poke it, wiggle it and combine this with enough positive expectation reinforcement about how this will free-up the vertebrae and the simple act of hands-on treatment and voila – the patient reports their pain has miraculously reduced.

There may indeed be a place for manual therapy, but it is not in the faulty tissue paradigm; the lack lustre of evidence suggesting we can accurately target a specific tissue should hopefully quell this. Instead, if using manual therapy with our patients we should be communicating that it is modulating the nervous system and that this can indeed be unreliable… so whilst it may reduce their pain today, if you send them away with a self-manipulation manoeuvre like a SNAG, it may not be as effective! Then the patient is informed appropriately and won’t end up flustered like our case Joe above.

You cannot change joint structure or orientation with any non-surgical intervention

We physios would rich if we had a pound every time a patient suggested their back pain is due to their pelvis being rotated or their vertebra being out of place. The madness does not stop there – when asked about prior treatments a great deal say how the chiropractor or physiotherapist, they were seeing would click their spine back into place for them and how good this was at alleviating their pain… for a few days… oh the power of the placebo effect!

But the idea that our body is out of alignment without any major trauma and that this is the cause of the pain is not well supported. Of course, there are exceptions – avascular necrosis, degenerative spinal conditions to name a few! Under such circumstances, the last thing the person needs is manual therapy… they need a sit down with an orthopaedic surgeon!

In a recent scoping review, four studies that examined the effects of non-surgical interventions on changes in anterior pelvic tilt (Brekke et al., 2020). Two were randomised control trials; one found no effect of 8 weeks of targeted hip and lumbar spine exercise, the other which used Rolfing (a myofascial release treatment), reported 1.7-degree reduction 24 hours post but did not include a follow-up beyond this time frame. Both used hand-held inclinometers to determine changes in angles when X-ray which is the gold standard. There exists no minimal clinically important difference and we have no idea of idea of the smallest detectable change that can be measured using the hand-held inclinometers, thus no clue if the change was simply noise in the system.

The SIJ – a joint which seems to bear the brunt of a lot of the maligned stigma is also often the target of manual therapy interventions. There is great contention as to if the SIJ can move but even if this is the case we (physiotherapists with your thumbs, hands and elbows…) cannot change its position! Multiple studies appear to confirm this. One found that high-velocity low amplitude movements applied to the SIJ did not alter its three-dimensional position as assessed using in a convenience sample of thirty healthy men (de Toledo et al., 2020). This is echoed in earlier findings by Tullberg et al., (1998). who applied 12 different techniques over the SIJ joint in 10 people with symptomatic SIJ pain, reporting that no change in three-dimensional position of the ilium relative to the sacrum was observed post treatment.

In idiopathic scoliosis, a recent systematic review found significant differences in the cobb angle following manual therapy interventions in adolescents up to two months after the intervention (Sun et al., 2023). But investigation of the included studies, the differences in the cobb angle between the experimental and control group were <1° with the small detectable change for cobb angle on x-ray being reported to be between 0.4° (Hurtado-Avilés et al., 2022) to 3.4°and a change in progression of 5% for it to be meaningful (ref scoliosis society) or 1 degree (Schreiber et al., 2019) suggesting that the changes reported in the recent review hold no clinical relevance and, in some studies, are below the SDC.

Manual therapy is a valuable treatment but only alongside active rehabilitation modalities

Yes, I believe for some people it has a place and is effective. There, I said it! But only if delivered alongside an active, well well-planned movement and exercise program geared around valued activities.

Why?

In 2019, it was estimated that 7% of the UK population was living with diabetes, with 40,000 of these children and a further one million with undiagnosed type II diabetes (T2DM) (Whicher et al., 2020). The recent NHS health survey undertaken in 2021 estimates that hypertension affects an estimated 1 in 3 people in the UK (Health Survey England, 2023) with almost ¾ of people aged 45 – 74 being overweight or obese (Health Survey for England, 2021).

I need not present any further evidence on the importance of structured exercise in the management of these conditions which forms a corner stone in the management of non-communicable diseases and considering many people see a physiotherapist in the UK annually, this is a massive opportunity for us to help with encouraging engagement with exercise.

So why, given the alarmingly high number of people who have non-communicable diseases, are we focusing on passive treatments that do not help manage the conditions? Advocates of manual therapy may rebuke this on the grounds that they “sprinkle” in their hands-on treatments alongside their exercise advice. But I really doubt they do, and in the event they do, we (collectively as a profession) are clearly still not doing enough to combat the lifestyle behaviours that are causing the statistics.

To take it further, the adherence to exercise interventions long term is incredibly poor. The classic example is pulmonary rehabilitation which has staggering non-adherence rates of 60% (Jones et al., 2014; Hayton et al., 2013) so let’s focus on getting better at the basics which coincidently are the things that are going to have the greatest effect on our patient’s long-term health.

On such grounds, I really struggle to see any rationale for passive hands-on treatments until we start getting the nations health in better order. Afterall, poking at sore spinous process or that stiff OA knee is going to do bugger all for Joe Blogs who has stage one hypertension and is pre-diabetic.

Instead, we should be having informed, motivational-interview style consultations to really identify what he values (activity-wise) and what the perceived barriers are to achieving this!

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References

Whicher, C. A., O’Neill, S., & Holt, R. G. (2020). Diabetes in the UK: 2019. Diabetic Medicine, 37(2), 242-247.

Date accessed 8th September 2023: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021-part-2/adult-health-hypertension

Date accessed 8th September 2023: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021/health-survey-for-england-2021-data-tables

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Sun, Y., Zhang, Y., Ma, H., Tan, M., & Zhang, Z. (2023). Spinal Manual Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. BioMed Research International, 2023.

Brekke, A. F., Overgaard, S., Mussmann, B., Poulsen, E., & Holsgaard-Larsen, A. (2022). Exercise in patients with acetabular retroversion and excessive anterior pelvic tilt: A feasibility and intervention study. Musculoskeletal Science and Practice, 61, 102613.

Brekke, A. F., Overgaard, S., Hróbjartsson, A., & Holsgaard-Larsen, A. (2020). Non-surgical interventions for excessive anterior pelvic tilt in symptomatic and non-symptomatic adults: a systematic review. EFORT open reviews, 5(1), 37.

de Toledo, D. D. F. A., Kochem, F. B., & Silva, J. G. (2020). High-velocity, low-amplitude manipulation (HVLA) does not alter three-dimensional position of sacroiliac joint in healthy men: a quasi-experimental study. Journal of Bodywork and Movement Therapies, 24(1), 190-193.

Tullberg, T., Blomberg, S., Branth, B., & Johnsson, R. (1998). Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine, 23(10), 1124-1128.

Schreiber, S., Parent, E. C., Hill, D. L., Hedden, D. M., Moreau, M. J., & Southon, S. C. (2019). Patients with adolescent idiopathic scoliosis perceive positive improvements regardless of change in the Cobb angle–Results from a randomized controlled trial comparing a 6-month Schroth intervention added to standard care and standard care alone. SOSORT 2018 Award winner. BMC musculoskeletal disorders, 20(1), 1-10.

Lewis, J. S., McCreesh, K., Barratt, E., Hegedus, E. J., & Sim, J. (2016). Inter-rater reliability of the Shoulder Symptom Modification Procedure in people with shoulder pain. BMJ Open Sport & Exercise Medicine, 2(1), e000181.

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Davidson, M. J., Nielsen, P. M., Taberner, A. J., & Kruger, J. A. (2020). Is it time to rethink using digital palpation for assessment of muscle stiffness?. Neurourology and urodynamics, 39(1), 279-285.

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Stolz, M., von Piekartz, H., Hall, T., Schindler, A., & Ballenberger, N. (2020). Evidence and recommendations for the use of segmental motion testing for patients with LBP–A systematic review. Musculoskeletal Science and Practice, 45, 102076.

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Aspinall, S. L., Leboeuf-Yde, C., Etherington, S. J., & Walker, B. F. (2019). Manipulation-induced hypoalgesia in musculoskeletal pain populations: a systematic critical review and meta-analysis. Chiropractic & Manual Therapies, 27(1), 1-19.

Schipholt, I. J. L., Coppieters, M. W., Meijer, O. G., Tompra, N., de Vries, R. B., & Scholten-Peeters, G. G. (2021). Effects of joint and nerve mobilisation on neuroimmune responses in animals and humans with neuromusculoskeletal conditions: a systematic review and meta-analysis. Pain reports, 6(2).

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