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Research Review By Dr. Brynne Stainsby©


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Date Posted:

May 2020

Study Title:

Effects of manual therapies on stability in people with musculoskeletal pain: a systematic review


Kendall JC, Vindigni D, Polus BI, Azari MF & Harman SC

Author's Affiliations:

Chiropractic, School of Health and Biomedical Sciences, RMIT University; Engineering, RMIT University, Bundoora, Australia.

Publication Information:

Chiropractic & Manual Therapies 2020: 28(13). https://doi.org/10.1186/s12998-020-0300-9

Background Information:

The global population is aging – it is estimated that by 2060, 28% of the population will be over the age of 65 (1). With this comes and an increased risk of escalating morbidity (people living longer in poor health) (2). Due to less coordinated gait, poor balance and decreased muscle strength, fall risk is a major health concern in the older population (3-5). Chronic musculoskeletal (MSK) pain in older adults has also been associated with a previous history of falls and an increased occurrence of future falls (6, 7). The severity and frequency of chronic MSK pain sites have been associated with reduced balance performance and increased fall risk (8). Manual therapy is commonly used for MSK pain and two prior systematic reviews have demonstrated evidence that manual therapy may also improve balance associated with reduction in pain intensity in symptomatic subjects (9, 10). The term stability has been used to denote how balance is controlled via a complex integration of information from multiple body systems. Put simply, deficits in balance control are associated with decreased stability. Clinical tests of stability such as sit-to-stand or single-leg stance can test the neurophysiological mechanisms that maintain balance and give us an idea of a particular patient’s capacity in this sense.

The objective of this systematic review was to examine the effectiveness of manual therapies for MSK pain on stability (defined for this review as experiencing a fall, self-reported fear of falling, and reduced performance on objective measures of mobility and balance). Further, the authors intend the results of this review to provide important information for future trials of manual therapy on MSK pain using clinical or objective stability measures.

Pertinent Results:

Literature Search and Included Studies:
  • A total of 2509 titles and abstracts were screened for eligibility, 150 potentially relevant articles were identified for full-text screening, and 26 were included in the study (11-36).
  • The MSK diagnoses included knee osteoarthritis (OA), knee/hip OA, low back pain (LBP), neck pain, fibromyalgia, ankle arthropathy and post-vertebral fracture.
  • Manual therapies included manipulation (13, 23, 24, 29, 30, 32, 36), mobilization (15, 21, 23, 24, 30, 32, 36) and massage (11-15, 19, 21, 22, 26, 30-33, 35).
  • Exercise was the most commonly compared intervention, prescribed as part of a supervised program, home exercise program or in combination. Comparison interventions also included no treatment, usual care or sham.
  • Outcome measures included clinical balance measures (gait speed, timed up-and-go [TUG], sit-to-stand, step test) and balance performance (static posture, force plate centre of pressure). No studies that met inclusion criteria were found that measured the number of falls or psychological concerns of falling.
  • Studies included in the meta-analysis included outcomes of gait speed, TUG test, step test and sit-to-stand test. There was a high level of heterogeneity, so results of the meta-analysis should be interpreted with caution.
  • Overall, the risk of bias analysis determined included studies were of low or unclear level of bias. It should be noted that performance bias (blinding of providers) was assessed to be high in all but one of the included studies.
Literature Summary:
  • Manual therapy significantly improved gait speed and TUG test performance compared to other interventions in the short-term only. Gait speed improved by 0.09 m/s (95% CI: 0.04, 0.13) while the TUG test scores significantly improved -0.53s (95% CI: -0.99, -0.07) in the short-term only.
  • Five out of eight of the studies using objective balance measures noted an improvement in balance.

Clinical Application & Conclusions:

This review identifies the possible effects of manual therapy on measures of balance and stability in people with MSK pain. Improvements have been identified in gait speed and timed up-and-go (TUG) performance following manual therapy, as well as improvement in objective balance measures. It is interesting to note that the most common presenting complaints in the included studies included lower limb and LBP. Future studies should investigate if the improvement in balance is related to body pain site, particularly if differences are observed between upper and lower limbs.

Clinically meaningful change in gait speed has previously been reported/defined as a change larger than 0.05 m/s, with a substantial change as 0.1 m/s (37). The average improvement of the included studies suggests a nearly substantial improvement in gait speed following manual therapy when compared to other interventions. It should be noted that the average improvement in the TUG test was statistically significant, but did not meet the threshold of a minimum clinically important difference. These results are preliminary and should be interpreted cautiously, however, any intervention that reduces pain intensity and may result in a decrease in falls warrants further, high-quality investigation.

Importantly, the reviewers noted that little information was provided regarding the optimal frequency and duration of the studied interventions. This highlights the need for future high-quality research regarding the effectiveness of manual therapy, the optimal dose for prescribing it, and perhaps the role of combining manual and active therapies.

Study Methods:

  • Only controlled trials published in the English language were included. To be included, participants must have been over 18 years of age with MSK pain of the spine or extremities (including multiple body sites), while studies of healthy participants or those with non-MSK pain were excluded. Studies must have included at least one component of manual therapy (manipulation, mobilisations or massage), and could have been applied in combination with other therapies. Outcome measures could include number of falls, clinical balance measures, objective balance measures and subjective measures of stability.
  • Six databases were searched in January 2018 using appropriate search terms for each database.
  • Two authors independently screened titles and abstracts for inclusion.
  • Two authors independently appraised each study using the 12-item Cochrane Risk of Bias assessment (38).
  • Data analysis was conducted by two independent authors.
  • Studies with outcome measures utilized by two or more studies were selected for meta-analysis. Short-term outcomes were classified as immediate to three-month follow-up, while long-term outcomes were classified as greater than three months. Studies that were not included in meta-analysis were included in the descriptive synthesis.

Study Strengths / Weaknesses:

  • Independent screening of titles and abstracts, and full texts.
  • Generally, only studies assessed to have a low risk of bias were included, though it should be noted that the authors did include studies with “unclear” risk of bias.
  • Assessment of risk of bias was performed with a validated set of criteria.
  • In addition to methodological quality, clinical relevance was also assessed.
  • Two authors independently extracted the data from the included articles.
  • The primary limitation of this study relates more to the quality of the body of evidence than the methodology of the review itself.
  • The research question and systematic search strategies were not thoroughly described.
  • Although the authors used a validated tool to assess risk of bias, the inclusion of studies with “unclear” risk of bias does require results to be interpreted with degree of caution.
  • The sample sizes of the included studies were not reported.
  • The participants and interventions were not clearly defined, which limits the external validity of the review.
  • Given the heterogeneity of the included studies, the findings of the meta-analysis should be interpreted with a great degree of caution.

Additional References:

  1. Cimas M, Ayala A, Sanz B, et al. Chronic musculoskeletal pain in European older adults: Cross-national and gender differences. Eur J Pain 2018; 22(2): 333–345.
  2. Rechel B, Grundy E, Robine JM et al. Ageing in the European Union. Lancet 2013; 381(9874): 1312–1322.
  3. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006; 35 Suppl 2: ii37-ii41.
  4. Patel KV, Phelan EA, Leveille SG, et al. High prevalence of falls, fear of falling, and impaired balance in older adults with pain in the United States: findings from the 2011 National Health and aging trends study. J Am Geriatr Soc 2014; 62(10): 1844–52.
  5. Tinetti ME, Kumar C. The patient who falls: “It’s always a trade-off”. JAMA 2010; 303(3): 258–66.
  6. Asai T, Misu S, Sawa R et al. Multi-chronic musculoskeletal pain is a useful clinical index to predict the risk of falls in older adults with normal motor function. Aging Clin Exp Res 2015; 27(5): 711–6.
  7. Leveille SG, Jones RN, Kiely DK et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA 2009; 302(20): 2214–21.
  8. Stubbs B, Schofield P, Patchay S et al. Musculoskeletal pain characteristics associated with lower balance confidence in community dwelling older adults. Physiotherapy 2016; 102(2): 152-8.
  9. Ruhe A, Fejer R, Walker B. Does postural sway change in association with manual therapeutic interventions? A review of the literature. Chiropr & Manual Ther 2013; 21(1): 9.
  10. Holt KR, Haavik H, Elley CR. The effects of manual therapy on balance and falls: a systematic review. J Manip Physiol Ther 2012; 35(3): 227–34.
  11. Abbott JH, Chapple CM, Fitzgerald GK et al. The incremental effects of manual therapy or booster sessions in addition to exercise therapy for knee osteoarthritis: a randomized clinical trial. J Orthop Sports Phys Ther 2015; 45(12): 975–83.
  12. Abbott JH, Robertson MC, Chapple C et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness. Osteoarthr Cartil 2013; 21(4): 525–34.
  13. Bennell KL, Egerton T, Martin J et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA 2014; 311(19): 1987–97.
  14. Bennell KL, Hinman RS, Metcalf BR et al. Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Ann Rheum Dis 2005; 64(6): 906–12.
  15. Bennell KL, Matthews B, Greig A et al. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord 2010; 11: 36.
  16. Beselga C, Neto F, Alburquerque-Sendin F et al. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther 2016; 22: 80–5.
  17. Castro-Sanchez AM, Mataran-Penarrocha GA, Arroyo-Morales M et al. Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial. Clin Rehabil 2011; 25(9): 800–13.
  18. Cheawthamai K, Vongsirinavarat M, Hiengkaew V et al. A comparison of home-based exercise programs with and without self manual therapy in individuals with knee osteoarthritis in community. J Med Assoc Thail 2014; 97(Suppl 7): S95–100.
  19. Cortés Godoy V, Gallego Izquierdo T, Lázaro NI. Effectiveness of massage therapy as co-adjuvant treatment to exercise in osteoarthritis of the knee: a randomized control trial. J Back Musculoskelet Rehabil 2014; 27(4): 521–9.
  20. Cuesta-Barriuso R, Gomez-Conesa A, Lopez-Pina JA. Manual therapy in the treatment of ankle hemophilic arthropathy. A randomized pilot study. Physiother Theory Pract 2014; 30(8): 534–9.
  21. Deyle GD, Allison SC, Matekel RL et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther 2005; 85(12): 1301–17.
  22. Deyle GD, Henderson NE, Matekel RL et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 2000; 132(3): 173–81.
  23. Dougherty PE, Karuza J, Dunn AS et al. Spinal manipulative therapy for chronic lower Back pain in older veterans: a prospective, randomized. Placebo-Controlled Trial Geriatr Orthop Surg Rehabil 2014; 5(4): 154–64.
  24. Fitzgerald GK, Fritz JM, Childs JD et al. Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: a multi-center, factorial randomized clinical trial. Osteoarthr Cartil 2016; 24(8): 1340–9.
  25. French HP, Cusack T, Brennan A et al. Exercise and manual physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: a multicenter randomized controlled trial. Arch Phys Med Rehabil 2013; 94(2): 302–14.
  26. Hicks GE, Sions JM, Velasco TO et al. Trunk muscle training augmented with neuromuscular electrical stimulation appears to improve function in older adults with chronic low Back pain: a randomized preliminary trial. Clin J Pain 2016; 32(10): 898–906.
  27. Jardine WM, Gillis C, Rutherford D. The effect of osteopathic manual therapy on the vascular supply to the lower extremity in individuals with knee osteoarthritis: a randomized trial. International Journal of Osteopathic Medicine 2012; 15(4): 125–33.
  28. Kim HJ, Yu SH. Effects of complex manual therapy on PTSD, pain, function, and balance of male torture survivors with chronic low back pain. J Phys Ther Sci 2015; 27(9): 2763–6.
  29. Lee KS, Lee JH. Effect of Maitland mobilization in cervical and thoracic spine and therapeutic exercise on functional impairment in individuals with chronic neck pain. J Phys Ther Sci 2017; 29(3): 531–5.
  30. Maiers M, Bronfort G, Evans R et al. Spinal manipulative therapy and exercise for seniors with chronic neck pain. Spine J 2014; 14(9): 1879–89.
  31. Rudolfsson T, Djupsjobacka M, Hager C et al. Effects of neck coordination exercise on sensorimotor function in chronic neck pain: a randomized controlled trial. J Rehabil Med 2014; 46(9): 908–14.
  32. Ruhe A, Fejer R, Walker B. Pain relief is associated with decreasing postural sway in patients with non-specific low back pain. BMC Musculoskelet Disord 2012; 13: 39.
  33. Trampas A, Mpeneka A, Malliou V et al. Immediate effects of Core-stability exercises and clinical massage on dynamic balance performance of patients with chronic specific low Back pain. J Sport Rehabil 2015; 24(4): 373–83.
  34. van den Dolder PA, Roberts DL. Six sessions of manual therapy increase knee flexion and improve activity in people with anterior knee pain: a randomized controlled trial. Australian Journal of Physiotherapy 2006;52(4):261–4.
  35. Yu SH, Sim YH, Kim MH et al. The effect of abdominal drawing-in exercise and myofascial release on pain, flexibility, and balance of elderly females. J Phys Ther Sci 2016; 28(10): 2812–5.
  36. Goertz CM, Xia T, Long CR et al. Effects of spinal manipulation on sensorimotor function in low back pain patients – a randomised controlled trial. Man Ther 2016; 21: 183–90.
  37. Perera S, Mody SH, Woodman RC et al. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc 2006; 54(5): 743–9.
  38. Higgins J, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0: The Cochrane Collaboration www.cochrane-handbook.org; 2011.

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