Massage, Traction, and Manipulation

Massage, Traction, and Manipulation  MASSAGE Worldwide, various forms of massage, traction, and manipulation have been used for several thousand years. Each modality represents a treatment for pain, and steadily increasing numbers of people are seeking these treatments. Although research on each of these approaches or modalities continues, a long-standing variable unites them all, that is, the concept of touch. In the 1940s, Rene Spitz reported on infants in foundling home who, though they were otherwise healthy and well taken care of, failed to thrive and often died in the absence of being held or touched. Kunz and Krieger additionally defined and taught the principles behind the related concepts of healing touch and therapeutic touch in the 1970s. Although no consensus exist regarding the complete physiology of massage, traction, or manipulation, these treatment approaches are generally thought to involve more than just the interaction of mechanical forces and human anatomy. The history of touch as a natural and essential component of healing and health maintenance is long. Throughout history, massage has been woven into the cultural context of medicine. Massage consists of both Eastern and Western variants. In the West, the practice and popularity of massage has varied over time. In recent years, the previous decline in the popularity of massage (probably related to technologic advancements in medicine), has been reversed into a resurgence of interest. In the United States, approximately $2-4 billion is spent each year for visits to massage therapists; these costs account for approximately 26% of the $11.7 billion spent on nontraditional healthcare in the 1990s. Increasing numbers of Americans are pursuing massage for various reasons (eg, relief of pain, relaxation, conditioning). Although little doubt exists that massage is beneficial for certain conditions, additional research is needed to establish its profile of efficacy. For excellent patient education resources, visit eMedicine's Muscle Disorders Center. Also, see eMedicine's patient education article Chronic Pain. Definition of basic massage concepts Massage is a therapeutic manipulation of the soft tissues of the body with the goal of achieving normalization of those tissues. Massage can have mechanical, neurological, psychological, and reflexive effects. Massage can be used to reduce pain or adhesions, promote sedation, mobilize fluids, increase muscular relaxation, and facilitate vasodilation. Massage easily can be a preliminary treatment to manipulation; however, it clearly targets the health of soft tissues, while manipulation targets joint segments. Massage primarily consists of hand movements, some of which may be traction based. Traction is defined as the act of drawing or pulling or application of a pulling force. Traction sometimes involves equipment, but it can also be applied manually. In addition, traction affects changes in the spinal column itself, with soft tissues only secondarily changed. Effects of massage, like those of traction, tend to be fairly nonspecific. Types of massage Western massage Western massage is the most common type of massage practiced in the United States today. Western massage organizes variations of soft-tissue manual therapy into several categories. Pare of France introduced the basic terminology for Western massage to the United States. The essence of Western massage is use of the hands to apply mechanical forces to the skeletal muscles and skin, though the intent may be to affect either more superficial or deeper tissues. Types of basic Western massage are characterized by (1) whether the focus of pressure is moved by the hands gliding over the skin (ie, effleurage), (2) by whether the soft tissue is compressed between the hands or between the fingers and thumb (ie, petrissage), (3) by whether the skin or muscle receives repetitive and compressive blows (ie, tapotement), or (4) s by whether hearing stresses are created at tissue interfaces below the skin (ie, deep friction massage). Effleurage In this approach, the practitioner's hands glide across the skin overlying the skeletal muscle being treated. Oil or powder is incorporated to reduce friction; hand-to-skin contact is maintained throughout the massage strokes. Effleurage can be superficial or deep. Light strokes energize cutaneous receptors and act by neuroreflexive or vascular reflexive mechanisms, whereas deep-stroke techniques mechanically mobilize fluids in the deeper soft tissue structures. Deep stroking massage is performed in the direction of venous or lymphatic flow, whereas light stroking can be in any direction desired. Effleurage may be used to gain initial relaxation and patient confidence, occasionally to diagnose muscle spasm and tightness, and to provide contact of the practitioner's hands from 1 area of the body to another. The main mechanical effect of effleurage is to apply sequential pressure over contiguous soft tissues so that fluid is displaced ahead of the hands as tissue compression is accomplished. Petrissage Petrissage involves compression of underlying skin and muscle between the fingers and thumb of 1 hand or between the 2 hands. Tissue is squeezed gently as the hands move in a circular motion perpendicular to the direction of compression. The main mechanical effects are compression and subsequent release of soft tissues, reactive blood flow, and neuroreflexive response to flow. Tapotement This percussion-oriented massage involves striking soft tissue with repetitive blows by using both hands in a rhythmic, gentle, and rapid fashion. Numerous variations can be defined by the part of the hands making an impact with the body. The therapeutic effect of tapotement may result from compression of trapped air that occurs on impact. The overall effect of tapotement may be stimulatory; therefore, healthy persons with increased tolerance for this approach are more likely to find this type of massage useful. Deep friction Pressure is applied with the ball of the practitioner's thumb or fingers to the patient's skin and muscle. The main effect of deep friction massage is to apply shear forces to underlying tissues, particularly at the interface between 2 tissue types (eg, dermis-fascia, fascia-muscle, muscle-bone interfaces). Deep pressure keeps superficial tissues from shearing so that shear and force are directed at the deeper tissue surface interface. Deep friction massage frequently is used to prevent or slow adhesions of scar tissue. Eastern massage Over the centuries, Eastern massage systems have been an integral part of the cultures where they are practiced. Systems for evaluation, diagnosis, and treatment are generally not grounded in conventional Western neurophysiology. Eastern massage includes, Shiatsu (ie, a Japanese system based on traditional Chinese Meridian theory with principles of Western science), among other approaches. The theory of Shiatsu is based on the system of the 12 traditional Chinese meridians (ie, major channels) of the body in which the energy or life force, or Chi, circulates. Acupressure points situated along the course of channels allow access to these channels. In acupressure massage forces are applied, largely by means of digital pressure, to the same points treated with acupuncture needles. Imbalances of energy along the meridians are believed to cause disease and can be rectified by localized finger pressure. Reflexology and auriculotherapy systems of massage that share the same meridian concept as that of Shiatsu. In these approaches, the meridians are believed to have whole-body representations on the extremities (similar to the homunculus of the brain). The feet (in reflexology) and the ear (in auriculotherapy) have been mapped in detail. Massage technique The practitioner controls several variables of massage, including milieu. Actual application of treatment includes rhythm, rate, pressure, direction, and duration. Most massage approaches involve a friction-reducing medium, so that the hands of the practitioner move along the patient's skin with minimal friction. Powders or oils are often used. Massage strokes also should be regular and cyclic. The rate of application for massage varies with the type of technique. In some approaches (eg, tapotement, percussion), the rate is several times per second while in others it is much slower. The amount of pressure depends on the technique and the desired results. Light pressure may produce relaxation and relative sedation and may decrease spasm; breakdown of adhesions and intervention at a deeper tissue level may require heavier pressure. Treatment of edema and stretching of connective tissue generally requires intermediate amounts of pressure. Direction of massage often is centripetal to provide better mobilization of fluids toward the central circulation. The sequence of tissues treated often is performed in centripetal fashion. When muscles are treated, motions generally are kept parallel to muscle fibers. If the treatment goal is to reduce adhesions, shearing forces are circular or at least include cross-fiber components. The area to be treated with massage depends upon the condition being treated and may vary from a well-circumscribed area to treatment of contiguous areas. Duration of treatment depends on the area being treated, desired therapeutic goals, and patient tolerance. Wide variation exists regarding treatment duration, which often is guided by changes occurring to tissue during massage application. If massage is performed before other treatments, duration may be determined by the result needed to optimize the next treatment step. Duration of a massage therapy program can range from 1 wk to months and depends on verifiable therapeutic goals. Patients must be reexamined from time to time, depending on the diagnosis and the therapeutic goals, to ensure satisfactory progress.   MASSAGE EFFECTS, INDICATIONS, CONTRAINDICATIONS, AND RESEARCH Physiologic effects of massage Massage produces some mechanical effects. Mechanical pressure on soft tissue displaces fluids. Fluid moves in the direction of lower resistance under the static forces of the practitioner's hands, but a moving locus of pressure creates a pressure gradient. Assuming no significant resistance, pressure is decreased proximal to the practitioner's advancing hand. Once mobilized fluid leaves the soft tissues, it enters the venous or lymphatic low-pressure systems. The amount of fluid mobilized in any single treatment is likely to be small; however, the physiatrist must be aware of this physiologic effect in patients with significantly compromised cardiovascular or renal function. When lymphedema is treated, massage is performed more proximally and then moves distally, based on the belief that proximal blockage in the lymph channels must be opened first to allow for subsequent distal mobilization of fluid and protein. Kneading and stroking massage decreases edema; compression converts nonpitting to pitting edema. In addition to strictly mechanical effects, these massage approaches release histamine, causing superficial vasodilation to assist in washing out metabolic waste products. Venous return increases, which subsequently increases stroke volume. Some evidence suggests that massage increases blood flow contralaterally; however, the mechanism of this postulated action has not been well established. These effects on mobilization of fluids are more important in flaccid or inactivated limbs because normal compression supplied by skeletal muscle contraction usually is not present in those cases. Studies in recent years suggest that massage may decrease blood viscosity and the hematocrit and increase circulating fibrinolytic compounds. Preliminary data suggest an explanation for the success of massage in decreasing deep vein thrombosis (DVT). Massage may be contraindicated in the presence of existing thrombosis. Other blood compounds that show increases through massage include myoglobin, creatine kinase, lactate dehydrogenase, and glutamic oxaloacetic transaminase. Temporary increases in these substances represent local muscle cell leakage from applied pressure. Lactate decreases in massaged muscles as well. Massage may decrease muscle spasm and increase force of contraction of skeletal muscle. Decreased spasm and increased endurance may result from wash out of metabolic waste products by fluid mobilization and increased blood flow. Decreased muscle soreness probably results from metabolic wash out. Reflexive changes Massage can stimulate cutaneous receptors, spindle receptors, and superficial skeletal muscle as well. These structures produce impulses that reach the spinal cord, producing various effects, including moderation of the facilitated segment. Somatovisceral reflex changes to the viscera are possible in this model.  Psychological effects of massage Massage generally increases feelings of relaxation and well being in patients. Whether this is from placebo effect or the result of some previously undiscovered reflex is not fully understood. Practitioners often incorporate a variety of psychophysical techniques, such as guided imagery, into massage treatment. A recent non-randomized prospective trial of massage therapy at a major U.S. cancer center sought to examine massage therapy outcome in a large group of patients. Over 3 y, 1290 patients were treated with regular (Swedish), light touch, or foot massage, based on the request of the patient. The patients filled out symptom cards before and after an average 20-min massage session. Symptom scores were reduced by approximately 50%, with outpatients demonstrating about 10% greater benefit than inpatients. Anxiety, nausea, depression, and pain demonstrated the greatest improvement in symptom score. Therapeutic goals and indications for massage therapy Massage may be used as primary therapeutic intervention or as an adjunct to other therapeutic techniques. Uses include, but are not limited to, (1) mobilization of intertissue fluids, (2) reduction or modification of edema, (3) increase of local blood flow, (4) decrease of muscle soreness and stiffness, (5) moderation of pain, (6) facilitation of relaxation, and (7) prevention or elimination of adhesions. Massage may be used to alter pathophysiology of a primary condition (eg, contracture) or to prevent or modify deleterious effects of a previously used treatment modality. Hospitalized patients who receive massage express improvements in mood, body image, self-esteem, and perceived levels of anxiety. This phenomenon is facilitated by reduction in physical symptoms and distress and may be accompanied by decreased tension, anxiety, and pain perception. Another therapeutic effect derived from massage is muscle relaxation. Massage appears to reduce tone and enhance circulation to the area. Muscle relaxation also may result from increased sensory stimulation caused directly by massage. This increased sensory input to the spinal cord may result in changes in reflex pathways, leading to central modulatory decreases of muscle tone. Massage can affect both local and remote circulation in skin and subcutaneous tissue. Studies suggest that massage also may decrease the likelihood of DVT by decreasing the hematocrit and overall blood viscosity and by increasing circulating fibrinolytic compounds. Other effects of massage are enkephalin release, endorphin production, promotion or absorption of fibrous tissue, restoration of connective tissue pliability, improvement of lymphatic flow (in some studies up to 7-9 times), and increased levels of natural killer (NK) cells. Tanabe and Nakayama have provided animal data that suggest that mechanical stimuli, such as massage, to adipocytes may inhibit expression of adipogenic transcription factor peroxisome proliferator-activated receptor, which is independent of systemic energy consumption. They postulate that such stimuli can assist in reducing the body's fat stores, and may help to reduce obesity. Contraindications to massage Massage is contraindicated when it could cause worsening of a particular condition, unwanted tissue destruction, or spread of disease. Massage can spread malignancy, thrombi, atherosclerotic plaques, and infected tissue. Absolute contraindications to massage include (1) DVT, because increased blood flow in a limb could cause thrombus to detach from the vessel wall, creating an embolism; (2) acute infection; (3) bleeding; and (4) new, open wounds. Relative contraindications include (1) incompletely healed scar tissue, (2) fragile skin, (3) calcified soft tissue, (4) skin grafts, (5) atrophic skin, (6) inflamed tissue, (7) malignancy, (8) inflammatory muscle disease, and (9) pregnancy. The physiatrist should be aware that massage must be used carefully in patients with chronic pain. The direct hands-on nature of massage may potentiate strong psychophysical effects and unintentional reliance of passive treatment modalities. In all patients, treatment end points must be established at the beginning, and treatment should be terminated when those end points are achieved. Research in massage Although many studies of the clinical utility of massage have been conducted, the quality of these efforts has been somewhat variable. Studies of massage have considerably varied in sample size and constitution, use of adequate controls, methodologic errors, and other limitations. The long-term efficacy of massage has not been validated. Future inquiry must establish the long-term efficacy of massage in a rigorous scientific fashion. Future studies must have valid experimental design that allows both pretesting and posttesting, appropriate sample sizes and statistical analysis, and reliable and valid measurement tools, and they must provide some degree of standardization of duration and frequency of treatment.   TRACTION Traction is the act of drawing or pulling and relates to forces applied to the body to stretch a given part or to separate 2 or more parts. Traction is used effectively in treatment of fractures. In physiatric practice, traction is often limited to the cervical or lumbar spine with the goal of relieving pain in, or originating from, those areas. Since the days of Hippocrates, correction of scoliosis has also involved traction. Various methods of traction have been performed that include having the patient apply pulling force manually with free weights and a pulley, by using motorized equipment, inversion techniques, or an overhead harness. Physiologic effects of traction In the cervical spine, the most reproducible result of traction is elongation. In a classic study, Cyriax reported manually applying force of 300 lb, with a resultant 1-cm increase in cumulative lumbar spinal interspace distance. Studies have shown that optimum weight for cervical traction to accomplish vertebral separation is 25 lb. In addition, 2- to 20-mm elongation of the cervical spine has been shown to be achievable with 25 or more pounds of traction force. Studies have shown that anterior intervertebral space shows the most increase in cervical flexion of 30°. Traction in the extended position generally is not recommended because it is often painful and may increase risk of complications from vertebral basilar insufficiency or spinal instability. Once friction is overcome in the lumbar spine, the major physiologic effect of traction is elongation. Investigators have reported widening of lumbar interspaces requiring between 70-300 lb of pull. This widening averaged up to slightly more than 3 mm at 1 intervertebral level. The length of time that the separation persists remains indeterminate with studies documenting distraction durations of 10-30 min after treatment. Data on dimensional and pressure changes of lumbar disks caused by traction are not conclusive. Decreases in interdiskal pressure with 50-100 lb of traction have been documented, but evidence exists that some applications actually cause increase in interdiskal pressure. Therefore, evidence is inconclusive, with much information favoring at least temporary reduction of the herniated component of an abnormal lumbar disk with concomitant traction. Outcome studies related to traction Few scientifically rigorous studies have been performed to allow us to distinguish the effect of traction from the natural history of pathology (eg, radiculopathy). Criteria have been suggested that would allow the true effects of traction to be delineated. These criteria include (1) randomized controlled trials, (2) blind outcome assessments, (3) equivalent co-interventions, (4) monitored compliance, (5) minimal contamination and attrition, (6) adequate statistical power and description of study design and interventions, and (7) relevant functionally oriented outcomes. No traction outcome study to date has incorporated these criteria. Despite inadequacies in the literature, randomized controlled trials that meet some of these criteria do provide insight into the efficacy of traction as a treatment modality. One review of randomized controlled trials of traction analyzed English-language studies done between 1966 and 2001. The only conclusion that could be drawn was that the evidence to support the effectiveness of traction for back pain relief is poor. What can be reasonably derived from these studies is that more work is needed to make evidence-based recommendations on the application of traction for back pain. Lumbar traction The Agency for Health Care Policy and Research (AHCPR) review of the literature on traction resulted in a conclusion that "spinal traction is not recommended in the treatment of acute low back problems." Studies that claim improvement after traction report modest and short-term improvements with limited or no improvement in overall function. In addition, these studies have significant design flaws. Although a particular group of patients may benefit from a particular type of traction for short- or long-term improvement in functional outcome, the current literature does not identify this patient population. Cervical traction Few randomized controlled trials address patient outcomes after cervical traction. Although many studies have revealed statistically significant findings, the clinical importance of those findings is not clear. Studies on emerging protocols for cervical traction, as well as on new devices for applying traction have been reported. The evidence for the efficacy of these devices and methods appear to need further study before widespread application can be recommended. Techniques for applying traction Cervical traction is generally accomplished with a free-weight-and-pulley system or an electrical motorized device. Adequate pull is achieved by using a head or chin sling attached to a system that can provide pull in a cephalic direction. Motorized devices are applied easily but require the patient to be attended. Free-weight-and-pulley systems often are used in the home with 20 or more pounds of water or sand and a pulley system attached to a door. If a traction force of only 20 lb is possible, the system is likely to fail to achieve therapeutic results. Advise patients not to attempt cervical traction at home alone because they may find themselves in uncomfortable positions and may need assistance removing the traction devices. Most home traction systems are difficult for patients to set up without assistance. Home cervical traction may cause increase in pain or may fail to produce significant pain relief unless professionally monitored on a periodic basis. At the initiation of home traction, the patient is required to demonstrate proper use of equipment to the satisfaction of the prescribing physician or therapist. In the lumbar spine, adequate pull with weights and pulleys or motorized devices to achieve vertebral distraction usually can be obtained with the proper apparatus. Generally, a harness is attached around the pelvis (to deliver a caudal pull), and the upper body is stabilized by a chest harness or voluntary arm force (for the cephalad pull). Motorized units have the advantage of allowing intermittent traction with less practitioner intervention. If the goal of traction force is to distract lumbar vertebrae, 70-150 lb of pull are usually needed. Friction between the treatment table and patient's body usually requires traction force of 26% of the total body weight before effective traction to the lumbar spine is possible. Many traction devices use a split table that eliminates the lower body segment friction. Body weight should theoretically provide enough pull to distract lumbar vertebrae and eliminate mechanical devices. Gravity traction is applied almost exclusively in the lumbar region. After 10 min of inversion traction, documented increases in intervertebral separation are noted; however, adverse effects also are reported frequently, including increased blood pressure, periorbital and pharengonal petechiae, headaches, blurred vision, and contact-lens discomfort. Other traction technique considerations In cervical traction, determine sitting versus supine position based on patient's comfort and ability to relax. Maximal distraction generally occurs between 20-30° of flexion without rotation or side bending. Supine position is chosen most commonly for lumbar traction since the sitting position may result in outcome limiting discomfort from the harness. Hip flexion of 15-70° is routinely incorporated to cause relative lumbar spine flexion; this may facilitate optimal vertebral separation. Studies have shown that, in the cervical spine, intermittent traction of 20 lb peak (10 seconds on, 10 seconds off, for a total of 15 min of treatment time) provided improvement in range of motion (ROM) with less accompanying pain than did 15 min of manual or static traction of 25 lb. Constant cervical distraction forces of 30 lb generate maximum vertebral separation in 7 seconds or less, and no further separation is gained with applications of up to 60 seconds. In addition to patient preference, data suggest that some relative advantage exists to an intermittent versus continuous protocol of cervical traction. Some studies report that continuous traction is necessary in the lumbar spine to fatigue muscles and allow strain to fall on joints; however, no statistical difference has been observed with either continuous traction of 100 lb for 5 min or intermittent traction of 100 lb, peaking for 15 min. As in traction on the cervical spine, improved patient tolerance favors an intermittent protocol. In the sitting position, application of approximately 10 lb is required to counterbalance the patient's head in cervical traction. Traction of 30 lb applied to a neck flexed up to 24° can cause vertebral separation, but increase of force to 50 lb produced no clear-cut additional separation. In the lumbar spine, a pull, which equals approximately 50% of the weight of the body part, is needed to overcome friction. As previously noted for the lower body, this amounts to approximately 26% of total body weight. The optimal duration of traction has not been clearly demonstrated. Studies have revealed recommendations varying from 2 min to 24 h in the cervical spine. Duration of approximately 15-25 min commonly is prescribed. Cervical traction generally is prescribed at a frequency of daily for the first week and then every other day (ie, 3 times per week) for total treatment duration of approximately 3-4 wk. In the lumbar spine, treatment generally is recommended in the 8- to 40-min range per session, daily for the first week, and then every other day (ie, 3 times per week) for a total of 3-4 wks. In both cervical and lumbar traction, goals of treatment determine the time course, as well as the end point of treatment. Possible treatment end points may include pain relief, achievement of normal ROM, return to work or other desired activity, lack of improvement and symptoms, and inability of the patient to cooperate with treatment. Indications for traction The literature does not give clear indications what types of neck or low back pain (LBP) may improve from traction. Studies strongly suggest that traction does not produce significant influence on long-term outcome of neck pain or LBP. Practitioners who rely on sound scientific advice may use traction rarely. Practitioners who are receptive to empirical treatments may be amenable to the concept that traction may separate vertebrae and decrease the size of herniated disks, thereby benefiting radiculopathy; however, no consensus has been reached among clinicians or researchers in this area. Contraindications to traction No scientific reports clearly delineate contraindications for traction. The practitioner must rely on empirical information and opinion. Old age has been cited as a relative contraindication. Most practitioners agree that contraindications to cervical or lumbar traction include, but may not be limited to, the following: (1) ligamentous instability, (2) osteomyelitis, (3) diskitis, (4) primary or metastatic tumor, (5) spinal cord tumor, (6) severe osteoporosis, (7) clinical signs of myelopathy, (8) severe anxiety, and (9) untreated hypertension. In the cervical spine, the practitioner also must take into account the fact that patients with vertebral basilar artery insufficiency may be more susceptible to cerebrovascular complications. Furthermore, patients with advanced rheumatoid arthritis or connective tissue disorders may be at risk for atlantoaxial instability. Other relative contraindications to traction in the cervical or lumbar spine include (1) midline herniated nucleus pulposus, (2) acute torticollis, (3) restrictive lung disease, (4) active peptic ulcer, (5) hernia, (6) aortic aneurysm, and (7) pregnancy. Referral considerations The physiatrist who intends to refer patients for traction is responsible for writing a detailed and specific prescription, including at least the following information: (1) patient's age, (2) sex, (3) diagnosis, (4) underlying medical conditions, (5) precautions needed, and (6) recommended follow-up. Traction should not be a single treatment approach, but rather one part of a comprehensive rehabilitation treatment program. The most effective use of traction is likely to improve the activity level, mobility, and overall function. Specific items to outline in traction referrals also should include the following information: (1) position (of the body, neck, or hip and knee), (2) mode of application (continuous or intermittent), (3) weight to be applied, (4) concurrent modalities (eg, heat), (5) frequency and duration of treatment, (6) re-evaluation guidelines and time frames, (7) guidelines for discontinuation, and (8) therapeutic goals. The future of traction Traction has enjoyed a long history of clinical acceptance based on little scientific understanding of its mechanism of action or efficacy. Significant questions exist regarding duration of symptom relief and other benefits derived. Given the difficulty of objective documentation of the benefits of traction, reduction in the use of traction in recent years is not surprising.

MANIPULATION Application Therapeutic manipulation has been practiced in almost all countries of the world since at least the time of Hippocrates. Recent times have seen rapid growth of manipulation and manual therapy and an increase in its public use. Some healthcare professionals' opposition to the use of manipulation is explained by the fact that manipulation requires skills significantly different from those acquired in allopathic medical schools. This difference separates practitioners who possess manipulation skills from those who do not. The techniques used in manipulation also fall outside of the mainstream of allopathic medicine. Goals Manipulation procedures are used in many ways by a variety of practitioners. The most common goal of a manipulative treatment is to increase the mobility of a particular area or region of the musculoskeletal system where restrictions are encountered. Although some practitioners focus on pain relief as a main outcome measure, others seek enhanced mobility, or reduction in restriction of vascular or lymphatic congestion as it relates to the rest of the body. Most of the 90 million annual manipulations performed in the United States by physicians and other practitioners are for complaints of musculoskeletal back and neck pain. Manipulation generally is directed at restoration of normal motion and elimination of pain secondary to disturbed biomechanics.  Definition A consensus definition of manipulation is the use of the hands applied to the patient incorporating the use of instructions and maneuvers to achieve maximal painless movement and posture of the musculoskeletal system. Most common types of manipulation involve passive mechanical forces applied to specific vertebral segments, regions, or other joint segments of the musculoskeletal system with a primary goal of restoration of diminished ROM.   TECHNIQUES OF MANIPULATION Introductions to the most common techniques of manipulation presently used in the United States are presented below. This list is limited to techniques that physicians are most likely to encounter. A brief discussion of direct versus indirect treatment is germane to the understanding of the rationale for choosing a particular technique. Once an area of restriction, or somatic dysfunction, is palpated, the means of correction must be chosen. One can elect to treat in the direction of the restriction, or into what is commonly called the ease of motion, that is, away from the restricted motion. A direct technique engages the motion barrier; this means that the practitioner directs forces into and through the motion barrier. On the contrary, an indirect technique allows the body's inherent neurologic or intrinsic forces to release the restriction, as the practitioner positions the area to be treated opposite the direction of a restriction. For example, if pain and reduced motion is elicited by actively rotating a patient's neck to the patient's right side, it can be deduced that the patient's restriction is on the right. Therefore, if the treatment selected moves the patient's neck further to the right, ie, into the restriction or barrier, this is a direct treatment. Conversely, if the patient's neck is rotated to the left, or away from the barrier, this is considered an indirect method of treatment. Direct thrust Direct (eg, high-velocity, low-amplitude) thrust techniques, including European mobilization with impulse, involve diagnosis of dysfunction of a vertebral segment by identifying position or motion abnormalities or related tissue texture changes, including tenderness to palpation or induced motion. The practitioner then rotates, side bends, and flexes or extends the adjacent vertebral segments, locking the facet so that further motion is limited to the segment in question. The vertebral segment is then passively moved to its limit of motion or barrier to remove slack motion, and a small force, localized to the specifically identified joint, is applied to hold that position. Brief, controlled thrust is applied in the direction perceived as limited, and a small motion in the desired direction occurs as the vertebra crosses its barrier. Forces, duration of actions, acceleration, and displacement values for direct thrusting techniques have been measured. These forces peak in the range of 100-400 N over approximately 150 ms. Direct manipulative techniques featuring forces applied over transverse or spinous processes are short-lever techniques. If force is applied distant to the vertebrae through the locked column, the procedure is considered a long-lever technique. All direct thrust techniques must have forces well localized and specifically directed, and structural diagnosis must be adequate before their application. Articulatory technique Articulatory technique, also referred to as low-velocity, high-amplitude technique, involves passive movement of a vertebral joint within reduced ROM defined by its resting position and dysfunctional limitation of motion. The extent of motion at its end point may vary, but the ultimate end point and dysfunctional barrier become the same, with the barrier becoming attenuated with repeated motion. The quality or feel of induced motion, in addition to the quantity of force and excursion, are normalized by this procedure. A small amount of additional force occasionally may take the vertebra through its barrier or restriction.   Indirect positional techniques Indirect positional techniques (eg, counterstrain and functional techniques) are based on the underlying principle that somatic dysfunction or hypomobility is caused by an inappropriately firing muscle group, rather than shortened passive tissue, such as joint capsule, ligament, or fascia. Thrust, articulation, and muscle energy techniques employ forces that could be expected to lengthen shortened passive tissues, whereas these positional techniques change an inappropriate engram of muscle behavior. Counterstrain Developed by Jones, counterstrain is an indirect myofascial technique that shares with functional technique an emphasis on relative positioning of a joint or body part as an essential component of treatment. Counterstrain treatment involves placing a joint or body part into position of maximal ease or comfort to relax ligamentous and myofascial soft tissue. This relaxation allows inappropriately shortened muscles to reset their spindles, which then normalizes proprioceptive input into the spinal cord. The restricting muscle generally is shortened excessively by this positioning (eg, counterstrain), and its antagonist muscle is overstretched (eg, strained) gently in the process. Find the optimal treatment position by minimizing pain associated with palpation pressure over a tender point. After this position of maximum ease is found, hold it for approximately 90-120 s with concurrent tender point monitoring. During this time, tenderness should fade to no more than 20-30% of its initial value. Occasional small, fine-tuning, passive positioning movements with verbal feedback from the patient may be needed. Tenderness is part of this feedback system; therefore, the patient must respond to the practitioner's questions. Return the patient slowly to a neutral position in 1 plane of motion at a time to prevent recurrence of inappropriate muscle firing. Counter strain is considered an indirect technique because positioning is always in a direction away from the restricted motion. If multiple tender points are encountered, treat them in order of decreasing tenderness. Then areas of highest accumulation of tender points (first proximally then distally) are addressed. Tender points are found beneath the skin by means of palpation over shortened and restricted muscles or over related anatomic structures (eg, tendons, muscles, and ligaments). Tender points generally do not coincide with trigger points or points associated with fibromyalgia. Counterstrain tender points usually are small fibrotic discrete areas thought to be manifestations of distal somatic dysfunction and are not associated with other signs of fibromyalgia, nor are they paired. Counterstrain tender points are distributed widely in generally reproducible locations, depending on the nature and location of associated somatic dysfunctions. Those associations are not based on known neurophysiologic or neuroanatomic referral patterns. Counterstrain is considered safe, effective, gentle, and atraumatic; therefore, it is a useful technique for the old, hospitalized, or immunocompromised patients, as well as for apprehensive patients and children. Counterstrain techniques are easy to perform, forgiving for the novice learner, and easily incorporated by the patient into a prescribed home exercise program. Functional techniques Functional techniques, as well as counterstrain, have a methodologic approach oriented to resetting inappropriate afferent impulses from nociceptors and mechanoreceptors, resulting in efferent alpha motor activity to the skeletal muscle, by placing the joint or body part into a position of maximum ease. Unlike in counterstrain, however, the position is found and monitored by the practitioner, sensing either increased resistance to trials of small induced motions or increased tissue tension of the nearby tissue when motion is induced. The most relaxed position is held in this balanced state. Functional technique practitioners feel that inherent body motions (eg, respiration) allow the firing pattern of the afferent muscles to reset so they are normalized in a neutral position. This approach, also unlike counterstrain, does not make use of tender points and may be somewhat more objective because practitioner's palpated findings determine positions of balance. The practitioner puts the patient through a sequence of positions with the goal of progressing toward anatomic neutral as the position of maximum ease or balance. Functional techniques are useful in both acute and chronic conditions because focus of this treatment is in the quality rather than quantity of motion, with restoration of normal function implying normal quality and ROM. Functional techniques require substantial experience on the part of the practitioner. Muscle energy Muscle energy is a direct nonthrusting technique (also known in the United States as isometrics and in Europe as mobilization) and has a strong relationship to proprioceptive neuromuscular facilitation. The physician positions the patient and removes slack as in direct thrust procedures and subsequently prevent active motion of the affected vertebral segment away from its barrier. The patient then exerts minimal-to-moderate isometric force against resistance offered by the physician for approximately 5-10 s and subsequently relaxes. The physician then finds that the barrier has been displaced and that the affected segment moves beyond its original barrier. This procedure is repeated 2-3 times with diminishing gains and increased ROM. Soft tissue technique Soft tissue technique uses mechanical stretch of skin, muscle, and fascia to increase motion. Lateral and linear stretch and deep inhibitory pressure are the most common procedures used. Soft tissue techniques are useful in virtually all patients and may function as first step in manipulative treatment involving multiple techniques. Soft tissue techniques are valuable in encouraging circulation and enhancing venous and lymphatic flow. The overall purpose of soft tissue technique is to relieve fascial and superficial muscle tension. Soft tissue techniques are learned easily and can be incorporated into clinical practice with virtually no difficulty. Myofascial release Myofascial release techniques are directed at vertebral, segmental, or generalized hypomobility. Myofascial release can be indirect (ie, when a restricted area is placed into a position of little resistance until subsequent relaxation occurs) or direct (ie, when the affected area is placed against a restrictive barrier with constant force until fascial release occurs). All the myofascia of the body are interconnected, and, when one area is tight or restricted, diminished movement occurs not only locally but potentially in distant related areas. Myofascial release practitioners palpate to assess tissue response and adjust applied forces of stretch, pressure, twist, or traction until affected tissues change toward normal. This progression may occur over a short period and is referred to as release. The mechanism of release may be biomechanical or neuroreflexive; however, fascial resistance to forces applied should be symmetric, and the tissue should be relatively mobile and responsive to force being applied. Myofascial release combines mechanical approaches of direct thrust, articulatory techniques, and muscle energy with neuroreflexive approaches of counterstrain, functional, and soft tissue techniques. Effective use of myofascial release requires considerable skill and experience in palpation, and training time is relatively long compared to that for other manipulative approaches. Craniosacral Craniosacral manipulation is based on the concept of a primary respiratory mechanism (ie, a cyclic, palpable, rhythmic wave of inherent motion appreciated most easily in the cranial and sacral areas). This wave may represent a continuous state of flux of CSF. This primary mechanism may entail inherent mobility of the CNS, CSF fluctuation, cranial bone articular mobility, involuntary motion between the sacrum and ilia, and mobility of interspinal and intercranial membranes. The craniosacral practitioner palpates the head and/or sacrum to feel pulsations of the wave motion, occurring in the range of 8-12 pulses per minute, as well as to evaluate symmetry, regularity, frequency, and amplitude of the wave. When abnormalities are found, apply general pressure to the skull and sacral areas to restore the wave to normal symmetry rhythm and amplitude. While this technique is considered somewhat controversial among nonpractitioners, its largest subset of potential patients may be infants with failure to thrive, birth defects, or head injuries, as well as adults with neurologic or CNS pathology. Recent growth in popularity of this manipulative approach requires physicians to have at least passing familiarity with it. Proficiency with craniosacral manipulation requires considerable training and experience.     MANIPULATION RISKS, BENEFITS, AND PATIENT SELECTION Risks and benefits of manipulation Few risks are involved in manipulative care. Complications from isometric or articulatory treatments have not been reported. The number of reports of complication of direct thrust manipulation actually is quite small, considering the number of manipulations performed annually. Most potential complications of manipulative care are avoidable. Evidence for the benefits of manipulation is mounting. Proponents report excellent results in treating acute, as well as chronic, musculoskeletal problems. Empirically, these outcomes are comparable to those achieved with more conventional treatments, many of which carry no proof of efficacy. Manipulative care has been shown to decrease use of medication and physical therapy, to be superior to conventional treatment and placebo manual care, and to be most efficacious in persons with noncomplicated acute LBP. Manipulation results in less disability and faster recovery, greater improvement in pain and activity tolerance, and is a valuable adjunct to an ongoing exercise program. Manipulation has been shown to be useful in treatment of upper, middle, and perirespiratory infections, as well as advanced cardiopulmonary disease, headache, and neck pain. Manipulative care in physiatric practice The physiatrist is usually able to identify, through focused musculoskeletal examination, patients who are most likely to benefit from manipulative care. Although some manipulation techniques have applicability to hospitalized patients, manipulation is most often appropriate for outpatients. This constituency includes patients with structural problems (eg, vertebral rotations, pelvic asymmetries, sacral torsions, other entities in which diagnosis relies on palpation skill). Selection of patients Perform general physiatric examination on each patient. Identify and treat any underlying pathology, including fractures, herniated disks, sprains, strains, hematomas, joint injuries, and peripheral and central neurological injuries. Use additional diagnostic studies as needed. The physiatrist contemplating manipulative intervention performs a focused detailed history and structural examination in areas suggested by symptoms or by the general examination. This involves observation, active gross and fine motion assessment, and general palpation and/or motion examination. Success of manipulative therapy often depends on accurate palpation diagnosis. Palpation and segmental autonomic changes may be significant components of structural diagnosis. Generally included in evaluation of vertebral or segmental levels are (1) bony structure asymmetry, (2) restricted vertebral motion relative to adjacent vertebrae in flexion/extension/side bending/rotation, (3) tissue texture changes, (4) local tolerance to palpation or induced motion, and (5) tenderness elicited over vertebral processes or by induced motion. Evaluate passive motion for range, symmetry, and amount of force needed to achieve full range, which is assessed in terms of quality or end field of motion. Evaluate combinations of vertebral motion as well (eg, flexion, rotation). Springing of the vertebrae and examination of tenderness or local pressure on interspinous ligaments often are useful techniques in determining musculoskeletal function and loss of joint mobility. Subcutaneous tissue texture changes, such as edema or fibrosis, may be noted by palpation and may indicate musculoskeletal pathology with associated segmental autonomic changes. Include examination of the ribs, occiput, and pelvis in the structural examination. Hypermobile musculoskeletal segments may not be amenable to manipulative intervention but may indicate presence of hypomobile segments in other locations and, if nontender, may be amenable to successful manipulation to resolve distant hypermobility. Thorough structural examinations, as described, may add 5-10 min to an initial visit and less than 5 min to subsequent patient examinations. The physiatrist choosing manipulation should possess a relatively high degree of basic palpation skills, so that referral to another physician or manipulative practitioner includes specific identification of structural dysfunction. In addition, palpation examination allows the physiatrist to determine areas needing manipulative treatment and to establish a potential end point of manual care.   MANIPULATION METHODS, INDICATIONS, AND CONTRAINDICATIONS Methods of manipulative practice Availability of manipulation care varies significantly, depending on geographic location and regional practice patterns. Physiatrists, who wish to use manipulation, but not to provide it themselves, generally refer patients either to a physician or a licensed nonphysician practitioner. Referral to another physician practitioner often works well, but potential problems exist, especially regarding patient referral. This issue may be addressed through a specific referral that states the exact nature and scope of evaluation and treatment requested, encouragement of discussion with referring physician, and a statement making clear the intent of the physiatrist to resume the remainder of the patient's care. If referral is to a licensed nonphysician practitioner, first diagnose the appropriate problem and write a specific prescription for manipulation. Manipulative care can be provided as part of a comprehensive therapy program; however, the physiatrist should write a detailed prescription for the specific are to be treated and identify the diminished motion to be restored, as well as frequency and length of treatment. This enables the physiatrist to monitor patient progress objectively and determine the end point and benefit of manipulative treatment. The practitioner may need 1-2 wk to learn minimal diagnostic palpation skills; however, the highly motivated physiatrist can use these skills frequently enough to maintain them easily in most practice situations. Physician referral to nonphysician manipulative practitioners is likely to bring the benefits of manipulative care to patients who have chosen the traditional physiatric approach to healthcare for musculoskeletal problems. The 3 main obstacles for the physiatrist interested in performing manipulation are acquisition of skills, maintenance of skills, and economic considerations. Manipulative techniques are best learned by performing them on colleagues and fellow learners under close supervision. Studies suggest that minimum learning time required may vary from 3-12 mo, depending on the modality being learned. This extended period of time has significant ramifications for the practitioner. Because of enhanced safety and small potential for harm, sufficient skill can be acquired by most practitioners in 1-2 k of formal training in each of the types of manipulation, including isometric/muscle energy, counterstrain, myofascial release, and articulatory techniques. Training time for these approaches is shorter because inappropriate or nonindicated indirect technique, unless repeated frequently or over a prolonged period, rarely causes detrimental effects. Postdoctoral training programs, such as those approved or offered by the American Academy of Physical Medicine and Rehabilitation, Colleges of Osteopathic Medicine, or other organizations, may provide a means by which the physiatrist can become acquainted with the skills necessary to begin manipulative care. Interest among physiatric residents in acquiring manipulative skills is increasing rapidly, and this fact has expanded training opportunities for physicians. Many residency programs now include required and/or optional training in manual medicine skills. Maintenance of manipulative skills is fairly easy for a full-time practitioner; however, it may be more difficult for the physiatrist whose practice does not feature a high volume of manipulative care. Infrequent use of manipulative skills results in decreased competence, but the actual minimum frequency of use needed to maintain competence or excellence varies considerably among practitioners. Physiatrists interested in providing manipulative care should consider the time and cost of acquiring and maintaining these skills. Manipulation, if performed appropriately, can be both time-efficient and financially feasible. Indications for manipulation Manipulation is appropriate for a variety of musculoskeletal problems, especially those of the thorax, rib cage, upper and lower extremities, back, pelvis, and neck. It is also useful when loss of motion or function is encountered or when localized tenderness or pain is noted on induced motion. Some clinical situations (eg, acute fractures, disk herniations with neurologic signs, tumors, acute inflammation, joint disease) may not respond to manipulative care because of local conditions that may constitute contraindications or hypermobility. Remember also to exclude systemic or visceral pathological conditions, or at least put them under concurrent care of the practitioner. Some physicians use manipulation for treatment, while others provide it in a more prophylactic manner. Adverse effects of manipulation The most commonly reported adverse effect is transient increase in discomfort lasting approximately 6-72 h. Minor temporary autonomic effects (eg, early or increased menses, increased perspiration, vasomotor changes) have been reported. Duration of manipulative care Direct techniques (eg, high velocity-low amplitude thrust) usually have immediate effect, and improvement is seen within a week. Indirect techniques may take longer for effect to be seen. If the patient's condition does not improve objectively within 2-4 wk, reevaluation of the structural diagnosis, manipulative approach, or other therapeutic plan is indicated. Determine duration of each course of therapy on a case-by-case basis. Contraindications for manipulation Different manipulative approaches vary as to the degree of invasiveness. Because of higher forces involved, direct techniques are the most invasive and, therefore, more likely to be contraindicated. Absolute contraindications for manipulative care, especially indirect techniques, are rare. Few relative contraindications exist. Manipulative care should be performed only for hypomobile vertebral segments or other structural dysfunctions deemed amenable to manipulation. Accurate structural diagnosis is critical. Inadequate practitioner skill is a major contraindication for all types of manipulative care. Articulatory techniques are contraindicated for patients with vertebral malignancy, infection or inflammation, myelopathy, multiple adjacent radiculopathies, cauda equina syndrome, vertebral bone disease, bony joint instability, and cervical rheumatoid disease. Direct manipulation (eg, high-velocity, low-amplitude) is contraindicated in those cases and in the presence of (1) spinal deformity, (2) systemic anticoagulation treatment, (3) severe diabetes or atherosclerotic disease, (4) degenerative joint disease, (5) vertebral basilar disease or insufficiency, (6) spondyloarthropathies, (7) ligamentous joint instability or congenital joint laxity, (8) aseptic necrosis, (9) local aneurysm, (10) osteoporosis, (11) acute disk herniation, or (12) osteomalacia. Haldeman, Kohlbeck, and McGregor retrospectively reviewed medical records cases of strokes temporally associated with cervical spinal manipulation. They concluded that no known mechanism exists to predict who is at risk for such an event and that the events are an inherent and idiosyncratic risk associated with this type of treatment and exceedingly rare. Patients with a tendency toward somatoform fixation in painful anatomic areas, as well as those with obsessional neurosis, are poor candidates for direct manipulative techniques. Pregnancy and known threat of miscarriage are absolute contraindications only to direct manipulative techniques. Conservative indirect techniques are considered safe (as long as a competent practitioner performs them) into the latter stages of pregnancy. Objective radicular signs are a contraindication to direct thrust techniques of all kinds. Active myositis or infection may constitute a contraindication for isometric care because of the need to provide active muscular contractions. Functional techniques, counterstrain, or other indirect approaches may be applied safely in these conditions. No contraindications have been documented for functional or counterstrain techniques. Complications of manipulation Complications of manipulation generally arise because practitioners are poorly skilled or trained or because contraindicated procedures are performed. No documented or anecdotal reports of complications resulting from articular, isometric, counterstrain, functional, soft tissue, or myofascial release exist. Most reported complications involve direct (eg, high-velocity, low-amplitude) thrusting techniques that generally have been done in the cervical region. In almost all cases, the neck was extended inappropriately during the procedure. Extremely serious consequences may occur with very low frequency, estimated to be approximately 1 case in 1-1.5 million manipulations. The Back Letter states that, "As to whether or not healthy patients should be concerned with the risk of cervical manipulation, the risk appears to be quite small." Risk to the patient is minimized by proper positioning of the patient with avoidance of extreme positions of flexion, extension, side bending, and rotation. Careful evaluation and treatment of patients with known or suspected osteoporosis or spinal disease also is important.   HYPOTHESIS OF THE ETIOLOGY OF SOMATIC DYSFUNCTION Manipulation is a mechanical intervention. Hypotheses that explain somatic dysfunction usually involve position and treatment of vertebral bodies, muscle, fascial segments, soft tissue, or other body parts. Acute pathologies (eg, fractures, ligamentous tears, tumors, avulsions, joint inflammation) are not considered amenable to manipulation as a primary mode of treatment. Some pattern of neuromuscular behavior resulting in early localized hypomobility may respond to manipulative care. Pain and edema may cause immobility leading to contracture or abnormal neuromuscular pattern. Precipitating pathology of somatic dysfunction may be largely resolved by the time diagnosis is made; however, pain also may arise from dysfunction and, along with impaired mobility, may be related directly to it. Pain and somatic dysfunction can create a self-perpetuating syndrome. The term somatic dysfunction is used to explain the musculoskeletal manifestation of restricted movement and impaired mobility of a body segment. It has also been called an osteopathic lesion, chiropractic subluxation, joint blockage, and loss of joint play, among others. Barrier models have been suggested to explain palpable findings. Normal joints possess an active and a larger passive ROM. A barrier or motion restriction produced by abnormal muscle contraction, ligamentous, or capsular shortening forms in one or more directions between the neutral position and normal limits so that patients are not able to achieve normal range. The manipulation practitioner then applies additional force to achieve normal passive ROM. The facilitated segment model assumes that a vertebral body, chronically malpositioned by contracture, overly active muscle, or other somatic dysfunction, floods the segmentally related area of the spinal cord with inappropriate nonfatiguing proprioceptive impulses. These impulses, in turn, spill over and facilitate outgoing motor neurons and autonomics in the same vertebral segment of the spinal cord. Then pathways are present for interaction between soma and viscera at related segments, and palpation diagnosis of visceral disease and determination of influence on the viscera are possible. This phenomenon allows asymptomatic abnormal segmental areas to develop symptoms from general illness, distant disease, or emotional stress. Physiatrists familiar with autonomic hyperreflexia and similar phenomena can relate easily to the concepts of somatovisceral reflexes and segmental spillover. The mechanical model of altered joint play is distinct from the neurophysiologic hypothesis of somatic dysfunction. All normal voluntary joint motion is accompanied by a wiggling motion in a direction perpendicular or, possibly, tangential to the plane of that motion. This joint play exists because joint surfaces are not perfectly congruent. Loss of joint play because of soft tissue restriction may inhibit voluntary motion from absence of the involuntary component. Passive intervention is needed to normalize function because lost joint play is in an involuntary direction. Therefore, pain arises from poor mechanical function. Hypothesis of action of manipulation The overriding mechanism by which manipulative techniques relieve pain is not understood fully. A simple categorization separates treatments into those that mechanically lengthen tight soft tissues from those that alter the firing rate of inappropriately shortened muscles to achieve relaxation or ease. Either of these treatment techniques eliminates hypomobility of an offending segment if soft tissue is lengthened or the muscle is relaxed sufficiently. Functional, muscle energy, most myofascial release, and counterstrain techniques, with use of small forces, can work only on neuroreflexive alteration of muscle activity. Direct thrust and articulatory techniques involve larger forces and, presumably, are able to stretch and elongate tissue. Restricted motion arises from abnormal muscle contraction and shortened or stiffened soft tissues. All forms of manipulation interfere with abnormal muscular contraction, either by producing afferent stimuli that attenuate hyperexcitable gamma-efferent systems or by elimination of proprioceptive input that stimulates the gamma-efferent system. Thrust and, possibly, articulatory and isometric techniques stimulate Golgi tendon organ input. Articulatory and isometric techniques may elicit permanent lengthening of collagenous tissue by inducing a permanent set with repeated stretching. Direct thrust techniques result in high stress levels and probably high strain levels in soft tissues over a short period of time. Nonuniform distribution of strain may develop, leading to localized tissue injury and subsequent healing with permanent elongation with the net result that vertebrae regain normal motion play, and the forces needed to produce motion then are normalized. Facet malposition or malfunction can be influenced directly with manipulation by passive joint motion. A bulging disk may be reduced or normalized by manipulation. The change in proprioceptive input to the spinal cord may close the gate on pain or remove abnormal facilitating proprioceptive input. Use of manipulation by physiatrists Goals of manipulation are to restore or optimize biomechanical function by improving motion, thereby facilitating mobility and minimizing pain, as well as increasing patient's overall level of wellness. Scientific evidence for the efficacy of manipulation has, in recent years, been mounting. General acceptance of the utility of manipulation in acute LBP and other forms of musculoskeletal pathology has resulted in recommendations that manipulation be directed toward restoration of normal motion, reduction of pain, and overall increase of physical activity. Prescribing of manipulation Referral of a patient to another practitioner for manipulation requires a prescription, which may be done by speaking with the practitioner. Manipulative care may also be included as a portion of a general strengthening, conditioning, and musculoskeletal educational program. The specific region to be manipulated, potentially suggested techniques, and discussion of any medical issues, considerations, or adverse effects also must be a part of the prescription. Include patient age, precautions, diagnosis, treatment recommendations, frequency, duration, and other comments in all prescriptions for manipulation. Follow-up patient examination is essential. If treatment has been unsuccessful, consider reformulation of the diagnosis or of the therapeutic manipulative approach. If manipulation procedures are producing discomfort lasting more than 8 h, consider changing to a less invasive, or possibly indirect, technique. Manipulative technique used in any intervention depends on the time course of the problem and the patient's age, general physical condition, medical history, contraindications, and the practitioner's expertise and training. These considerations underscore need for careful history taking and physical examination, structural examination, and functional diagnosis. A musculoskeletal problem amenable to manipulation must be identified for this approach to be effective. This identification of the source of pain is particularly important for patients with subacute or chronic pain. Note that complete eradication of pain is rare. This fact may lead to patients' becoming dependent on manipulation. Having well defined biomechanical end points of treatment (eg, normal ROM and tissue texture) helps formulate an effective end to treatment. Especially in the patient with chronic pain, manipulation should be directed at obtaining optimal biomechanical musculoskeletal condition as quickly as possible. Research relating to manipulation Numerous clinical trials of spinal manipulative therapy have been reported in the literature. Furthermore, manipulative therapy has been the subject of multiple international consensus meetings. Trials have attempted to improve knowledge by comparing thrust to nonthrust (ie, direct vs indirect) techniques and joint specific to nonjoint specific manual therapies by varying frequency and intensity of interventions and by comparing different types of joint specific manipulation techniques. Studies in the literature have varied in terms of research design, criteria for improvement, time of evaluation, and techniques examined. The wide variations among studies have made blinded reviews and objective meta-analysis difficult. Anatomy and physics of manipulation Knowledge of biomechanics of direct thrust manipulation has considerably advanced, whereas indirect (ie, nonthrust) manipulation has been studied less. The external mechanical forces involved, duration of application of those forces, and gross anterior and/or posterior displacements have been measured in human subjects, and relative displacements have been measured in cadaver studies. Internal forces and relative displacements of vertebral bodies resulting from applied forces has not been studied. Research has been conducted on the neurologic and neuromuscular responses to direct thrusting procedures; however, study of other types of manipulative therapies in terms of biomechanical parameters or physiologic responses to them has been limited. What has been learned about pain and mechanoreceptors, spinal cord physiology, and normal spinal biomechanics in the last 2 decades has contributed to our understanding of manual medicine and the treatment of somatic dysfunction. Knowledge about small tissue strains is accumulating and being assimilated into thinking about manual medicine. Two primary areas of development and scholarly inquiry include (1) examination of the association of somatic dysfunction with both acute and chronic pain and (2) objective measurement of somatic dysfunction. Further inquiry is warranted to answer questions about the mechanism and efficacy of therapy in the current era of healthcare cost containment.