Manipulative and Body-Based Practices: An Overview-NCCAM

Introduction
Under the umbrella of manipulative and body-based practices is a heterogeneous group of CAM interventions and therapies. These include chiropractic and osteopathic manipulation, massage therapy, Tui Na, reflexology, rolfing, Bowen technique, Trager bodywork, Alexander technique, Feldenkrais method, and a host of others

Manipulative and body-based practices focus primarily on the structures and systems of the body, including the bones and joints, the soft tissues, and the circulatory and lymphatic systems. Some practices were derived from traditional systems of medicine, such as those from China, India, or Egypt, while others were developed within the last 150 years (e.g., chiropractic and osteopathic manipulation).

Although many providers have formal training in the anatomy and physiology of humans, there is considerable variation in the training and the approaches of these providers both across and within modalities. For example, osteopathic and chiropractic practitioners, who use primarily manipulations that involve rapid movements, may have a very different treatment approach than massage therapists, whose techniques involve slower applications of force, or than craniosacral therapists. Despite this heterogeneity, manipulative and body-based practices share some common characteristics, such as the principles that the human body is self-regulating and has the ability to heal itself and that the parts of the human body are interdependent. Practitioners in all these therapies also tend to tailor their treatments to the specific needs of each patient.


Clinical Studies: Mechanisms

Biomechanical studies have characterized the force applied by a practitioner during chiropractic manipulation, as well as the force transferred to the vertebral column, both in cadavers and in normal volunteers.8 In most cases, however, a single practitioner provided the manipulation, limiting generalizability. Additional work is required to examine interpractitioner variability, patient characteristics, and their relation to clinical outcomes.

Studies using magnetic resonance imaging (MRI) have suggested that spinal manipulation has a direct effect on the structure of spinal joints; it remains to be seen if this structural change relates to clinical efficacy.

Clinical studies of selected physiological parameters suggest that massage therapy can alter various neurochemical, hormonal, and immune markers, such as substance P in patients who have chronic pain, serotonin levels in women who have breast cancer, cortisol levels in patients who have rheumatoid arthritis, and natural killer (NK) cell numbers and CD4+ T-cell counts in patients who are HIV-positive.9 However, most of these studies have come from one research group, so replication at independent sites is necessary. It is also important to determine the mechanisms by which these changes are elicited.


Clinical Studies: Trials
Forty-three clinical trials have been conducted on the use of spinal manipulation for low-back pain, and there are numerous systematic reviews and meta-analyses of the efficacy of spinal manipulation for both acute and chronic low-back pain.10-14 These trials employed a variety of manipulative techniques. Overall, manipulation studies of varying quality show minimal to moderate evidence of short-term relief of back pain. Information on cost-effectiveness, dosing, and long-term benefit is scant. Although clinical trials have found no evidence that spinal manipulation is an effective treatment for asthma,15 hypertension,16 or dysmenorrhea,17 spinal manipulation may be as effective as some medications for both migraine and tension headaches18 and may offer short-term benefits to those suffering from neck pain.19 Studies have not compared the relative effectiveness of different manipulative techniques.

Risks
There are some risks associated with manipulation of the spine, but most reported side effects have been mild and of short duration. Although rare, incidents of stroke and vertebral artery dissection have been reported following manipulation of the cervical spine.22 Despite the fact that some forms of massage involve substantial force, massage is generally considered to have few adverse effects. Contraindications for massage include deep vein thrombosis, burns, skin infections, eczema, open wounds, bone fractures, and advanced osteoporosis.21,23

Patient Satisfaction
Although there are no studies of patient satisfaction with manipulation in general, numerous investigators have looked at patient satisfaction with chiropractic care. Patients report very high levels of satisfaction with chiropractic care.27,28,31 Satisfaction with massage treatment has also been found to be very high.30


Definitions
Alexander technique: Patient education/guidance in ways to improve posture and movement, and to use muscles efficiently.

Bowen technique: Gentle massage of muscles and tendons over acupuncture and reflex points.

Chiropractic manipulation: Adjustments of the joints of the spine, as well as other joints and muscles.

Craniosacral therapy: Form of massage using gentle pressure on the plates of the patient's skull.

Feldenkrais method: Group classes and hands-on lessons designed to improve the coordination of the whole person in comfortable, effective, and intelligent movement.

Massage therapy: Assortment of techniques involving manipulation of the soft tissues of the body through pressure and movement.

Osteopathic manipulation: Manipulation of the joints combined with physical therapy and instruction in proper posture.

Reflexology: Method of foot (and sometimes hand) massage in which pressure is applied to "reflex" zones mapped out on the feet (or hands).

Rolfing: Deep tissue massage (also called structural integration).

Trager bodywork: Slight rocking and shaking of the patient's trunk and limbs in a rhythmic fashion.

Tui Na: Application of pressure with the fingers and thumb, and manipulation of specific points on the body (acupoints).

Ref#: http://nccam.nih.gov/health/backgrounds/manipulative.htm#def