Examples of Manipulation and Body-Based Approaches

This category of complementary and integrative health (CIH) approaches includes a number of widely used therapies.  Often, yoga, tai chi, and qi gong (which were discussed in Chapter 5, “Moving the Body”) are included in this category.  So are manipulative therapies such as chiropractic (which is considered mainstream in the VA Health System), osteopathy, and massage, which are described in more detail in this chapter.  Because massage is on List One, it is featured as a Whole Health tool.  Some other, less familiar therapies in this group that are important to know about include:

Alexander Technique

Developed by an Australian actor of that name, Alexander Technique (AT) was developed in the late 19^th century.^[943]  It is widely used by performing artists and has been found to assist with performance anxiety, though it is not clear that it helps with posture, respiratory function, or performance.^[944]  It may help balance in older adults.^[945]  AT was found to help with pain in a small group of music students.^[946]  It focuses on developing proper body mechanics to minimize poor posture and excess tension in various parts of the body.  This technique is quite safe.

A 2012 systematic review of 18 studies found strong evidence of benefit for chronic back pain and moderate evidence for Parkinson’s-associated disability.^[947]  The need for more study was needed, but there was a suggestion of benefit for general chronic pain, stuttering, respiratory function, and posture.  A 2017 trial comparing acupuncture and AT found that both led to significant reductions in pain and disability at 12 months, compared to usual care.^[948]  A small 2018 trial found that group AT classes were beneficial for neck pain^[949] confirming findings of a 2015 trial.6

Feldenkrais

Feldenkrais, more formally known as Feldenkrais Method (FM), was developed by physicist Moshe Feldenkrais in the 20^th century.^[950]  It may be offered in classes or one-on-one sessions.  People explore their body’s movement patterns and learn exercises that teach their bodies to more effectively carry themselves in space (enhance proprioception) in ways that minimize pain or unhealthy body positioning. 

A 2015 systematic review including seven studies found favorable effects of FM for balance and preventing falls in aging populations, dexterity, body image perception, and comfort.^[951]  It was noted that risk of bias in reviewed studies was high.  Authors noted that FM “...is not a healing or disease-specific mechanism of action but rather one based on more generic learning and self-improvement.”  While few studies have been done, a 2015 trial found improvement in quality of life in people with Parkinson’s disease,^[952] and a 2017 study of 53 people found that FM was comparable with “back school” for treatment of chronic nonspecific low back pain.^[953]  FM has few adverse effects when taught by a knowledgeable instructor.

The Resources section at the end of this chapter has additional information on FM and AT, as well as other approaches. 

Osteopathy

Osteopathic medicine is widely used by doctors of osteopathy (DOs) throughout the United States.  It was developed in 1872 by Dr. Andrew Taylor Still.  His focus was on developing a system of medical care that would promote the body’s innate ability to heal itself.^[954]  He called this system of medicine osteopathy.¹²  As of 2020, there were 36 U.S. osteopathic medical schools, with 31,000 enrolled students (1/4 of all U.S. medical students).^[955]  Their curriculum involves 4 years of academic study, similar to what their MD colleagues receive, in addition to 150 to 200 hours of training in Osteopathic Manual Therapy (OMT), which may also be referred to as osteopathic manipulative medicine (OMM).  OMT might be thought of as being related to specific treatments or interventions, while OMM is more the overarching philosophy of osteopathic care.

Osteopathic physicians subscribe to the practice of treating the whole person, and trainees receive extensive training in structure and function of the musculoskeletal system.  As of 2019, there were just over 121,000 DOs in the United States.^[956]  Approximately 50% of all osteopathic physicians go on to utilize OMT in their practice.^[957]  56% of DOs are primary care physicians.^[958] 

A survey of 927 patietns at 17 different clinics found that most patients receiving OMT were seen for musculoskeletal pain, have worse overall health-related quality of life than average, and they were more likely to be older, female, more educated, white, and wealthier than would be expected based on the demographics of the general population surrounding the clinic.^[959]  This is not necessarily the case for all clinics or all geographic regions.

The four tenets of osteopathic medicine include the following^[960]:

1. The body is a unit.
2. The body possesses self-regulatory mechanisms.
3. Structure and function are reciprocally interrelated.
4. Rational treatment is based on an understanding of body unity, self-regulatory mechanisms, and the interrelationship of structure and function.

During OMT, clinicians look for “somatic dysfunctions,” which are improperly functioning components of the body’s framework.  These components include skeletal and myofascial structures and related vascular, lymphatic, and neural elements.  Evaluation is accomplished through palpation of tender spots, identification of asymmetric bony landmarks, watching for restricted joint motion, and noting abnormal tissue texture. 

Osteopathic (and General Spinal Manual Therapy) Techniques

Osteopathy is one of several types of manipulative therapy.  Many of the techniques it enlists are used by chiropractors as well.  Once a somatic dysfunction has been identified, osteopathic physicians and others will use various techniques, including^[961]:

1. High-velocity low-amplitude (HVLA).  The practitioner uses HVLA thrust techniques to push through a joint restriction and restore the range of motion of a joint.
2. Springing techniques.  The person doing OMT repetitively and gently rocks or pulses movement against the restriction of a joint to restore the range of motion of that joint.
3. Muscle energy technique.  The osteopath creates resistance and asks the patient to push against it to rebalance the tension of the muscles around a dysfunctional joint.
4. Soft tissue techniques.  The physician kneads, stretches, or applies inhibitory pressure to relax soft tissues.
5. Strain-counterstrain techniques.  These techniques involve palpating tender points and then moving joints and muscles into positions where the pain is least.  The position is held until the restriction releases (usually within approximately 90 seconds).  This technique retrains the nervous system to relax the muscle via the Golgi tendon reflex.
6. Facilitated positional release.  In these techniques, the joint or tissue is taken to the position of most comfort.  Traction or compression is applied to facilitate the release of tissue tension.
7. Still technique.  This technique is set up like facilitated positional release, but after traction or compression is applied, the joint is moved through its restrictive barrier.
8. Cranial osteopathy.  This gentle manual technique emphasizes balancing the tension of the dura mater of the brain and working with subtle rhythmic pulsations of the cerebrospinal fluid to correct disturbances in the neuromuscular system.  There are practitioners whose entire practices are based on craniosacral therapy.
9. Lymphatic techniques.  These approaches promote the movement of the lymphatic fluid to promote healing.  They are often used for lymphedema.

It can be helpful to watch demonstrations of the various OMT techniques on YouTube to get a better feel for them.  There is an ongoing effort to fully describe mechanisms of manual therapy; there is a great deal still to learn.^[962]  Manipulation-induced hypoalgesia seems to happen at a systemic level for people, but how much that makes a difference is unclear.^[963]

Efficacy of Osteopathy

Some of the studies described below focused on spinal manipulative therapy (SMT) in general, meaning they also apply to other manipulative therapies, such as chiropractic.  There are many theories about how SMTs work, including by complex effects on the fascial system.  A 2017 study of various lab measures in healthy men found that thoracic manipulation leads to immediate sympathetic activation and reduction in salivary cortisol and a reduced testosterone to cortisol ratio 6 hours after treatment.^[964]  Vasodilation seems to occur in areas beyond those manipulated after treatment.^[965]

Low Back Pain (LBP).  All major international guidelines for LBP (e.g., the British National Institute for Health and Care Excellence, the American College of Physicians, the American Pain Society, European Guidelines, the Italian Clinical Guidelines, and the Belgian Health Care Knowledge Centre) recommend SMT as a treatment option for acute and chronic symptoms.  Patients most likely to respond to SMT include those with^[966]:

• Pain present for less than 16 days
• Symptoms in the legs that do not go below the knees
• Low likelihood of avoiding activity due to fear of pain
• One or more hypomobile lumbar segments noted on palpation
• Internal rotation of one or both hips greater than 35 degrees

In the past few years, several large-scale reviews have found SMT to be beneficial for treating various types of low back pain:

• A 2019 review of 47 trials including 9,211 people found that SMT produces similar effects to other recommended therapies for chronid low back pain.^[967]
• A 2017 review featured in Journal of the American Medical Association reported that 15 studies (1711 patients) offered moderate-quality evidence for benefit of SMT for acute back pain, noting that there was substantial heterogeneity to results.^[968] 
• Similarly, a 2017 review of nonpharmacologic therapies for back pain notes that evidence continues to support effectiveness of SMT for chronic low back pain as well.^[969]
• SMT is suggested as one of several nonpharmacologic options for treating acute and chronic low back pain in a recent clinical practice guideline form the American College of Physicians (strong recommendation, low-quality evidence).^[970]
• A 2016 comparative effectiveness review by the Agency for Healthcare Research and Quality concluded there is moderately strong evidence spinal manipulation was as effective for back pain as other active interventions.^[971] 
• A 2014 review also concluded that OMT reduces pain and improves function in both acute and chronic nonspecific low back pain.^[972]
• A 2016 review found that chiropractic care, specifically, was equally effective as physical therapy for low back pain, based on findings from six trials.^[973]
• When compared to therapeutic exercise, OMT was more helpful for chronic nonspecific low back pain (though both had significant benefit).^[974]
• A 2019 review or 26 studies concluded that muscle energy techniques are effective for reducing both acute and chronic low back pain.^[975]

Neck Pain.  A randomized, controlled trial (RCT) of 41 patients receiving OMT for chronic neck pain found significant reduction in pain intensity at 12 weeks compared to sham treatment,^[976] and another RCT of 201 patients found improved short-term physical and long-term psychological outcomes with OMT compared to usual care.^[977]  Yet another RCT found SMT was more effective than medication in subacute and acute neck pain.^[978]

Headaches.  A 2010 study of 80 patients found that, compared with those receiving massage therapy, the group receiving SMT had greater improvements in pain and disability.^[979]  Craniosacral therapy, a very gentle form of manipulation of the skull bones and the sacrum, is also thought to be effective for headaches.^[980]  One systematic review concluded that massage therapy, physical therapy, relaxation, and chiropractic SMT might be as effective as the drugs propranolol and topiramate for migraine prevention.^[981]

Guidelines developed after a 2009 review of 21 articles concluded that spinal manipulation and massage are recommended for episodic or chronic migraines, but was not clearly beneficial for episodic or chronic tension-type headaches.^[982]  One OMT-specific trial involving 63 patients found that direct and indirect myofascial release techniques were more effective than the control intervention for tension headache.^[983]  Another OMT-specific RCT of 29 patients found that participants who did relaxation exercises and received three osteopathic treatments had significantly fewer days per week with headaches than those who relied on relaxation exercises alone.^[984]  A retrospective review of the medical records of 631 patients between 2002 and 2007 found that patients treated with OMT at an osteopathic clinic had a 50% reduction in cost compared to those who received conventional hospital care.^[985] 

Chronic Pain in General

A review of ten trials with 681 patients with a variety of forms of pain found that craniosacral therapy led to “significant and robust effects” lasting up to six months.^[986] 

Other Diagnoses. For other conditions, recent research indicates the following (noting that this list is by no means comprehensive):

• Heart surgery recovery.  OMT is effective in reducing pain and speeding up functional recovery in people who have had heart surgery with sternotomy.^[987]
• Pneumonia.  Thoracic and abdominal lymphatic pump therapy is used to facilitate flow through the lymphatics and activate the immune system.^[988]  The Multicenter Osteopathic Pneumonia Study in the Elderly evaluated 406 patients over age 50 with pneumonia.  Protocol analysis found decreased mortality rates and duration of antibiotics treatment in the OMT group as compared to the group that received conventional care.19
• Pregnancy.  Two RCTs have found that OMT has “medium to large” treatment effects in preventing progressive, back-specific dysfunction during the third trimester of pregnancy.^[989],[990]  A 2003 RCT compared 160 women who received OMT throughout pregnancy to 161 women who did not and found decreased frequency of meconium-stained amniotic fluid and decreased occurrence of preterm delivery in the OMT group.^[991]
• Fibromyalgia.  A small study favored OMT for lowering pain threshold, perceived pain, chronic pain, and ability to perform activities of daily living.^[992]
• Gastroesophageal reflux disease (GERD).  A trial involving 20 people receiving visceral OMT found potential benefit for GERD.^[993] 
• Chronic obstructive pulmonary disease (COPD).  When OMT was added to medical treatment, people with chronic obstructive pulmonary disease did significantly better on all spirometery measures studied.^[994]

Osteopathy and Other Forms of SMT: Safety

Most studies of the risk of spinal manipulation do not distinguish between which practitioners do the manipulation, be it osteopaths, chiropractors, physical therapists, or others.  Common transient effects after treatments include local pain, headache, tiredness or fatigue, and radiating pain.  These occur in 30% to 61% of patients.^[995]  These symptoms begin within four hours and usually resolve within 24 hours.  One systematic review found that worsening disk disease occurs in less than 1 in 3.7 million patients.^[996]  Another study found that 4.3% of subjects experienced neck stiffness after initial spinal manipulation, and it disappeared for all cases after 2 weeks.^[997]  Spinal manipulation was noted to have a low risk of stroke ranging from 1.46 to 5 strokes per 100,000 manipulations.^[998]  A 2017 review of 118 studies found that the range of complications of manipulation ranged from 1 in 20,000 to 1 in 250 million manipulations.^[999]  A 2019 review in the British Medical Journal also noted that safety data is reassuring overall.25

Chiropractic Care

Chiropractic care was originally developed in the late 1800s as a drug-free approach to health care, which was very appealing at that time, since many of the drugs in use had some serious side effects.  The word “chiropractic” combines the Greek words cheir (hand) and praxis (practice) to describe a treatment done by hand.^[1000]  Hands-on therapy—especially spinal manipulation and other manual treatments—is central to chiropractic care.

There are over 100,000 chiropractors worldwide; a large proportion of them are in the U.S.^[1001] In the U.S., chiropractic care has historically been one of the most commonly used CIH approaches.^[1002]  Approximately 14% of the general U.S. population will see a chiropractor in a given year,^[1003] and in patients with chronic pain the rate is as high as 40%.^[1004]  Chiropractic care is covered by Medicare and most U.S. insurance carriers.  It has been provided in the Department of Defense health care system since 1995 and in the Department of Veterans Affairs health care system since 2004.^[1005]  In 2015 the Joint Commission added chiropractic care to its pain management standards for health care facilities.^[1006]  With these and other advancements and integration, today’s chiropractic profession is often thought of as being “at the crossroads” between complementary and conventional medicine.^[1007]

Training and Practice

Doctor of Chiropractic (DCs)—also known as chiropractic physicians or simply chiropractors—are licensed and regulated in every U.S. state and the District of Columbia.  There are 15 U.S. chiropractic schools, each accredited by the Council on Chiropractic Education,^[1008] with a curriculum of four academic years covering the biomedical sciences, public health, and other areas similar to medical school.  Residency training is optional for chiropractors, but those seeking advanced training may complete a one-year residency program and/or fellowship programs of another 1-2 years.

Chiropractors are typically trained and licensed to diagnose and manage a broad range of conditions using many treatments except prescription drugs and surgery.  Most commonly this includes musculoskeletal problems like low back pain, arthritis, sports injuries, or other problems involving joints and muscles.  An analysis of the use of complementary health approaches for back pain, based on data from the 2002 NHIS, found that chiropractic was by far the most commonly used therapy.  Among survey respondents who had used any of these therapies for their back pain, 74% (approximately 4 million Americans) had used chiropractic.  Among those who had used chiropractic for back pain, 66% perceived “great benefit” from their treatments.^[1009]

History of Chiropractic Care in the VA

In response to Veteran demand, Congress authorized VA to begin providing chiropractic services in 1999.  Since late 2004, chiropractic services have been included as part of the standard Medical Benefits Package available to all enrolled Veterans.^[1010]  VA provides these services on-station and/or by community care mechanisms at all medical centers.  In VA, DCs are physician-level licensed independent practitioners similar in level to optometrists and podiatrists. 

VA chiropractic services are used by Veterans across the continuum of care, yet there is particular value in populations with a high prevalence of musculoskeletal conditions such as OEF/OIF/OND Veterans, chronic pain populations, women Veterans, older adults, and spinal cord injury/illness.  From fiscal years 2005 through 2015 the number of VA chiropractic clinics increased from 27 to 65, and the number of Veterans receiving care at these clinics increased from over 4,000 to over 37,000.  The number of Veterans receiving community chiropractic services during this time increased from over 1,000 to over 15,000.^[1011]

Components of Chiropractic Care

A visit to a chiropractor starts with a history in which the patient discusses their current problem, overall health, and specific goals for care.  The chiropractor will review any medical records, images, or other studies related to the patient’s health, and perform a standard physical examination of the area in question.  This includes standard medical orthopedic and neurological examination procedures, along with some specialized hands-on assessment of the muscles and joints.  It is rare that new x-rays or other studies will be needed, but if so, the chiropractor will order the applicable tests.  Once a diagnosis is made and it is determined that chiropractic treatment is appropriate, the chiropractor will work with the patient to formulate an individualized treatment plan that may include the following:

• Education and instruction on self-care, prevention, ergonomics, and how to best manage the problem from the patient’s perspective
• Appropriate home exercises to improve flexibility, strength, and/or balance
• Manual therapies for the joints, such as manipulation or mobilization (explained in more detail below)
• Manual therapies for the muscles, such as stretching, massage, and myofascial techniques
• Various mind-body approaches, such as progressive muscle relaxation or stress reduction
• Nutrition and dietary advice
• Acupuncture

Some problems respond to chiropractic care more quickly than others, and some may not respond at all.  In general, newer (acute) problems begin to improve within the first 1-2 visits, whereas older (chronic) problems might take 4-5 visits to show any response.  A typical rule of thumb is to plan an initial trial of 4-6 visits.  If there is no improvement, and no reasonable change in course that the chiropractor can provide, then the trial should be stopped, and other treatment options considered.  On the other hand, most patients do report some good benefit within the initial 4-6 sessions.  Some may be fully improved and will be discharged from care with appropriate home instructions.  Others may have partial benefit, and another few sessions could be provided to attempt to reach additional improvement.  Even in longstanding, difficult problems, most patients tend to reach their plateau of improvement with chiropractic care within 8-12 visits.  For chronic pain conditions that improve after the initial trial and then worsen sometime afterward, it can be appropriate to use additional chiropractic treatment from time to time to assist with flare-ups. 

Important Facts About Spinal Manipulation

As mentioned above, various manual (hands-on) treatments are the mainstay of chiropractic practice.  Although there are many names for various techniques, from a biomechanical perspective manual therapies can be classified into two groups: mobilization and manipulation.  In each of those, the patient’s joints are being moved by a doctor or other clinician.  In mobilization techniques, the joint is moved by applying lower amounts of force using slower and typically repetitive movements.  In manipulation techniques, the joint receives a quicker, single thrust which aims to “pop” the joint.  Following are the most common FAQs about manipulation.

What Causes The Popping Sound?  Are My Bones Cracking?

Your bones are not cracking!  The popping sound is caused by movement of the joint surfaces and the joint’s lubricating fluid.  To understand this better, you need to know a little bit more about the spinal joints.

A joint is made up of the surfaces of two bones that must slide over or pivot around each other for normal movement.  These surfaces are lined with smooth cartilage and enclosed in an elastic tissue called the joint capsule.  This capsule is filled with a fluid which lubricates and nourishes the cartilage. 

The fluid is pressurized and has gasses dissolved inside, similar to carbonated soda.  When a joint is injured or too stiff, the joint capsule becomes painful (left image below).  During spinal manipulation, the joint capsule is stretched, and some gas bubbles are released inside the capsule—similar to the bubbles that are released when a soda bottle is opened.  And that is what causes the popping sound.

Many times, back and neck pain is the result of joints that are not moving properly.  Imagine a door that only opens halfway because of a stiff hinge.  You could still use it, but it is more troublesome than a door that opens fully.  Tight spinal joints can be thought of in the same way as stiff hinges.  When a proper force is applied to a “stuck” joint, its motion can be improved.  Also, through a nervous system reflex, manipulation decreases muscle spasm or tension, and decreases pain sensation.

Does It Hurt?

A carefully administered adjustment usually does not hurt.  Many people feel a great deal of relief right afterward.  But if your joints are very stiff, there could be some temporary increased soreness that typically goes away quickly and leads to improvement. 

Is Spinal Manipulation Safe and Effective?

Spinal manipulation is very safe.  There is a large amount of scientific evidence on the safety and effectiveness of spinal manipulation, so much so that it is included in widely recognized medical guidelines for the treatment of most low back and neck pain complaints.28^,29^{,[1012],[1013]}  The risk of injury occurring as a side effect of manipulation is extremely low, especially when compared to other common treatments for back and neck pain.  However, as with all medical procedures, there is some inherent risk.  VA chiropractors are well-trained and experienced to determine the safety of manipulation in your particular case.  General research findings related to spinal manual therapies are summarized in the “Osteopathy” section of this chapter.

What Clinicians Deliver Spinal Manipulation?

Spinal manipulation can be delivered by MDs (although this is very rare) and sometimes by DOs.  In some states, manipulation is being added to the scope of practice for physical therapists.  However, manipulation is typically associated with the chiropractic profession.  Chiropractic education requires extensive classroom work and hundreds of supervised patient encounters involving manipulation.  Previous reports estimate that chiropractors provide over 94% of the spinal manipulation treatments in the U.S.^[1014]

Relationship between Chiropractic Care, Opioids and Other Interventions

One important reason to consider chiropractic care is that it may prevent patients from receiving other types of treatments that have greater risk and higher cost.  Studies have shown that patients with spinal pain conditions who receive chiropractic care are less likely to receive opioids.^{[1015],[1016],[1017]}  For spine-related conditions, early access to chiropractic services correlates with decreased chronic work disability, advanced imaging, spinal injections, elective lumbar surgery, and overall health care expenditures.^{[1018],[1019],[1020],[1021],[1022]}  Data from United Healthcare on over 4 million episodes of care for non-surgical spine conditions shows that patients who never see a DC have double the total episode cost ($1,309 vs. $654) and are much more likely to receive an opioid prescription (13.3% vs. 4.8%) or an unnecessary MRI (48.7% vs. 26.2%) than patients who see a DC as the initial clinician for that problem. 

 Whole Health Tool: Massage

What Is It?

Massage has been used since before recorded history, and it remains a popular CIH approach.  Therapeutic massage (massage to help specifically for pain) is on the VA Integrative Health Coordinating Center’s (IHCC) List One (see Chapter 14).  It is mandated that therapeutic massage will be available in all VA facilities for pain treatment, and sites continue to explore how it will be made available and under what circumstances.  The Massage Therapist Qualification Standard was released in March 2019.^[1023]

In 2012, 6.9% of Americans had experienced some form of massage in the past year.^[1024]  Use in people with pain is much higher; a Canadian study reported that 56% of patients with nonspecific chronic back pain and 48% with arthritis or other musculoskeletal disorders had used it over the last 12 months.^[1025]  Aside from mind-body approaches and animal-assisted therapies, massage is currently one of the most widely available complementary approaches used in the VA.  In 2015, 52 of 131 (40%) of sites surveyed reported offering some form of massage therapy to their Veterans.16

Massage therapist training and licensing standards vary greatly from state to state.^[1026]  There is also variability from school to school.  Common certifications you will see after a therapist’s name include CMT (certified massage therapist) and LMT (licensed massage therapist).  CAMT stands for “certified acupressure massage therapist.”

Types of Massage Therapy

Massage therapy has been defined as “the systematic manipulation of soft tissue with the hands that positively affects and promotes healing, reduces stress, enhances muscle relaxation, improves local circulation, and creates a sense of well-being.”  Types of massage therapy include the following^{[1027],[1028],[1029]}:

• Swedish massage (and similar schools) involves stroking and kneading the body using various methods.  5 basic massage techniques are used, including:
• Effleurage—stroking with various degrees of pressure.  This is what most people think of when they think of a massage.
• Petrissage—a kneading motion, done with the fingers and thumbs in a circular pattern
• Tapotement—rhythmic, vigorous tapping or slapping done to stimulate deep tissues
• Friction—use of the palm, forearm, heel of the hand, or even the elbows to roll, ring, and compress tissue
• Vibration—can be done using hands or using a machine
• Shiatsu is based on massaging over trigger points and pressure points.  Therapists most commonly use the balls of their thumbs and follow points called tsubos, which are often pressed or held, and correlate with acupuncture points. 
• Neuromuscular massage involves applying pressure throughout the body, not just in areas that are sore.  Pressure is usually much higher than other forms of massage therapy.  Neuromuscular therapy (or neuromuscular technique) involves a careful examination and manipulation of the soft tissues of a specific area of the body.  It is often used to treat chronic pain.
• Visceral massage involves the gentle manipulation of the visceral organs of the abdomen and pelvis.  Mayan abdominal massage, which has been passed down for centuries, is one example.

How Massage Works

Massage is thought to reduce the effects of stress on the muscles and to ease tension and correct unhealthy postures, all of which can contribute to chronic disease in various ways. Massage therapy’s healing benefits are thought by many to occur, at least in part, through the movement of the fascia, the net of connective tissue that surrounds the muscles and other tissues.  When the fascial network is subjected to an injury or stress, resultant adaptations by the body (shifts in how the body carries itself, for example) can have widespread health consequences.  Massage therapy and other touch therapies are thought to restore fascial balance.18

Even as far back as 2004, a meta-analysis of 37 studies found that a single massage therapy session led to the following^[1030]:

• Reduced anxiety and depression (multiple sessions were actually found to have comparable benefits to psychotherapy)
• Lowered blood pressure
• Decreased heart rate

Single sessions were not found to immediately reduce pain, improve mood, or lower cortisol levels, but repeated sessions were noted to reduce pain. 

When to Use It

The Evidence Map below  demonstrates the QUERI Evidence Map of Massage for Pain, which covers research through February 2016.^[1031]  Note that the farther up and to the right a given condition’s circle is, the more favorable the literature is for massage for being beneficial.  Note the following:

• The best support is for lower back pain, neck pain, shoulder pain, labor, and pain in multiple areas
• There are weaker findings supporting potential benefits for TMK, fibromyalgia, cancer pain, and neck/shoulder pain.

Evidence Map of Systematic Reviews Describing the Effect of Massage for Pain

It can be helpful to go into more detail as far as research findings.

Pain.  Pain is one of the main reasons people use massage, and research favors massage for many aspects of pain control.  Pain is the indication for which massage is covered for Veterans. 

• General pain.  A 2016 review of 60 high- and 7 low-quality studies concluded that massage therapy should be strongly recommended as a pain management option, compared to no treatment.  It also “weakly recommended” massage for improving mood and health-care related quality of life.84  A review of 26 trials found that massage therapy, as a stand-alone treatment, reduces pain and improves function in some musculoskeletal conditions (back pain, knee arthritis, shoulder pain), but did not show a clear benefit when compared to other active treatments.^[1032] Another 2016 review of 16 studies found weak evidence of benefit for pain and
• Back pain.  A 2015 Cochrane review of 25 trials did not find massage to be an effective low back pain treatment, though in the short-term people reported benefits.^[1033]
• Neck pain.  A 2014 meta-analysis concluded that there is moderate evidence supporting that massage therapy improves neck pain, but not dysfunction (e.g., limited range of motion).^[1034]
• Post-surgical pain.  A 2016 review of 12 high- and 4 low-quality studies found enough data to “weakly recommend” massage for reducing pain and anxiety in patients undergoing surgical procedures.^[1035]  A 2017 review of 10 studies including 1,157 patients found that massage therapy may alleviate post-operative pain, though methodological quality of studies was low.^[1036]  Another review found it serves as a useful adjunct to medications for reducing post-cardiac surgery pain intensity.^[1037]
• Cancer pain.  A 2016 review of 16 studies found that “...weak recommendations are suggested for massage therapy, compared to an active comparator, for the treatment of pain, fatigue, and anxiety.”93  A 2105 meta-analysis of 12 studies with 559 participants concluded, “massage significantly reduces cancer pain compared to no massage or conventional care.”^[1038]  Reflexology, which includes foot massage, was found to have more of an effect than aromatherapy or body massage.  In contrast to these results, a Cochrane review concluded that overall, studies were too small to draw a conclusion.^[1039]
• Arthritis.  A 2017 review found seven small trials involving 352 people which concluded there is low- to moderate-quality evidence supporting massage over non-active therapies for improving osteoarthritis or rheumatoid arthritis outcomes.^[1040]
• Fibromyalgia.  A unique 2015 study looked at which types of massage therapy were most helpful in fibromyalgia.^[1041]  (Many studies do not differentiate the types of massage used when data is compiled.)  It was found that “myofascial release had large, positive effects on pain and medium effects on anxiety and depression.”  Shiatsu and connective tissue massage also improved several outcomes, but Swedish massage was not found to do so.  Another 2014 meta-analysis of nine trials involving 404 patients with fibromyalgia found that treatment with massage therapy for five weeks or longer led to immediate and lasting improvements in pain, depression, and anxiety.^[1042]

Blood Pressure.  A 2014 systematic review concluded that massage therapy combined with anti-hypertensives was more effective than the drugs alone for lowering blood pressure.^[1043]  Reduction of systolic pressure averaged about 7 points, and 3.6 points for diastolic pressures.  However, overall quality of the studies was poor.  There are a number of theories surrounding how massage affects blood pressure, including that it may decrease sympathetic nervous system activity and alter adrenal cortex activity.^[1044] 

Other Indications.  While more research is needed, massage therapy’s overall safety and broad availability make it a worthwhile approach to consider.  Natural Medicines, which summarizes research for given therapeutic approaches, rates massage as “Likely Effective” for back pain and cancer related pain and “Possibly Effective” for ADHD, fibromyalgia, labor pain, low birth weight, and stress.  The verdict is still out for many other conditions, including alcohol use disorder, asthma, carpal tunnel syndrome, dementia, diabetes, headache, multiple sclerosis, osteoarthritis, Parkinson’s, premenstrual dysphoric disorder, rheumatoid arthritis, and other types of pain.^[1045]  Abdominal massage may be effective for constipation management in elderly people,^[1046] as well as in people taking opioids.^[1047]

A wide-ranging 2016 review concluded that massage therapy “...has been shown to have beneficial effects on varying conditions including prenatal depression, preterm infants, full-term infants, autism, skin conditions, pain syndromes including arthritis and fibromyalgia, hypertension, autoimmune conditions including asthma and multiple sclerosis, immune conditions including HIV, and breast cancer and aging problems including Parkinson’s and dementia.”^[1048]  A 2018 review of 8 trials with 657 participants found that acupoint massage likely maintains cognitive function in older adults.^[1049]

What to Watch Out for (Harms)

When done by a skilled therapist, massage therapy is quite safe.91  Contraindications to massage, according to some therapists, include the following106:

• Infectious or contagious skin conditions
• Acute inflammation (e.g., rheumatoid arthritis, appendicitis)
• Massage near open skin wounds, burns, or other friable tissues
• Varicose veins and venous inflammation (thrombophlebitis)
• Sites of tumors or metastases.  Even though it is unlikely that massaging an area with cancer would be any more likely to cause metastases to split off than exercise would, many practitioners recommend avoiding direct massage of cancerous areas
• Low bone density (for techniques that use high pressure)
• Coagulopathies that would result in massage therapy causing severe bruising
• Risk of recurrent bleeding at a site that has recently been injured or traumatized

A good therapist will always clarify whether there are any particularly vulnerable places, or places where a person simply prefers not to be touched.  Appropriate draping should always be practiced. 

In conclusion, when you are helping Veterans to create Personal Health Plans (PHPs), keep body-based therapies in mind.  They can be useful for many different patient conditions.

Manipulative and Body-Based Therapy Resources

Websites

VA Whole Health and Related Sites

• Evidence Map of Massage for Pain.  Compilation of systematic review data by VA Health Services Research and Development (HSR&D). https://www.hsrd.research.va.gov/publications/esp/massage.pdf
• Integrative Health Coordinating Center SharePoint on Massage Therapy. https://www.va.gov/WHOLEHEALTH/professional-resources/IHCC.asp
• CIH Listservs.  To be added, contact:
• Massage Therapy listserv: vhamassage@DVAGOV.onmicrosoft.com
• Other listservs: Lana.Frankenfield@va.gov
• National CIH Subject Matter Experts, as of FY 2020.
• Chiropractic: Anthony Lisi.  Anthony.Lisi@va.gov
• Massage Therapy: Sharon Weinstein.  Sharon.Weinstein@va.gov
• Chiropractic Care.  http://vaww.rehab.va.gov/CS/index.asp 

Whole Health Library Website

• Personal Health Plan Template. https://wholehealth.wisc.edu/wp-content/uploads/sites/414/2018/08/Brief-Personal-Health-Plan-Template.pdf

Other Websites

• American Association of Colleges of Osteopathic Medicine.  https://www.aacom.org
• American Chiropractic Association.  https://www.acatoday.org
• American Massage Therapy Association (AMTA) Research Roundup. https://www.amtamassage.org/resources/massage-and-health/?src=navdropdown
• American Osteopathic Association.  https://osteopathic.org
• Associated Bodywork and Massage Professionals. https://www.abmp.com/
• Chiropractic: In Depth.  National Center for Complementary and Integrative Health (NCCIH).  https://nccih.nih.gov/health/chiropractic
• Feldenkrais Guild of North America.  www.feldenkrais.com
• Massage Therapy: What You Need to Know.  National Center for Complementary and Integrative Health (NCCIH).  https://www.nccih.nih.gov/health/massage-therapy-what-you-need-to-know
• National Certification Board for Therapeutic Massage and Bodywork. https://www.ncbtmb.org/
• The Complete Guide to the Alexander Technique.  https://www.alexandertechnique.com/at.htm

Books

• Atlas of Osteopathic Techniques, Alexander Nicholas (2015)
• Basic Clinical Massage Therapy: Integrating Anatomy and Treatment, James Clay (2008)
• Body, Breath, and Being: A New Guide to the Alexander Technique, Carolyn Nicholls (2014)
• Chiropractic Technique: Principles and Procedures, Thomas Bergmann (2010)
• Feldenkrais: The Busy Person’s Guide to Easier Movement, Frank Wildman (2006)
• Myofascial Pain and Dysfunction, Volume 1, David Simons (1998).  Excellent resource for strain-counterstrain
• Myofascial Pain and Dysfunction, Volume 2, Janet Travell (1992)
• Osteopathic and Chiropractic Techniques for manual Therapists: A Comprehensive Guide to Spinal and Peripheral Manipulations, Giles Gyer (2017)
• Osteopathic Techniques: The Learner’s Guide, Sharon Gustowski (2017)
• Somatic Dysfunction in Osteopathic Family Medicine, Kenneth E. Nelson (2014)
• The World’s Best Massage Techniques: The Complete Illustrated Guide to Eastern and Western Techniques, Victoria Stone (2010)

Special thanks to Amy Bauman, MD who wrote the original Whole Health Library tool on Osteopathy that inspired the content of the Osteopathy section.

The section on Chiropractic Care was contributed by Anthony J. Lisi, DC, Director, VHA Chiropractic Service, and Section Chief, Chiropractic Service, VA Connecticut Healthcare System.