Research Review By Dr. Michael Haneline©

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Date Posted:

October 2014

Study Title:

Clinical effectiveness of manual therapy for the management of musculoskeletal and nonmusculoskeletal conditions: systematic review and update of UK evidence report

Authors:

Clar C, Tsertsvadze A, Court R, et al.

Author's Affiliations:

Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, England.

Publication Information:

Chiropractic & Manual Therapies 2014, 22: 12.

Background Information:

Several years ago, Bronfort et al. (1) published a paper on the effectiveness of manual therapies that is known as the UK evidence report (RRS reviewed this original report – search for the Research Review titled "Effectiveness of Manual Therapies - The UK Evidence Report" - posted in 2010). That paper provided a comprehensive summary of the evidence supporting the effectiveness of manual treatment for a variety of musculoskeletal and non-musculoskeletal conditions.

In forming their conclusions, the authors of the UK Report considered systematic reviews of randomized clinical trials (RCTs), evidence-based clinical guidelines, as well as all RCTs that were not included in the first two categories. They also considered the quality of the included evidence in forming their conclusions. They discovered 26 categories of conditions that contained RCT evidence for the use of manual therapy. The breakdown of these types of conditions was 13 musculoskeletal, nine non-musculoskeletal, and four classes of chronic headache.

Spinal manipulation/mobilization was reported by Bronfort et al. to be effective for several conditions (e.g., low back pain, headache, cervicogenic dizziness, several extremity joint conditions, and thoracic manipulation/mobilization for acute/subacute neck pain). On the other hand, the evidence was considered to be inconclusive regarding manipulation/mobilization and massage for a number of other conditions.

The purpose of the current review was to build on the prior UK evidence report. The current review:
  • only dealt with evidence that was rated as ‘inconclusive’ or ‘negative’ by Bronfort et al. or was not included in their report;
  • included additional types of studies (e.g., controlled cohort studies, non-randomized controlled clinical trials (CCTs), and qualitative studies) that were not included by Bronfort et al.;
  • synthesized evidence published since Bronfort et al.; and
  • compared the ‘inconclusive’ and ‘not effective’ conclusions garnered from the additional included studies to those of Bronfort et al.

Summary:

The database searches yielded 16,976 non-duplicate records. After applying the inclusion criteria, 178 articles were incorporated into the review and summarized. The records were comprised of 72 systematic reviews, 96 RCTs, and 10 non-randomized studies.

Based on the evidence that was reviewed, serious adverse events after manual therapy were very rare, which was in agreement with the prior UK evidence report.

Studies that were rated by Bronfort et al. as ‘inconclusive’ or ‘negative’ were compared to, and integrated with, the additional studies identified in the current review. In most instances the new evidence did not change the previous ratings; however, in some cases there were changes to the ratings which are itemized below.

Manual Therapies Which New Evidence Resulted in Additions or Changes to Ratings

Musculoskeletal Conditions:
  • Neck Pain – Manipulation and mobilization with or without soft tissue treatment for the treatment of neck pain was not included in the UK evidence report. The current review found inconclusive, yet favorable evidence for these procedures.
  • Temporomandibular Disorders – Not reported in the previous publication, the current review was inconclusive (unclear) evidence regarding mandibular manipulation, as well as inconclusive, favorable evidence regarding intra-oral myofascial therapy, and osteopathic manual therapy applied to the cervical and temporomandibular joint regions.
  • Myofascial Pain Syndrome – Not previously reported, inconclusive (favorable) evidence was found for ischemic compression and integrated neuromuscular inhibition technique in the treatment of myofascial pain syndrome. However, the evidence for trigger point release in active upper trapezius trigger points was inconclusive and non-favorable.
  • Carpal Tunnel Syndrome – Not previously reported, Diversified chiropractic care, Neurodynamic technique, and soft tissue mobilization (with or without Graston instrument) were considered to have inconclusive (unclear) supporting evidence.
  • Rotator Cuff Disorder – Bronfort et al. reported that the evidence for manipulation / mobilization with exercise was inconclusive (favorable) in the treatment of rotator cuff disorder. However, new evidence in the current study was considered to be moderate (positive) in support of the procedures.
  • Adhesive Capsulitis – Not reported in the UK Report, mobilization with movement, osteopathy (Niel-Asher technique), and manual therapy with exercise were shown to have inconclusive (favorable) evidence supporting the treatment of adhesive capsulitis.
  • Minor Neurogenic Shoulder Pain – Not reported previously. New evidence was inconclusive (favorable) for cervical lateral glide mobilization and / or high velocity low amplitude manipulation with soft tissue release and exercise.
  • Soft Tissue Shoulder Disorders – Not previously reported, the evidence for myofascial treatments (ischemic compression, deep friction massage, and therapeutic stretch) in the treatment of soft tissue shoulder disorders was moderate (positive).
  • Ankle Sprains – The use of muscle energy technique for ankle sprains was not previously reported, but it was shown to have inconclusive (favorable) support in the current review.
  • Ankle Fracture Rehabilitation – Kaltenborn-based manual therapy was not covered in the previous report, but new research showed the evidence to be inconclusive (favorable).
  • Plantar Fasciitis – Trigger point therapy in the treatment of plantar fasciitis was not included in the previous UK Report. However, new evidence found in the current review was considered to be inconclusive (favorable).
Headache & Other Conditions:
  • Cervicogenic Headache – The previous report indicated that the evidence supporting mobilization in the treatment of cervicogenic headache was inconclusive (unclear). However, new evidence included in the current study showed moderate, positive support.
  • Tension-Type Headache – The evidence supporting osteopathic care and spinal mobilization for the treatment of tension-type headaches was found to be inconclusive (favorable), based on new evidence in the current review.
  • Miscellaneous Headache – The previous UK Report reported that the evidence for mobilization in the treatment of miscellaneous headaches was inconclusive (favorable). However, new evidence in the current review pointed to moderate (positive) support for mobilization.
Non-Musculoskeletal Conditions:
  • Asthma – The evidence for spinal manipulation in the treatment of asthma was previously considered to have moderate (negative) support, but the current review reported it as inconclusive (unclear). The rating of inconclusive (favourable) for osteopathic manual therapy in treating asthma remained unchanged. Cranio-sacral therapy was not previously reported, but new evidence judged the therapy to be inconclusive (favorable).
  • Attention Deficit Hyperactivity Disorder – Osteopathic treatment for this disorder was not included in the UK Report, but based on new evidence, its supporting evidence was found to be inconclusive (unclear).
  • Cancer Care – This condition was not addressed in the previous report. The current review showed that there was inconclusive (unclear) evidence for chiropractic care; moderate (positive) for massage including myofascial release / strain / counterstrain; and moderate (negative) for manipulation in osteosarcoma.
  • Cerebral Palsy – Not previously reported, osteopathic manual therapy (cranio-sacral, cranial, myofascial release) was found to have inconclusive (unclear) supporting evidence.
  • Chronic Fatigue Syndrome / Myalgic Encephalomyelitis – Osteopathic manual therapy was not previously reported, but the current review found the evidence to be inconclusive (favorable).
  • Chronic Pelvic Pain (interstitial cystitis / painful bladder syndrome / chronic prostatitis) – Myofascial therapy was reported to have inconclusive (favorable) evidence in the current review, although it was not included in the first UK Report.
  • Chronic Pelvic Pain in Women – Not previously reported, there was inconclusive (favorable) evidence for the distension of painful pelvic structures.
  • Chronic Prostatitis / Chronic Pelvic Pain / Female Urination Disorders – Osteopathic manual therapy was not included in the UK Report, but the current review found the evidence to be inconclusive (favorable).
  • Cystic Fibrosis – Mobilization in the treatment of cystic fibrosis was not addressed in the previous report; however, the current review found the evidence to be inconclusive (unclear).
  • Pediatric Dysfunctional Voiding – There was inconclusive (favorable) evidence reported for osteopathic manual therapy, but it was not included in the previous report.
  • Infant Colic – Spinal manipulation for infant colic was previously reported to have inconclusive (negative) evidence, but based on new evidence is now considered inconclusive (favorable).
  • Menopausal Symptoms – Fox’s low force osteopathic technique plus cranial techniques was not included in the previous report, but was found to have inconclusive (favorable) support in the current review.
  • Gastrointestinal Disorders (reflux disease, duodenal ulcer) – Not previously reported, new evidence was found regarding spinal manipulation for this condition which was considered to be inconclusive (unclear).
  • Gastrointestinal Disorders (irritable bowel syndrome) – Osteopathic manual therapy was found to have inconclusive (favorable) support based on new evidence which was not previously reported.
  • Hypertension (stage 1) – Osteopathic manual therapy and Gonstead full spine chiropractic were not included in the UK Report, but new evidence for both was considered inconclusive (unclear) in the current report.
  • Intermittent Claudication – Osteopathic manual therapy in the treatment of intermittent claudication was not previously reported, but new evidence pointed to inconclusive (favorable) support for this modality.
  • Venous Insufficiency – Myofascial release manual therapy combined with kinesiotherapy was not included in the UK Report; however, the current review found new evidence that gave it inconclusive (favorable) support.
  • Insomnia – Not previously reported, new evidence supporting spinal manipulation in the treatment of insomnia was inconclusive (unclear).
  • Parkinson’s Disease – Osteopathic manual therapy in the treatment of Parkinson’s disease was not previously reported, but based on new evidence in the current review, the therapy was considered have inconclusive (favorable) support.
  • Chronic Obstructive Pulmonary Disease in elderly adults – Osteopathic manual therapy for this condition was not included in the previous report, but new evidence is inconclusive (favorable).
  • Back Pain During Pregnancy – Spinal manipulation for back pain during pregnancy was not covered in the prior UK Report. New evidence in the current review points to inconclusive (favorable) support for the procedure.
  • Care during labor / delivery – Not previously reported, new evidence in support of spinal manipulation during labor is inconclusive (unclear).
  • Care of Preterm Infants – Physiotherapeutic / osteopathic manual therapy in the care of preterm infants was not part of the previous report. The evidence found in the current review is inconclusive (unclear).
  • Surgery Rehabilitation – Osteopathic manual therapy as part of surgery rehabilitation was not included in the UK Report, but it was found to have inconclusive (favorable) evidence in the current review.
  • Stroke Rehabilitation – Mobilization in stroke rehabilitation was not covered in the UK Report; however, the current review found inconclusive (unclear) evidence.
  • Systemic Sclerosis – Not previously reported, the evidence in support of McMennell joint manipulation for systemic sclerosis was inconclusive (unclear).

Clinical Application & Conclusions:

The authors provided an overview of the strength of evidence relating to a variety of manual therapies that were provided for many different conditions. This information represents a starting point for general clinical research and decision-making inquiries, and will be helpful to clinicians in the selection of manual procedures to treat these conditions.

It is important to keep in mind that the current review only dealt with evidence that was rated as ‘inconclusive’ or ‘negative’ in the UK Evidence Report by Bronfort et al. Thus, the higher quality evidence that was reported in the previous study was by design not included – please see our review of the prior UK Evidence Report.

Study Methods:

A comprehensive literature search of multiple databases was conducted using the same search criteria utilized in the Bronfort et al. study. The primary search was carried out in August 2011 with an update search undertaken in March 2013.

In order to be eligible for inclusion, studies had to be systematic reviews, RCTs or CCTs, cohort studies with a comparison group, or qualitative studies of patients' perceptions of manual therapy. Primary studies had to include at least 20 participants who were treated with any type of manual treatment (e.g., manipulation / mobilization performed by a manual therapist, chiropractor or osteopath). Studies could only be included if the evidence was rated as ‘inconclusive’ or ‘negative’ by Bronfort et al., or not included in that report.

Study selection and extraction of data from the papers was carried out by 2 independent reviewers. Any disagreements over which studies to include were resolved by discussion.

Several different assessment tools were used to assess new and additional evidence, which led to a rating being assigned to each study. Studies were rated as:
  • high quality, when more than two thirds of the criteria were met;
  • medium quality, when more than a third of the criteria were met; or
  • low quality, when one third or fewer criteria were met.
Based on criteria, such as study quality, consistency of results, and study size, the evidence was rated as being:
  • ‘high quality positive or negative evidence’;
  • ‘moderate quality positive or negative evidence’; or
  • ‘inconclusive favorable, non-favorable or unclear evidence’.
Thus, there could be high or moderate quality evidence with positive or negative findings. The evidence could also be rated as inconclusive, with favorable or non-favorable findings, or it could be unclear.

Study Strengths / Weaknesses

The systematic review methods that were utilized were acceptable and the authors took care to include as much evidence as possible.

The authors concluded that “Overall, there was limited high quality evidence for the effectiveness of manual therapy.” This was mainly because of the low to moderate quality and inconsistency of the evidence that was reviewed. However, this statement does not really provide a balanced perspective on each type of manual therapy and the conditions treated, or of manual therapy overall, since the current study only reviewed evidence that was rated as ‘inconclusive’ or ‘negative’ by Bronfort et al. Thus, the higher quality evidence that was previously reported in the UK evidence report was not included. Moreover, Bronfort et al. concluded that certain manual therapies were effective for several conditions.

The studies that were included in the review mostly had small sample sizes and methodological flaws, such as unclear methods of randomization, uncertainties about treatment allocation, and numerous studies that did not utilize blinding.

When comparing studies, there was substantial variation in the types of manual therapies and their modes of application, as well as differences in control treatments. These disparities limited the ability to effectively compare the results of the studies.