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Year : 2021  |  Volume : 3  |  Issue : 2  |  Page : 121-125

An educative overview on manipulative therapy

Department of physiotherapy, Sardar Bhagwan Singh University, Dehradun, Uttarakhand, India

Date of Submission29-Nov-2021
Date of Decision13-Dec-2021
Date of Acceptance18-Dec-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Prof. Maneesh R Arora
Sardar Bhagwan Singh University, Dehradun - 248 001, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_75_21

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Physiotherapists, chiropractors, and osteopaths utilise manual therapy to treat musculoskeletal pain and dysfunction. It is a structured approach to giving hands-on physical treatment within a biopsychosocial framework. Many different hand-on treatments fall under the umbrella of manual therapy. Physical therapists have greatly contributed to the current diversity in manual therapy approaches and techniques. This article on continuing physiotherapy education gives an educative overview to the students and professionals about manual therapy or manipulative therapy.

Keywords: Manual therapy, Dysfunction, Fixation

How to cite this article:
Arora MR. An educative overview on manipulative therapy. Indian J Phys Ther Res 2021;3:121-5

How to cite this URL:
Arora MR. An educative overview on manipulative therapy. Indian J Phys Ther Res [serial online] 2021 [cited 2023 Jun 6];3:121-5. Available from: https://www.ijptr.org/text.asp?2021/3/2/121/335673

Phillip E. Greenman wrote in his book that manipulative therapy is one of the means of correcting somatic dysfunction. Just as different types of antibiotics are used to treat various infections, different approaches are used to correct various types of somatic dysfunctions.[1] These include manipulations, mobilizations, movement with mobilization (MWM), functional exercises, soft tissue releases, dry needling, and core exercises.

Somatic dysfunction is a diagnostic term that refers to the interruption or disruption of numerous components of the body framework system, such as skeletal, articular, myofascial structures, as well as its related circulatory, lymphatic, neurological, and other structures. It is most commonly caused by postural deviations that repeatedly occur during daily activities and at work or by sudden traumatic movements resulting from a slip or fall. Since the cause of somatic dysfunction can be multifactorial, the means to restore the somatic function has to have a wider framework of interventions. Below is an attempt to make one understand the various models of clinical management which help in treating somatic or musculoskeletal dysfunction.

The clinical management of somatic dysfunctions can be explained with four theories or models.[2] Pain modulation theory is related to the neurophysiological basis of pain with an underlying inflammatory cause and thus works on pain gate mechanism. As per the biomechanical theory, pain is related to a structural or an anatomical source, with a defined etiology, resultant pathological process, and precise diagnostic labeling. The psychosocial model includes theories related to patients' cognitions, emotions, attitudes, coping strategies, and sociological factors. According to chronic pain and pain sensitization model, peripheral and central sensitization is associated with autonomic mechanisms of pain.

In his book, Robin McKenzie emphasized that most pain presentations of musculoskeletal origin are temporary and self-limiting in nature, and all that is needed is assurance to the body that it is all getting better. Statistically, it was proven that 44% of patients with nonspecific back pain recovered within 1 week of onset of low back pain (LBA), and 86% of patients recovered within 1 month.[3] However, it has been observed that if the myofascial or articular etiologies that caused the dysfunction to appear persist, the dysfunction will return and augment and intensify the degenerative processes in the system. Therefore, improving the musculoskeletal, articular flexibility and stability will offer a more permanent and radical solution, as shown in [Figure 1] with dotted lines.
Figure 1: Myofascial pain with respect to time, stress and interventions

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  What is Manipulative Therapy? Top

Manipulative therapy is the mode of therapeutic intervention which is practiced by various healthcare providers such as physiotherapists, chiropractors, and osteopaths so as to treat musculoskeletal pains and disability.[4] These techniques are drug-free, nonsurgical methods that can be used to reduce pressure in articulations, improve range of motion, reduce muscle imbalance, promote lymphatic drainage, decrease inflammation, and augment nervous flow to the tissue. Spinal manual therapy has been proven to be more successful than a variety of comparable treatments in the treatment of low back pain.[5]

  Types of Manipulation Top

Osteopaths developed long-lever techniques, also called low-velocity high-amplitude techniques. In long-lever techniques, thrust or manipulation is delivered in nonspecific manner not directly to the vertebra – for example, through the shoulder, ilium, or scapular area. During this type of manipulation, for example lumbar roll, the therapist passively moves many of the vertebral joints simultaneously within their range of motion to produce the cavitation in long-lever manipulation.

Chiropractors developed the short-lever manipulation, also known as high-velocity low-amplitude (HVLA) manipulation, and this involves a low-amplitude thrust applied at a contact point on a specific area, such as spinous process, lamina process, or mammillary process, of a chosen lumbar vertebra. During this maneuver, the therapist delivers a rapid rotating force to the overlying skin tissue of the afflicted joint at an angle of around 90° during this maneuver.

The purpose of the manipulation is to remove the joint hypomobility or, in other words, its fixation or misalignment. A good manual therapist by various evaluative procedures will first find a fixation and then manipulate it to restore pain-free joint function.

A fixated joint is one that is not just misplaced in a bad posture, but also no longer has the ability to move in one or more directions without pain. It does not return to neutral automatically; instead, it remains struck.

The causes of these fixations can be:

  1. Trauma that results in:

    1. Slipping of nucleus pulposus of the intravertebral disc in one direction
    2. Edema infiltration that irritates the fibrous joint capsule
    3. Ligamentous contractions or adhesions.

  2. Muscular imbalances might be a risk factor for several conditions.

This biomechanical malpositioning results in the generation of pain and tissue changes.

Muscular imbalances can slowly lead to joint misalignment and thus fixation.

These fixations or positional faults not only produce somatic dysfunctions but can also impose functional limitation that inhibits fascial motion and causes broad dysfunction, as well as visceral dysfunction and, as a result, would lead to loss of overall health [Figure 2].
Figure 2: Myofascial imbalance and articular fixations

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  How to Find These Fixations? Top

Interexaminer reliability studies demonstrate that the typical methods of motion palpation, as well as additional methods such as functional leg length assessment, applied kinesiology, and passive intervertebral movements, are considered to be reasonably accurate. However, tenderness and tissue-asymmetry-restriction-tenderness (TART) techniques have the highest intertester dependability.[6] X-ray evidence of these fixations appears to be a promising method of recording these fixations.

Pain and tenderness alone are not very good indicators of fixations as they can be due to some pathologies or inflammations; tenderness assessment and more specifically application of TART principle can be considered for confirmation along with other methods to locate a fixation.

  1. TART

  2. Osteopathic world has given a useful sequence for assessing a misaligned area by means of palpation.[7]

    1. Tissue texture abnormality, i.e., difference in temperature, fascial glides asymmetrical, etc.
    2. Asymmetry ascertained by palpation, as well as during motion, and tone appraisal

      1. In static palpation in terms of position of bones
      2. Asymmetry observed during motion of bones.
      3. Functional asymmetry

    3. Restriction of normal motion

    4. To be appreciated in terms of quality of movement and range of motion or end feel.

    5. Tenderness

    Pain provocation resulting in the reproduction of familiar symptoms.

    Other methods which have good reliability and validity are also used apart from TART principles to find these fixations.[8]

  3. Passive motion palpation is best defined as the motion palpation challenge of an articulation without the influence of weight-bearing.

  4. As per the concept of Bind and Ease, if the joint is fixated, i.e., it has crossed the barrier, it can easily move on the same side but cannot move to the opposite side. Example, when the joint has got fixated to the left side, it can still be moved to the left side but cannot move the right side, i.e., it is restricted in its motion to the opposite side of fixation. This is an important diagnostic tool in not only finding the joint that has fixated but also finding the direction of its fixation [Figure 3].
    Figure 3: Restriction of motion in joint accessory movement

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  5. Functional leg length

Leg length testing and analysis is another method performed for determining the presence of mechanical faults in various regions of the body. It is used in prone or supine.

Observations and interpretations of changes in apparent leg length guide the practitioner to find the presence of articular dysfunction or misalignment in various regions of the body. It is said to be reliable and a valid tool in finding the fixations.[9]

Once a fixation is found and there are no contraindications, treatment techniques can be applied based on the skillset acquired by the clinician. The mechanical effects of manual therapy include the restoration of tissue extensibility and range of motion of hypomobile joints.

The techniques that are commonly employed are:

  • Manipulations i.e., HVLA
  • Mobilization/MWMs
  • Bone adjustors
  • Drop tables.

Low-amplitude and high-velocity manipulations

All manipulations are carried at the elastic barrier but before the anatomical barrier. There is very little room between the elastic and anatomical limit called as paraphysiological space, and going beyond, the anatomical limit will cause an injury or permanent damage, so a low amplitude thrust is required. Further, because if you slowly cross the elastic barrier, the stretch reflex of the intrafusal fibers will increase the tone in the muscles which control it and this will offer counter resistance, so high velocity is used [Figure 4].
Figure 4: Barriers to motion

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Audible sound or click, though usually accompanies the manipulation, is not the key for overcoming fixations.

Flynn et al. compared the effects of a lumbopelvic manipulation in patient who had an audible joint sound with the manipulation and with those who did not have it. They reported no difference in outcomes (disability, pain, lumbar flexion, and active range of motion) between patients who had an audible pop with the manipulation and those who did not. The beneficial effects of manipulation do not appear to be dependent on the production of a joint sound.[10]

To facilitate the ease of these corrections, some tools such as bone adjustors can also be used, popularly known as adjustor. Physiotherapists also call this as PIM, i.e., Physiotherapy Instrument for Mobilization [Figure 5] and [Figure 6]. It works on the simple principle of physics: force = mass × acceleration.
Figure 5: Physiotherapy instrument for mobilization. Being used for posterior innominate fixation

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Figure 6: Physiotherapy instrument for mobilization

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In a normal high-velocity slow-amplitude, we need to apply a lot of body weight because whatever high velocity we use it cannot match a spring-loaded device's acceleration. The PIM or adjuster uses a lot of less mass because the acceleration is very high as the entire thrust is achieved in less than 3 ms.

Similarly, drop tables that have end barriers to restrict motion are used by chiropractors to correct the fixation. Their little movement play allows a very safe and purposeful correction even for those healthcare providers who are not able to generate sufficient safe and high-velocity force required for manipulations [Figure 7].
Figure 7: Drop table for manipulation

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Manual therapy or manipulative therapy is a physical treatment primary used by physiotherapist, chiropractitioners, and osteopaths to treat musculoskeletal pain and disability. Recent research indicates complex neurophysiologic mechanisms and psychological effects of manual therapy intervention. Hence, manipulative therapy is an evidence-based, structured, and skillful hands-on approach delivered by the physiotherapy professionals within a biopsychosocial context.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Greenman P. Principles of Manual Medicine. 3rd ed. United States: Lippincott Williams and Wilkins; 2003.  Back to cited text no. 1
Smart K, Doody C. The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Man Ther 2007;12:40-9.  Back to cited text no. 2
Dixon AS. Diagnosis of low back pain-sorting the complainers. The Lumbar Spine and Back Pain. New York. Grune and Stratton. 1976:77-92.  Back to cited text no. 3
Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain: An update of a Cochrane review. Spine (Phila Pa 1976) 2011;36:E825-46.  Back to cited text no. 4
Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A. A meta-analysis of clinical trials of spinal manipulation. J Manipulative Physiol Ther 1992;15:181-94.  Back to cited text no. 5
Dishman RW. Static and dynamic components of the chiropractic subluxation complex: A literature review. J Manipulative Physiol Ther 1989;12:152.  Back to cited text no. 6
McPartland J, Goodridge J. Counterstrain and traditional osteopathic examination of the cervical spine compared. J Bodyw Mov Ther 1997;1:173-8.  Back to cited text no. 7
French SD, Green S, Forbes A. Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low-back pain. J Manipulative Physiol Ther 2000;23:231-8.  Back to cited text no. 8
Cooperstein R, Lew M. The relationship between pelvic torsion and anatomical leg length inequality: A review of the literature. J Chiropr Med 2009;8:107-18.  Back to cited text no. 9
Flynn TW, Childs JD, Fritz JM. The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain. J Manipulative Physiol Ther 2006;29:40-5.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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