Manipulation therapy involves the use of human touch or mechanical devices to improve body movement. Manipulation therapy is used to treat a variety of injuries, conditions and diseases such as back pain, neck pain, shoulder pain, headaches, arthritis and fibromyalgia.

The many types of manipulation therapy include chiropractic medicine, massage therapy, osteopathic medicine and acupressure.

Before therapy, a practitioner may conduct a physical examination and review the patient's medical history and list of medications. Patients may be asked to describe their pain symptoms.

Potential benefits of manipulation therapy include relief of pain and improvement in mobility and function. There are few risks associated with most types of manipulation therapy. However, some patients may experience no improvement or an increase in their pain. In rare cases, manipulation of the cervical spine has resulted in stroke.

Many people turn to manipulation therapies when they cannot alleviate pain with traditional medical therapies. Although there is little documented risk associated with manipulation therapy, few clinical trials have been performed to evaluate the effects of most types of manipulation therapy.

Many types of manipulation therapy are considered complementary and alternative medicine (CAM). Complementary therapies are those that are used in addition to mainstream treatments, such as medication or surgery. Alternative therapies are those that are used in place of mainstream treatments. CAM therapies are holistic, meaning they are aimed at treating the whole person – mind, body and spirit. Patients are advised to consult their physician before beginning manipulation therapy or any other form of CAM.

Some professions that incorporate manipulation therapy are not alternative or complementary. For example, the American Academy of Osteopathy emphasizes that osteopathic medicine is a complete, well-established, primary system of medical care.

Manipulation therapy focuses on the structures and systems of the body, such as the bones, joints, soft tissues and the circulatory, lymphatic and nervous systems. It is based on the belief that body parts are interdependent and that, with proper guidance, the human body often has the ability to heal itself. The goal of manipulation therapy is to facilitate the natural healing process.

In the United States, manipulation therapy is practiced by chiropractors, osteopathic physicians, massage therapists, acupressurists and other types of practitioners. Physical therapists and occupational therapists may also incorporate aspects of it. The approach to treatment varies widely among individual practitioners, as does the training received.

According to the National Center for Complementary and Alternative Medicine, between 3 percent and 16 percent of adults receive chiropractic treatment within a given year and between 2 percent and 14 percent receive some type of massage therapy.

Manipulation therapy is used to treat many types of pain, including:

• Injuries. Sprains, strains, dislocations, fractures and other traumatic injuries are sometimes treated with manipulation therapy. It may be used in addition to other types of treatments such as immobilization, medications and physical therapy.
  
  
• Back pain. This is one of the most common medical conditions in the United States and other Western nations. Patients often receive chiropractic treatment for conditions such as herniated discs.

• Neck pain. Most conditions affecting the neck cause pain and stiffness along the base and sides of the neck. However, problems with the structures of the neck can also cause pain over the top of the head (tension headache), over the upper back (neck strain and fibromyalgia) or over the shoulder (neck strain or a pinched nerve in the neck). A common source of neck pain that may be treated with manipulation therapy is whiplash.
  
  
• Arthritis. A group of more than 100 conditions involving pain in the joints. Types of arthritis treated by manipulation therapy include:
  
• • Osteoarthritis
  • Rheumatoid arthritis
  • Ankylosing spondylitis

• Shoulder pain. Frozen shoulder is a term used to describe a stiff shoulder joint with decreased range of motion. Other painful shoulder conditions include injuries to the rotator cuff (the muscles that attach by tendons to the upper arm bone) and shoulder impingement syndrome, which results from compression of the rotator cuff tendons and subacromial bursa (a fluid-filled sac that separates bones in the shoulder joint).
  
  
• Tendinitis (inflammation of a tendon). The most common cause of tendinitis is overuse.
  
  
• Bursitis (inflammation of a bursa). Bursae are fluid-filled sacs that function as gliding surfaces to reduce friction between the tissues of the body. There are 160 bursae in the body, located in areas such as shoulders, elbows, hips and knees.
  
  
• Headaches. Types of headaches include tension headaches (sometimes described as a tight band around the head), migraines (characterized by throbbing pain and other symptoms, such as nausea) and cluster headaches (characterized by excruciating, piercing pain on one side of the head).

• Carpal tunnel syndrome. Involves pain or numbness caused by compression of a nerve in the wrist. It is the most common nerve entrapment disorder.
  
  
• Fibromyalgia. A chronic pain condition characterized by musculoskeletal aches, pain and stiffness, soft tissue tenderness, general fatigue and sleep disturbances.
  
  
• Complex regional pain syndrome. Pain that may occur after an injury to the arm or leg. It is often described as a burning sensation and is much worse than anticipated for the injury.
  
  
• Myofascial pain syndrome (MPS). Chronic condition that affects the fascia (connective tissue that covers the muscles). MPS may involve a single muscle or a group of muscles. It may be caused by injury or excessive strain in various areas of the body.
  
  
• TMJ disorder. The temporomandibular joints connect the lower jawbone (mandible) to the skull. These joints are used more than any other joint in the body and can become damaged through means ranging from infection to stress.
  
  
• Other sources of joint pain or muscle pain.

There are many types of manipulation therapy. They include:

• Chiropractic medicine. Concentrates on musculoskeletal and neuromuscular disorders and their effect on the rest of the body. Chiropractic medicine is based on the belief that misaligned vertebrae can affect the spine’s range of motion and the nerves radiating from the spine. As a result, the organs served by these nerves may function improperly or become diseased. Spinal realignment may restore range of motion and improve nerve and organ function.
  
  
• Osteopathic medicine. A holistic form of medicine that emphasizes repairing structural imbalances and preventive care. Osteopathic physicians try to maintain correct relationships between bones, muscles and connective tissues. Practitioners sometimes use osteopathic manipulative treatment (OMT), in which they use their hands to apply force in an effort to treat structural abnormalities. Unlike chiropractic medicine, however, osteopathy also embraces medication and surgery. Patients who see an osteopathic physician often use this practitioner as their primary care physician for a broad range of conditions and concerns.
  
  
• Massage therapy. Incorporates techniques involving manipulation of the soft tissues of the body through pressure and movement. This is sometimes used in combination with medications to treat pain. Practitioners may massage the entire body or a specific body part (e.g., the back, feet or hands). Massage helps patients relax and distracts attention away from pain. The many forms of massage therapy include Swedish massage (applies strokes, kneading and friction to muscles and active and passive movements of joints), shiatsu (an Oriental method based on the idea that energy flows through the body in meridians and that blockage of these channels causes disorders), trigger point therapy (concentrates on tender or irriated areas of muscle) and deep tissue massage (uses slow strokes and greater finger pressure to release tension from deeper muscles).
  
  
• Acupuncture. Procedure adapted from Chinese medicine in which specific body parts are pierced with fine needles to relieve pain.
  
  
• Acupressure. Application of pressure to specific points of the body to control pain. It is similar to acupuncture but does not involve needles.
  
  
• Alexander technique. Aims to identify improper movements and correct them. The patient is educated and guided in ways to improve posture and movement to use muscles efficiently.
  
  
• Ayurveda. Traditional holistic healthcare system of India, emphasizing the mind-body connection and incorporating techniques such as touch, sound, aroma and nutritional therapy.
  
  
• Bowen technique. Gentle massage of muscles and tendons over acupuncture and reflex points. By gently touching and moving certain parts of the body, the body is re-energized and able to heal itself.
  
  
• Craniosacral therapy. Uses gentle hand and finger touch, movement and pressure of the skull plates. The craniosacral system is composed of the membranes and cerebrospinal fluid that surround and protect the brain and spinal cord. Craniosacral therapy claims to remove abnormalities or blockages that prevent the cerebrospinal fluid from moving properly. Several studies have not demonstrated any benefit from this type of therapy.
  
  
• Feldenkrais method. Technique that educates patients about improving movement and enhancing overall body function. Through this method, patients may improve range of motion and flexibility, and discover the innate capacity for efficient movement. The improvements in movement may enhance the patient’s functioning in other aspects of daily living.
  
  
• Jin Shin Tara. An acupressure-like treatment that originated in Japan, has been used to address trauma pain and, according to the U.S. National Institutes of Health, is being studied for possible use in stroke rehabilitation.
  
  
• Manipulation under anesthesia. Uses a combination of manipulations, passive stretches and maneuvers to break up fibrous adhesions and scar tissue around the spine and surrounding tissue. It can be performed under general anesthesia, with a mild sedative or after anesthetic solutions are injected into tissues of the spine.
  
  
• Myofascial release. Attempts to end pain and restore joints’ range of motion through gently stretching that may resolve restrictions on fascia, a type of connective tissue that covers organs, muscles and other soft internal structures.
  
  
• Naprapathy. System that tries to ease pain by manually manipulating connective tissue that may be irritating nerves.
  
  
• Naturopathic medicine. A holistic form of medicine that emphasizes prevention and incorporates techniques including acupuncture, manipulation therapy, nutrition, herbs and counseling.
  
  
• Reflexology. Technique based on the principle that there are reflexes in the feet and hands that correspond to every body part. By stimulating and applying pressure to the hands or feet, circulation is increased and specific bodily and muscular function is believed to be improved.
  
  
• Rolfing. Involves deep tissue massage. Also called structural integration, Rolfing is not a cure for a particular disease or physical ailment, but a systematic approach that tries to restore balance to the entire body.
  
  
• Trager bodywork. Gentle rocking and shaking of the patient’s trunk and limbs in a rhythmic fashion. It is aimed at promoting relaxation and increasing mobility and mental clarity. It is used by athletes for performance enhancement or patients with musculoskeletal and back problems.
  
  
• Tuina. Application of pressure with the fingers and thumbs and manipulation of acupressure points in the body. This has been used in China for 2,000 years. It is based on the principle that massage and manipulation techniques can help the body heal itself. Tuina (also called tui na) is similar to acupressure, but includes both pressure and movement at pressure points, whereas acupressure is static.
  
  
• Traction. A procedure in which a mechanical device is used to correct fractures or dislocated bones, overcome muscle spasms or relieve pressure. Traction can be used to treat problems in the spine, arms, legs or neck. It is sometimes used as part of a chiropractic treatment.
  
  
• Zero balancing. Incorporates massage and gentle positioning of the body in an effort to balance the body’s structures with internal energy.

Patients do not need a referral from an M.D. (doctor of medicine) to see some practitioners of manipulation therapy, such as an osteopathic physician or a chiropractor. Depending on insurance coverage and location, individuals may need a referral for some other practitioners.

The practitioner often begins by reviewing the patient’s medical history (including a list of medications) and conducting a physical examination.

Patients may be asked to describe the pain in a pain assessment. They may be given a diagram of the body and asked to mark areas where they are experiencing pain. Questions to assess the pain may include:

• Can you describe the pain?
• Where does the pain occur?
• How long have you experienced the pain?
• Have you experienced this type of pain in the past?
• Is the pain constant or does it come and go?
• Are there any movements that make the pain worse?
• Do you have limited movement?

Manipulation therapy sessions vary widely according to the type of treatment technique used. With most treatments, patients have numerous visits over a period of time.

Some practitioners, such as chiropractors, may use modalities (physical agents) such as thermotherapy, cryotherapy or electrical therapy. Many therapies include preventive techniques in which patients learn special exercises or other methods to prevent pain in the future.

Manipulation therapy has several potential benefits. They include:

• Some patients may experience pain relief.
  
  
• Some types of manipulation therapy include education, so patients may learn about their condition.
  
  
• Some patients experience improved range of motion, strength, coordination, balance and function.
  
  
• Some types of manipulation therapy are aimed at preventing pain. Therefore, some patients are able to avoid future pain.

There are also certain risks associated with some types of manipulation therapy. They include:

• Chiropractic manipulation of the spine may result in pain or discomfort, but side effects are usually mild and ease within days.
  
  
• In rare cases, manipulation of the cervical spine has resulted in stroke or tearing (dissection) of an artery, which may also cause a stroke.
  
  
• Massage therapy usually does not have side effects, but there are some patients who should not be treated with massage. They include individuals with deep vein thrombosis (blood clot in the legs), burns, skin infections, eczema, open wounds, fractures and advanced osteoporosis.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about manipulation therapy:

1. What is manipulation therapy, and how can it help me?
   
   
2. What types of manipulation therapy are there, and how do they affect my body?
   
   
3. How effective are the different types of manipulation therapy at treating my condition?
   
   
4. What type of manipulation therapy should I receive to treat my pain?
   
   
5. Is the technique recommended for me an addition to or a replacement for mainstream medicine?
   
   
6. What are the potential benefits and side effects of manipulation therapy for me?
   
   
7. Do you recommend a particular therapy center or therapist for me?
   
   
8. How long should it be before I see results?
   
   
9. Am I likely to find manipulation therapy painful?
   
   
10. What should I do if I still ache a few days after a session?