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Manual therapies include spinal manipulation, joint mobilization, and massage. Spinal manipulation is most commonly practiced by chiropractors. These approaches are generally designed to increase range of motion of the joints and relieve musculoskeletal pain.
Spinal manipulation and mobilization involve positioning and moving a joint within or beyond the normal range of motion. In 1994, the United States Agency for Health Care Policy and Research (AHCPR) issued a clinical practice guideline that concluded that manipulation could be useful for acute low back pain, if used within the first month of symptoms. Evidence for benefit in acute low back pain is much stronger than for chronic pain (Shekelle, 1992; Bronfort, 1999). In addition, studies suggest that manipulation and mobilization are beneficial in the management of acute and subacute neck pain and muscle tension headache (Hurwitz, 1996). More research is needed to further clarify the types of pain that might benefit from this kind of therapy, the optimal timing of therapy in order to achieve maximal benefit, and the duration of benefits.
Overall, the side effects of spinal manipulation are rare. Mild, transient effects include discomfort, fatigue, headache, and sometimes nausea and dizziness. Serious adverse events are rare, with estimates varying from one complication per one million visits (Newswanger, 2000) to between three and six per ten million (Kaptchuk, 1998). When serious complications have occurred, they have more often involved cervical or neck adjustments: concern over rare but possible spinal cord injury with manipulations continue to worry some clinicians. Certainly the training and patient selection of therapists using these approaches is crucial.
Spinal manipulation should be performed only by licensed practitioners, either a chiropractor or osteopathic physician. The main premise of chiropractic is that spinal manipulation results in improved spinal mobility that supports the integrity of the joint cartilage and intervertebral disks. There is evidence that it can reduce muscle spasm and alleviate spinal nerve root compression. There are two categories of adjustments, low-velocity and high velocity. Low velocity adjustments apply slow stretching, pulling, compression or pushing forces. High-velocity techniques apply firm contact pressure, move the selected joint to its end range of motion and then deliver a quick manual thrust in a precise direction in order to increase joint mobility. Some chiropractic techniques are low force or non-force (where no "clicking" or release sound is heard). These chiropractic techniques also can be effective for pain. In addition to manipulation, chiropractic care will often include various soft-tissue techniques, ergonomic advice (the safe use of the body in relation to its environment, such as work conditions), and rehabilitative exercises.
The main premise of osteopathy is that the primary role of the physician is to facilitate the body's inherent ability to heal itself. Osteopathic physicians use standard methods of diagnosis and treatment, but place additional emphasis on the achievement of normal body mechanics as central to good health. Because of the close association between the spinal vertebrae and the autonomic nervous system, the neuromuscular system is considered to play a vital role in maintaining the body's internal system of balance. Osteopathic manual therapy includes spinal manipulation and techniques that work on the soft tissue (the fascia that connects bone and muscle) to effect changes that may be deeper and last longer (Lesho, 1999). Osteopathy uses low velocity maneuvers to "mobilize" regions of the spine. The maneuvers are not as specific as chiropractic adjustments and are not done with the express purpose of restoring neurological function but to increase range of motion.
Massage can be beneficial in the treatment of depression and various pain syndromes (Field, 2002; Hurley, 2001; Cherkin, 2001; Ernst, 1999). There are many different forms of massage therapy from both the Eastern and Western traditions. These include Swedish massage, acupressure/shiatsu, deep tissue massage, reflexology and many others. Massage appears to have a number of beneficial physiologic effects, including increased local blood flow, improved lymph drainage and activation of pain suppression mechanisms. These may contribute to tissue repair, pain reduction, relaxation and improved mood state (Wright, 2001). In addition massage can lead to decreased stress as evidenced by decreased cortisol, improved sleep patterns and enhanced immune function, all of which can lead to improvements in pain. More research is needed to further clarify its use for pain management.
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