Journal of Alternative Complementary & Integrative Medicine Category: Medicine Type: Research Article

Evidence of Manual Physical Therapy, the Trend of the Last Twenty Years

Osamu Fujinawa1*
1 Department of rehabilitation, Physical Therapy Course, School of Health Science, Graduate School of Health Science, Fukui Health Science University, Japan

*Corresponding Author(s):
Osamu Fujinawa
Department Of Rehabilitation, Physical Therapy Course, School Of Health Science, Graduate School Of Health Science, Fukui Health Science University, Japan
Tel:+81 09025355024,
Email:fujinawa@fukui-hsu.ac.jp

Received Date: Mar 09, 2023
Accepted Date: Mar 15, 2023
Published Date: Mar 22, 2023
DOI:10.24966/ACIM-7562/100333

Abstract

Manual Physical Therapy (PT) programs take important parts of PT and applied many types of physical disorders. A purpose of this article is to search evidence of manual or manipulative PT programs and to confirm their applications. A systematic literature search was performed for relevant articles in Physiotherapy Evidence Database (PEDro) for articles of systematic reviews and clinical trials. Selected articles were categorized in following aspects, 1) year of publication and divided two periods which were before 2010 and from 2011 to 2021, 2) divisions of disorders or impairments, and 3) programs of PT practices, and 4) evidence levels. Selected articles indicated evidence levels as following: ‘strong evidence’, ‘moderate evidence’, ‘weak evidence or unclear’, and ‘no evidence or no report’. PEDro selected 96 articles includeing 38 before 2010 and 84 after 2011. Evidence of PT programs before 2010 showed that strong evidence was two (4%), moderate evidence was 35 (49%), poor or unclear evidence was 27 (38%) and no evidence or no research was 7 (10%). Evidence from 2011 to 2021 indicated strong evidence was 19 (10%) articles, moderate evidence was 95 (52%), and week evidence/unclear evidence was 46 (26%) and no evidence/no report was 14 in total.

Keywords

Evidence; Manual therapy; Manipulative therapy

Introduction

Evidence based Physical Therapy (PT) is required recently in the field of medicine. Useful data base of medicine has been supplied and Physiotherapy Evidence Database (PEDro) has been clinically used to search evidence. Manual PT programs take important parts of PT and these are applied many types of physical disorders. A purpose of this article is to search evidence of manual or manipulative PT programs and to confirm their applications.

Methods

Search Strategy 

A systematic literature search was performed for relevant articles in PEDro for articles of systematic reviews and clinical trials at January 2020, July and August 2021 and January 2022. Search terms included ‘manual therapy’, ‘manipulative therapy’ and ‘evidence’. These results of search indicated many physical therapy (PT) programs, not only manual therapy or manipulative therapy, but also PT exercises, muscle strength training, acupuncture, balneotherapy, and so on. Therefore, following categorization was used after search. 

Categorization 

Selected articles were categorized in following aspects, 1) year of publication and divided two periods which were before 2010 and from 2011 to 2021, 2) areas of disorders or impairments, and 3) programs of PT practices and 4) evidence levels. 

Grading of evidence levels 

All selected articles indicated evidence levels as following: ‘strong evidence’, ‘moderate evidence’, ‘weak evidence or unclear’, and ‘no evidence or no report’. Therefore, evidence levels of this report were also used the same grading system as above.

Results

According to article search from PEDro, 96 articles were selected in total [1-96]. All searched articles of EBM were used as code numbers of articles in tables 1-3, because many of searched articles reported plural disorders and/or impairments of different divisions of the body and PT programs. There were 49 divisions or areas of disorders and/or impairments in the results of search (Table 1). Table 1 also indicated that articles of EBM were 38 before 2010 and 84 after 2011. Seven articles of six disorders were searched only before 2010, 39 articles of 26 new disorders were additionally searched from 2011 to 2021, and 75 articles of 16 disorders in the both periods.

Table 1

 

Divisions, areas of disorders and/or impairments

 

Before 2010

 

After 2011

Only

 

Only

 

Both

 

 

  

 

# Articles

Code # of article

 

# Articles

Code # of article

 before

# Articles

after

# Articles

periods

# Articles

2010

2011

1

Asthma and allergy

1

1

4

 

 

 

1

1

 

 

 

 

2

Chronic pain

1

1

70

 

 

 

1

1

 

 

 

 

3

Fibromialgia

1

1

32

 

 

 

1

1

 

 

 

 

4

Insomia

1

1

57

 

 

 

1

1

 

 

 

 

5

Paediatric health conditions

1

2

36, 37

 

 

 

1

2

 

 

 

 

6

Therapeutic benefit of the audible release

1

1

69

 

 

 

1

1

 

 

 

 

7

Ankle and foot

1

2

12, 38

1

4

1, 20, 30, 51

 

 

 

 

1

6

8

Elbow

1

4

17, 19, 47, 64

1

3

11, 31, 63

 

 

 

 

1

7

9

Headache

1

1

29

1

1

14

 

 

 

 

1

2

10

Infants with kinetic imbalance due to suboccipital strain

1

1

9

1

1

22

 

 

 

 

1

2

11

Low back pain

1

7

3, 21, 33, 49, 54, 56, 65

1

12

6, 25, 26, 39, 48, 58, 72, 73, 74, 75, 76, 89

 

 

 

 

1

19

12

Lower extremities

1

1

12

1

1

42

 

 

 

 

1

2

13

Myofascial pain

1

1

87

1

1

7

 

 

 

 

1

2

14

Neck

1

2

88, 89

1

2

16, 18

 

 

 

 

1

4

15

Neck pain

1

1

50

1

5

8, 13, 23, 52, 96

 

 

 

 

1

6

16

Neck pain (acute)

1

2

44, 84

1

1

13

 

 

 

 

1

3

18

Neck pain (clonic)

1

2

85, 86

1

2

13, 59

 

 

 

 

1

4

19

Neurological disorders

1

1

27

1

2

93

 

 

 

 

1

3

20

Pregnance related disorders

1

1

56

1

1

43

 

 

 

 

1

2

21

Shoulder

1

3

61, 62, 88

1

6

10, 34, 45, 66, 71, 92

 

 

 

 

1

8

22

Suboccipital area

1

1

9

1

1

28

 

 

 

 

1

2

23

Wrist

1

1

15

1

2

11, 93

 

 

 

 

1

3

24

Cervical headache

 

 

 

1

3

5, 60, 68

 

 

1

3

 

 

25

Childhood respiratory disease

 

 

 

1

1

66

 

 

1

1

 

 

26

Chronic musculoskeletal pain in female breast cancer survivors

 

 

 

1

1

67

 

 

1

1

 

 

27

Chronic obstructive airways disease (COPD)

 

 

 

1

3

46, 90, 91

 

 

1

3

 

 

28

Cost-effectiveness of manual therapy for the management of musculoskeletal conditions

 

 

 

1

1

82

 

 

1

1

 

 

29

Cranium

 

 

 

1

1

28

 

 

1

1

 

 

30

Disorders of the spinal disc

 

 

 

1

1

59

 

 

1

1

 

 

31

Hypertension the blood pressure

 

 

 

1

1

31

 

 

1

1

 

 

32

Manipulation-induced hypoalgesia in musculoskeletal pain populations

 

 

 

1

1

2

 

 

1

1

 

 

33

Mechanical neck pain

 

 

 

1

1

94

 

 

1

1

 

 

34

Musculoskeletal disorders

 

 

 

1

2

83, 93

 

 

1

2

 

 

35

Musculoskeletal pain

 

 

 

1

3

2, 80, 95

 

 

1

3

 

 

36

Neck and arm pain

 

 

 

1

1

55

 

 

1

1

 

 

37

Non-musculoskeletal disorders

 

 

 

1

1

24

 

 

1

1

 

 

38

Pain

 

 

 

1

1

78

 

 

1

1

 

 

39

Pain and range of motion

 

 

 

1

1

79

 

 

1

1

 

 

40

Paterofemoral pain

 

 

 

1

1

77

 

 

1

1

 

 

41

Phonophobia

 

 

 

1

1

28

 

 

1

1

 

 

42

Photophobia

 

 

 

1

1

28

 

 

1

1

 

 

43

Postpartum-related low back, pelvic girdle, or combination pain

 

 

 

1

1

91

 

 

1

1

 

 

44

Primary or early secondary prevention

 

 

 

1

1

35

 

 

1

1

 

 

45

Restless legs syndrome (RLS)

 

 

 

1

1

41

 

 

1

1

 

 

46

Spine

 

 

 

1

2

40, 81

 

 

1

2

 

 

47

Thorax and chest

 

 

 

1

4

18, 53, 67, 81

 

 

1

4

 

 

48

TMJ

 

 

 

1

2

11, 31

 

 

1

2

 

 

49

Upper extremities

 

 

 

1

2

18, 23

 

 

1

2

 

 

 

Total

22

38

 

43

84

 

6

7

26

39

16

75

Table 1: Articles of Manual Physical Therapy Cited from PEDro.

Table 2

Research methodology and disorders

Programs of physical therapy practices

M

M

O

Level of evidence

# Articles

Code # of article

 

 

 

 

 

 

& O

 

(++)

(+)

(+/-)

(-)

Notes

Sysmatic review

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

Tension headache

 

Manual therapies

1

 

 

 

 

1

 

 

1

29

 

 

 

 

2

Infants with kinetic imbalance due

Manual therapy/Chiropractic/ Osteopathy

1

 

 

 

 

 

1

 

1

9

 

 

 

to suboccipital strain (KISS) syndrome.

 

3

Chronic pain

Osteopathic manual treatmen

1

 

 

 

1

 

 

 

1

70

 

 

 

 

4

Fibromyalgia syndrome

 

Aerobic exercise and cognitive behavioral therapy

 

 

1

1

 

 

 

 

1

77

 

 

 

 

 

 

 

Massage

1

 

 

 

1

 

 

 

1

77

 

 

 

 

 

 

 

Muscle strength training,

 

 

1

 

1

 

 

 

1

77

 

 

 

 

 

 

 

Acupuncture

 

 

1

 

1

 

 

 

1

77

 

 

 

 

 

 

 

Spa therapy (balneotherapy).

 

 

1

 

1

 

 

 

1

77

 

 

 

 

 

 

 

Spinal manipulation

1

 

 

 

 

1

 

 

1

77

 

 

 

 

 

 

 

Manipulation

1

 

 

 

 

1

 

 

1

77

 

 

 

 

 

 

 

Movement/body awareness

 

 

1

 

 

1

 

 

1

77

 

 

 

 

 

 

 

Vitamins

 

 

1

 

 

1

 

 

1

77

 

 

 

 

 

 

 

Herbs

 

 

1

 

 

1

 

 

1

77

 

 

 

 

 

 

 

Dietary modification

 

 

1

 

 

1

 

 

1

77

 

 

 

 

5

Neck pain

 

Educational videos, mobilization, and exercises, low-level laser therapy

 

1

 

 

1

 

 

 

1

50

 

 

 

 

6

Acute neck pain

 

Chiropractic manipulation

1

 

 

 

 

1

 

 

1

44

 

 

 

 

7

Chronic neck pain

 

A course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks posttreatment.

1

 

 

1

1

 

 

 

1

84

 

 

 

 

 

 

 

Mobilization

1

 

 

 

2

 

 

 

2

85

86

 

 

 

 

 

 

Manipulation

1

 

 

 

2

 

 

 

2

85

86

 

 

 

8

Chronic mechanical neck pain

 

A single session of spinal manipulation.

1

 

 

 

1

 

 

 

1

83

 

 

 

 

 

 

 

Mobilization

1

 

 

 

 

1

 

 

1

83

 

 

 

 

 

 

 

Ischemic compression

1

 

 

 

 

1

 

 

1

83

 

 

 

 

 

 

 

A single session of massage or manual traction

1

 

 

 

 

 

1

 

1

83

 

 

 

 

9

Non-specific chronic neck pain

 

Preventive spinal manipulative therapy (SMT)

1

 

 

 

 

1

 

 

1

58

 

 

 

 

10

Neck conditions

 

Thoracic spine manipulation

1

 

 

 

 

 

 

 

 

 

 

 

 

 

11

Neck disorder

 

Thoracic manipulation

1

 

 

 

1

 

 

 

1

89

 

 

 

 

12

Whiplash-associated disorders

 

Educational videos, mobilization, and exercises

 

 

1

 

1

 

 

 

1

50

 

 

 

 

13

Whiplash-associated disorders without arm disorders

 

Interventions that focused on regaining function as soon as possible

 

 

1

 

1

 

 

 

1

50

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

14

Chronic neck pain after whiplash

 

Manipulation and ischemic pressure

1

 

 

 

1

 

 

Immediate

1

85

 

 

 

 

 

 

 

Mobilization

1

 

 

 

 

1

 

 

1

85

 

 

 

 

 

 

 

Ischemic pressure

1

 

 

 

 

1

 

 

1

85

 

 

 

 

15

Chronic neck pain not due to whiplash and without arm pain and headaches

A course of spinal manipulation or mobilization

1

 

 

 

1

 

 

 At 6, 12, and up to 104 weeks posttreatment

1

84

 

 

 

 

16

Low back pain

 

Chiropractic manipulation

1

 

 

 

 

 

1

 

1

3

 

 

 

 

 

 

 

Deep dry needling

 

 

1

 

 

1

 

 

1

89

 

 

 

 

 

 

Acute low back pain

Physical therapist-directed therapeutic exercises

 

 

1

 

 

 

1

 

1

21

 

 

 

 

 

 

Non-specific low back pain

Specific exercise interventions

 

 

1

 

1

 

 

 

1

49

 

 

 

 

 

 

 

Manual therapy

1

 

 

 

 

1

 

 

1

54

 

 

 

 

 

 

Chronic low back pain

Combined manipulation, stabilizing exercises, and physician consultation

 

1

 

 

1

 

 

 

1

64

 

 

 

 

 

 

Chronic low back pain due to spinal disk degeneration

Spinal mobilization

1

 

 

 

1

 

 

 

1

57

 

 

 

 

17

Shoulder conditions

 

 

1

 

 

 

 

1

 

 

1

88

 

 

 

 

18

Non-specific shoulder pain

Thoracic manual therapy

1

 

 

 

1

 

 

 

1

65

 

 

 

 

19

Lateral epicondylalgia.

 

Mobilization with movements (MWMs)

1

 

 

 

2

 

 

Short/

2

17

47

 

 

Long term

 

 

 

 

Manipulative therapy at the cervical spine

1

 

 

 

 

1

 

Short term

1

47

 

 

 

 

20

Lateral epicondylopathy

 

Deep transverse friction massage with Mill's manipulation

1

 

 

 

1

 

 

 

1

63

 

 

 

 

21

Chronic lateral epicondylalgia

 

Specific manipulative therapy

1

 

 

 

1

 

 

Pain-free grip strength

1

87

 

 

 

 

22

Shoulder impingement symptoms

 

Facilitatory taping with routine physiotherapy

 

 

1

 

1

 

 

Short term

1

61

 

 

 

 

23

Carpal tunnel syndrome

 

 Graston Instrument-assisted soft tissue mobilization (GISTM)

1

 

 

 

1

 

 

 

1

15

 

 

 

 

 

 

 

Soft tissue mobilization (STM)

1

 

 

 

1

 

 

 

1

15

 

 

 

 

24

Hip osteoarthritis

 

Manipulative therapy combined with multimodal or exercise therapy

 

1

 

 

 

1

 

 

1

12

 

 

 

 

25

Knee osteoarthritis

 

Manipulative therapy of the knee and/or full kinetic chain

 

1

 

 

1

 

 

 

1

12

 

 

 

 

26

Patellofemoral pain syndrome,

 

Manipulative therapy of the knee and/or full kinetic chain

 

1

 

 

1

 

 

 

1

12

 

 

 

 

27

Ankle inversion sprain

 

Manipulative therapy of the knee and/or full kinetic chain

 

1

 

 

1

 

 

 

1

12

 

 

 

 

28

Plantar fasciitis

 

Manipulative therapy of the knee and/or full kinetic chain

 

1

 

 

 

1

 

 

1

12

 

 

 

 

29

Metatarsalgia

 

Manipulative therapy of the knee and/or full kinetic chain

 

1

 

 

 

1

 

 

1

12

 

 

 

 

30

Hallux limitus/rigidus

 

Manipulative therapy of the knee and/or full kinetic chain

 

1

 

 

 

1

 

 

1

12

 

 

 

 

31

Hallux abducto valgus

 

Manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy

 

1

 

 

 

 

1

 

1

12

 

 

 

 

32

Morton's neuroma

 

Manipulation and mobilization

1

 

 

 

1

 

 

Short term

1

38

 

 

 

 

33

Neural dysorders

 

Neural mobilization.

 

 

1

 

 

1

 

 

1

27

 

 

 

 

34

Paediatric health conditions

 

Chiropractic manipulation

1

 

 

 

 

2

 

 

2

36

37

 

 

 

35

Pregnancy-related back and pelvic pain

 

Complementary manual therapies

1

 

 

 

 

1

 

 

1

43

 

 

 

 

36

Insomnia

 

Chiropractic manual therapy

1

 

 

 

 

1

 

 

1

56

 

 

 

 

37

Asthma and allergy

 

Chiropractic care

1

 

 

 

 

 

1

 

1

4

 

 

 

 

38

Therapeutic benefit of the audible release

 

Spinal manipulative therapy

1

 

 

 

 

 

1

 

1

69

 

 

 

 

39

Painful musculoskeletal disorders

 

 

 

 

1

 

 

 

1

 

1

93

 

 

 

 

 

 

 

Subtotal

38

10

17

2

32

26

7

67

67

 

 

 

 

Clinical trials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40

Fibromyalgia syndrome

 

Osteopathic manipulative treatment with other forms of standard medical care

 

1

 

 

1

 

 

 

1

32

 

 

 

 

 

 

 

Osteopathic manipulative treatment

1

 

 

 

 

1

 

 

1

32

 

 

 

 

41

Forward bending range

 

Passive physiological flexion technique

 

 

1

 

1

 

 

 

1

33

 

 

 

 

 

 

 

Manual therapy directed at the elbow and cervicothoracic spine

1

 

 

 

1

 

 

 

1

19

 

 

 

 

 

 

 

Subtotal

2

1

1

0

3

1

0

4

4

 

 

 

 

 

 

 

 

Total

40

11

18

2

35

27

7

71

71

 

 

 

 

 

 

 

 

%

56

15

26

3

49

38

10

100

 

 

 

 

 

Table 2: Evidence before 2010.

Table 3

Research methodology and disorders Programs of physical therapy practices M M O Level of evidence         # Articles Code # of 
            & O   (++) (+) (+/-) (-) Notes   article
Sysmatic review                            
  1 Temporomandibular joint disorders   Manipulative and multimodal therapy    1     1     Short term 1 11
  2 Cervicogenic headache   Cervical manipulation and mobilization 1       1       1 68
        Self-applied cervical mobilization 1       1       1 68
        Cervico-scapular strengthening         1       1 68
        Cervical and thoracic manipulation 1       1       1 68
        Cervical manipulation and mobilization with cervico-scapular strengthening   1   1         1 68
  3 Cervical range of motion and mouth opening.   Cervical high-velocity low-amplitude techniques (HVLA)  1       1       1 31
  4 Pain relief   Manipulative therapy  1       1     Immediately 1 78
          1         1   Short term-follow-up. 1 78
  5 Asthma   Manipulative therapy 1           1 Disability and perceived (asthma) recovery. 1 78
  6 The audible release associated with spinal manipulative therapy Spinal manipulative therapy 1           1   1 69
  7 Tension-type headache   Chiropractic treatment 1         1     1 14
  8 Pain at rest    A single session of joint mobilization 1       1       1 79
  9 Pain with most painful movement   A single session of joint mobilization 1       1       1 79
  10 Lower limb neurodynamic test outcomes in adults Spinal manipulative therapy 1         1     1 60
        Spinal manipulation 1       1     Short-term 1 59
  11 Neck pain   Manipulation, manual therapy, and exercise in combination with other modalities   1   1         1 13
        Home exercise programs: self-mobilizations, therapeutic exercise to reduce neck pain, function, and disability and improving QOL         1       1 96
        Directional manipulation to the thoracic spine. 1           1   1 52
        Mobilization as well as massage in combination with other therapies   1     1       1 13
        Mobilization or manipulation techniques 1       1       1 73
      Acute neck pain Exercise alone           1     1 13
        Manipulation and mobilization in combination with other modalities.   1     1       1 13
        Exercise alone           1     1 13
        Thoracic manipulation 1           1   1 13
        Trigger point therapy  1           1   1 13
      Chronic neck pain Manipulation, manual therapy, and exercise in combination with other modalities   1   1         1 13
        Stretching, strengthening, and endurance exercises alone       1         1 13
        Mobilization as well as massage in combination with other therapies   1     1       1 13
        Manipulation alone 1         1     1 13
        Transcutaneous nerve stimulation             1   1 13
        Thoracic manipulation 1           1   1 13
        Laser             1   1 13
        Traction             1   1 13
      Mechanical neck pain Thoracic manipulation versus mobilization 1           1   1 94
  12 Motor performance of the deep cervical flexors Manual therapy targeted to active TrPs in the sternocleidomastoid muscle 1       1       1 5
  13 Neck pain-associated disorders   A multimodal approach including manual therapy, self-management advice, and exercise   1     1       1 16
  14 Whiplash-associated disorders   A multimodal approach including manual therapy, self-management advice, and exercise   1     1       1 16
  15 Chronic mechanical neck pain   A single session of spinal manipulation 1     1 1     Immediate 1 83
        Mobilization 1       1     Immediate 1 83
        Ischemic compression 1         1   Immediate 1 83
        A single session of massage or manual traction 1           1 Immediate 1 83
          1                  
  16 Chronic mechanical neck pain not due to whiplash and without arm pain and headaches Sspinal manipulation or mobilization  1     1 1      6, 12, & to 104 weeks post tx 1 84
  17 Chronic musculoskeletal pain in female breast cancer survivors: Manual therapy 1       1       1 67
  18 Musculoskeletal thoracic spine and chest wall pain Spinal manipulation 1         1     1 80
  19 Musculoskeletal pain Manipulation-induced hypoalgesia 1           1   1 2
  20 A variety of musculoskeletal conditions   Shared Decision-Making     1       1   1 93
  21 Low back pain (LBP)   Maniulation 1       1       1 73
        Mobilization 1       1       1 73
        Deep dry needling techniques           1     1 89
      Acute LBP Spinal manipulative therapy  1           1   1 74
          1                  
      Acute LBP and back-related buttock or thigh pain. Thrust manipulative procedures 1     1         1 26
      Acute low back pain with related (referred) lower extremity pain Repeated movements, exercises, or procedures to promote centralization to reduce symptoms       1         1 26
      Acute, subacute, or chronic low back pain with mobility deficits  Repeated movements, exercises, or procedures to promote centralization to reduce symptoms       1         1 26
      Acute–subacute LBP Manipulation 1     1       Short-term (1–3 m) 1 48
        Manipulation and mobilization combined with UMC   1     1     Short-term 1 48
      Subacute and chronic low back and back-related lower extremity pain  Thrust manipulative and nonthrust mobilization procedures 1     1         1 26
      Subacute and chronic low back and back-related lower extremity pain  Thrust manipulative and nonthrust mobilization procedures  1     1         1 26
      Subacute and chronic low back pain with movement coordination impairments Trunk coordination, strengthening, and endurance exercises       1         1 26
      Post lumbar microdiscectomy Trunk coordination, strengthening, and endurance exercises       1         1 26
      Chronic low back pain Regional manual therapy (RMT) with standard physical therapy    1     1       1 95
        Manipulation 1     1 1     Short time 1 48
        Manipulation + mobilization + UMC   1     1     Short and long-term 1 48
        Mobilization and soft-tissue-techniques + exercise and UMC   1       1   Short and long-term 1 48
        Manipulation + extension exercise   1         1 Short and long-term 1 48
        Movement-based classification (MBC) systems         1       1 72
      Chronic nonspecific low back pain Spinal manipulative therapy (SMT) 1       1     After 3 weeks 1 6
        Motor control exercise     1   1 1     1 75
      Chronic low back pain with radiating pain Flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking   1       1     1 26
      Subacute and chronic low back pain and radiating pain Lower-quarter nerve mobilization procedures     1     1     1 26
      Signs of nerve root compression along with peripheralization of symptoms or a positive crossed straight leg raise Intermittent lumbar traction in the prone position     1     1     1 26
      Acute or subacute, nonradicular low back pain or patients with chronic low back pain Intermittent or static lumbar traction     1     1     1 26
      Increase the perceived threat or fear associated with low back pain Education and counseling strategies     1       1   1 26
Should not: (1) promote extended bed-rest or (2) provide in-depth, pathoanatomical explanations for the specific cause of the patient's low back pain
        Should emphasize (1) the promotion of the understanding of the anatomical/structural strength inherent in the human spine, (2) the neuroscience that explains pain perception, (3) the overall favorable prognosis of low back pain, (4) the use of active pain coping strategies that decrease fear and catastrophizing, (5) the early resumption of normal or vocational activities, even when still experiencing pain, and (6) the importance of improvement in activity levels, not just pain relief      1   1       1 26
      Chronic low back pain without generalized pain Moderate- to high-intensity exercise     1 1         1 26
      Chronic low back pain with generalized pain Incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies     1 1         1 26
      Non-specific low back pain (NSLBP) Non-thrust manipulation with segmental 1       1       1 39
        Distal dry needling     1   1       1 39
      Acute NSLBP Motor control exercise     1   1 1     1 75
        Spinal manipulative therapy  1       1 1     1 75
        Other forms of exercise         1 1     1 75
      Acute-subacute NSLBP Manipulation 1     1       Short-term (1–3 m) 1 48
        Manipulation + UMC   1     1     Short-term 1 48
        Manipulation + mobilization + exercise/UMC    1     1     Short-term 1 48
        Manipulation + mobilization 1                  
      Recurrence NSLBP at one year Motor control exercise           1     1 75
      Pain and disability in older persons with chronic low back pain Manual therapy 1         1     1 25
  22 Spine-related painful conditions   Superficial versus deep dry needling or acupuncture     1   1     No differences 1 40
  23 Management of older people with chronic LBP   Manual therapy  1         1     1 2
  24 Pregnancy and related conditions (back pain, other symptoms)  Spinal Manipulative Therapy (SMT)  1         1     1 55
  25 Pregnancy-related back and pelvic pain   Manual therapies 1         1     1 43
  26 Postpartum-related low back, pelvic girdle, or combination pain Chiropractic care 1         1     1 91
  27 Upper extremity ROM during ULNT   Cervical or thoracic spinal manual therapy 1       1     Increased 1 18
  28 Pain of upper extremity   Cervical or thoracic spinal manual therapy 1       1     Decreased 1 18
  29 Skin conductance of the arm   Cervical or thoracic spinal manual therapy 1       1     Increased 1 18
  30 Skin temperature of the arm   Cervical or thoracic spinal manual therapy 1       1     Decreased 1 18
  31 Childhood respiratory disease   Manual therapy: chiropractic, osteopathic medicine, and massage 1       1       1 66
  32 Shoulder conditions   Manual therapies 1       1       1 45
      Shoulder impingement syndrome (SIS)  Manual therapies 1       1 1     1 45
        Cervicothoracic spinal thrust/non-thrust  1           1   1 92
        Spinal thrust/non-thrust + shoulder manual therapy + exercise intervention   1     1     Pain and function 1 92
      Rotator cuff-associated disorders (RCs) Manual therapies 1       1 1     1 45
      Adhesive capsulitis (AC) Manual therapies 1       1 1     1 45
      Nonspecific shoulder pain Manual therapies 1       1 1     1 45
      Shoulder impingement syndrome (SIS)  Exercise, particularly combined with physical therapy protocols     1   1       1 45
      Adhesive capsulitis (AC) Exercise, particularly combined with physical therapy protocols     1   1       1 45
      RC Physical therapy protocols     1   1     Short term 1 45
      Calcific tendinitis RC. Extracorporeal shockwave therapy      1   1       1 45
      Shoulder impingement syndrome (SIS)  Low-level lase     1   1     Only modality  1 45
      Rotator cuff-associated disorders (RCs) Low-level lase     1   1     Only modality  1 45
      Adhesive capsulitis (AC) Low-level lase     1   1     Only modality  1 45
      Nonspecific shoulder pain Low-level lase     1   1     Only modality  1 45
  33 Shoulder pain and disorders   Manual and manipulative therapy + multimodal or exercise therapy for rotator cuff   1     1       1 10
  34 Non-surgical shoulder conditions   Thrust manipulation 1         1     1 62
  35 Soft tissue injuries of the shoulder                        
      Persistent subacromial impingement syndrome Multimodal care     1     1     1 34
      Subacromial impingement syndrome Multimodal care     1     1     1 34
      Rotator cuff tendinitis Dietary-based multimodal care     1   1       1 34
      Nonspecific shoulder pain Multimodal care vs wait list or usual care by a general practitioner     1   1       1 34
  36 Lateral epicondylopathy   Manipulative and multimodal therapy to specific joints and the full kinetic chain combined generally with exercise   1     1     Short term 1 11
        Manipulation (cervical HVLA)   1     1     Increased pain-free handgrip strength 1 31
  37 Carpal tunnel syndrome   Manipulative and multimodal therapy to specific joints and the full kinetic chain combined generally with exercise   1     1     Short term 1 11
  38 Painful musculoskeletal disorders   Background: Shared Decision-Making (SDM)             1   1 93
  39 Hip osteoarthritis   Manipulative therapy combined with multimodal or exercise therapy   1       1     1 12
  40 Knee osteoarthritis   Manipulative therapy combined with multimodal or exercise therapy   1     1       1 12
  41 Patellofemoral pain syndrome   Manipulative therapy combined with multimodal or exercise therapy   1     1       1 12
        Spinal manipulations  1       1     Medium term. 1 76
  42 Ankle inversion sprain   Manipulative therapy combined with multimodal or exercise therapy   1     1       1 12
  43 Plantar fasciitis   Manipulative therapy combined with multimodal or exercise therapy   1       1     1 12
  44 Metatarsalgia   Manipulative therapy combined with multimodal or exercise therapy   1       1     1 12
  45 Hallux limitus/rigidus   Manipulative therapy combined with multimodal or exercise therapy   1       1     1 12
  46 Hallux abducto valgus   Manipulative therapy combined with multimodal or exercise therapy   1         1   1 12
  47 Restless legs syndrome (RLS)   Exercises     1   1       1 41
        Acupuncture     1   1       1 41
        Pneumatic compression devices     1   1       1 41
        Near-infrared light      1   1       1 41
        Whole-body cryotherapy     1   1     Short-lasting effects 1 41
        Repetitive transcranial stimulation     1   1     Short-lasting effects 1 41
        Transcutaneous stimulation     1   1     Short-lasting effects 1 41
  48 Chronic ankle instability    Strain counterstrain 1       1     Dynamic ankle stability 1 20
  49 Plantar fasciitis   Manual therapy  1       1       1 51
        Joint and soft tissue mobilization with stretching and strengthening   1     1       1 51
        Manual therapy (MT)  1       1       1 30
        Joint and soft tissue mobilization techniques with stretching and strengthening   1     1       1 30
  50 Myofascial trigger points (MTrPs) in multiple body areas Dry needling     1   1       1 7
  51 Fibromyalgia   Balneotherapy      1     1     1 81
        Mind-body therapies     1     1     1 81
        Aerobic exercise and cognitive behavioral therapy     1   1       1 77
        Massage 1         1     1 77
        Muscle strength training     1     1     1 77
        Acupuncture     1     1     1 77
        Spa therapy (balneotherapy).     1     1     1 77
  52 Tight hamstrings    Instrument-assisted soft tissue mobilization (IASTM) + proprioceptive neuromuscular facilitation (PNF)  1       1       1 42
  53 Chronic obstructive pulmonary disease (COPD)   Manual therapy 1       1 1     1 46
  54 Chronic obstructive pulmonary disease (COPD)   Spinal manipulative therapy 1       1     Lung function and exercise performance 1 90
  55 Safety of spinal manipulative therapy in children    Spinal manipulative therapy 1         1   Under 10 years 1 22
  56 Musculoskeletal shoulder symptoms:   Thoracic spinal manipulations (high-velocity, low-amplitude thrust manipulations; HVLATMs) and message 1       1       1 71
  57 Primary or early secondary prevention of diseases   Chiropractic treatment  1           1   1 35
  58 Chronic non-cancer pain   Osteopathic manual treatment  1       1       1 70
  59 Hypertension   Manipulation (cervical HVLA) 1       1       1 31
  60 Cost-effectiveness of manual therapy for the management of musculoskeletal conditions Manual therapy 1       1       1 82
        Subtotal 75 32 38 18 90 43 20 171 159  
Clinical trials                            
  61 Cervicogenic headache   Manual therapy targeted to active TrPs in the sternocleidomastoid muscle 1       1       1 5
  62 Prevention and treatment of non-musculoskeletal disorders Spinal manipulative therapy  1           1   1 24
  63 Non-specific chronic neck pain (NCNP)   Preventive spinal manipulation 1       1       1 58
  64 Tension-type headache   Manual therapy techniques 1       1       1 28
  65 Neck pain, grip force control, and upper extremity muscle activity Cervical manipulation 1           1   1 8
  66 Photophobia   Manual therapy techniques, applied to the suboccipital region 1         1     1 28
  67 Photophobia   Manual therapy techniques, applied to the suboccipital region 1         1     1 28
  68 Pericranial tenderness.   Manual therapy techniques, applied to the suboccipital region 1         1     1 28
  69 Cervical spine flexion range of motion and pain   Seated thoracic manipulation and targeted supine thoracic manipulation 1       1     Supine may be more effective 1 53
  70 Neck and arm pain with evidence of neural mechanosensitivity: Soft tissue mobilization versus therapeutic ultrasound 1     1         1 23
  71 Hindfoot fractures   Initiating manual therapy and therapeutic exercises   1     1       1 1
        Subtotal 10 1 0 1 5 3 2   11  
        Total 85 33 38 19 95 46 22 182 170  
        % 54 21 24 10 52 25 12 100    

Table 3: Evidence from 2011 to 2021.

Evidence of PT programs before 2010 in table 2 indicated 66 systematic reviews, 4 clinical trials, and 70 articles in total. The evidence showed that strong evidence was two (4%) PT programs, including aerobic exercise and cognitive behavioral therapy for fibromyalgia syndrome and a course of spinal manipulation or mobilization for chronic neck pain. Therefore, only one article of manual therapy was reported in this period of year. Moderate evidence was 35 (49%) of PT programs for 15 disorders, and 18(25%) manual PT and 21 articles. Poor or unclear evidence was 27 (38%) of PT programs for 13 disorders and 16 (23%) of manual PT and 16 articles. No evidence or no research was 7 (10%) systematic reviews of PT programs and 5 (7%) of manual PT and 5 articles. 

Evidence from 2011 to 2021 in table 3 listed PT programs and levels of evidence for 71 disorders. Table 3 indicated 159 systematic reviews, 11 clinical trials and 170 articles in total. Strong evidence of PT programs was 18 systematic reviews, 1 clinical trial and 19 (10%) articles of manual PT in total. Moderate evidence was 90 systematic reviews, 5 clinical trials and 95 (52%) articles, and 46 manual therapies for 32 disorders in total. Week evidence/unclear evidence was 43 systematic reviews, 3 clinical trials and 46 (26%) articles, and 22 manual therapies of 22 articles for 19 disorders in total. No evidence/no report was 20 systematic reviews, 2 clinical trials and 22 (12%) articles, and 14 manual therapies for 10 disorders in total. These results were summarized in table 4 which indicated two periods of publication and levels of evidence.

Discussion

Comparison of evidence before 2010 and after 2011 

Articles of manual PT were cited from PEDro indicated 7 articles of 6 disorders only before 2010; in contrast, these indicated 39 articles of 26 disorders after 2011 (Table 1). 

Six disorders (seven articles) were only searched before 2010; in contrast, additional 26 new disorders (39 articles) were searched from 2011 to 2021, and 16 disorders were selected in both period of years (30 articles before 2010 and 45 articles after 2011). 

Manual PT has been applied not only neuromusculoskeletal disorders but also has been applied other body systems or disorders, including the respiratory system like asthma and allergy, photophobia, phonophobia, and so on. The results of these searches suggest increasing this trend especially after 2011. However, these trials of manual PT were reported ‘poor or unclear evidence’ and/or ‘no evidence or no research’ (Tables 2 & 3). Numbers of article increased after 2011 than before 2010 from 71 to 170 and increasing ratio was 2.4 times (Table 4). Strong evidence of PT programs increased from two (3%) to 19 (10%) and increasing ratio was 9.5 times. Moderate evidence also increased from 35 (48%) to 95 (52%) and increasing ratio was 2.5. In contrast, weak evidence/unclear was from 27 (38%) to 46 (25%) and increasing ratio was 1.7 times, and no evidence/no report was from 7 (10%) to 22 (12%) and increasing ratio was 3.1 times. These result suggest that application of PT programs have been clarified in recent 10 years, and that neuromusculoskeletal disorder or dysfunctions should be evaluated carefully to apply manual or manipulative PT. 

Table 4

Periods of

Numbers of article

 

 

Evidence level

 

 

publication (year)

 %

(++)

(+)

(+/-)

(-)

Total

Before 2010

71

2

35

27

7

71

 

%

3

49

38

10

100

2011∼2021

170

19

95

46

22

182

 

%

10

52

25

12

100

Increasing ratio

2.4

9.5

2.7

1.7

3.1

2.6

Table 4: Numbers of article and evidence level. 

Feature of articles before 2010 (Table 2) 

Strong evidence of PT programs for two disorders were aerobic exercise and cognitive behavioral therapy for fibromyalgia syndrome and a course of spinal manipulation or mobilization. First program of PT was not manual PT; therefore, only one article of manual PT was searched, and strong evidence of manual PT was not enough in this period. Moderate evidence was reported 35 (49%) of PT programs for 15 disorders, and 18 (25%) manual PT and 21 articles. These results also indicated that almost half of PT programs were manual PTs and were applied for musculoskeletal disorders. Poor or unclear evidence was reported 18 disorders of 26 PT programs and 27 articles. 

These results were manual PTs for fibromyalgia (3 articles), chronic mechanical neck pain (3 articles) and chronic whiplash related neck pain (2 articles) and no musculoskeletal disorders including pediatric health conditions, pregnancy related back and pelvic pain, insomnia. No evidence or no research was reported 7 disorders of 7 PT programs and 7 articles. These were manual PT for infants with kinetic imbalance due to suboccipital strain (KISS) syndrome, chronic mechanical neck pain, low back pain, asthma and allergy, and audible disorders. These results of poor or no evidence were application for chronic conditions and/or non-musculoskeletal disorders. 

Feature of articles after 2011 

The results indicated that strong evidence was manual PT for chronic mechanical neck pain, acute, subacute and chronic low back pain. Manual PT was so effective for chronic neck pain and any stages of low back pain. Moderate evidence of manual PT showed effective application for many types of musculoskeletal disorders and also no musculoskeletal disorders including Chronic Obstructive Pulmonary Disease (COPD) and hypertension. These researches introduced effects of manual PT for a respiratory disorder and a sympathetic nervous system. Week evidence/unclear evidence was manual PT for many cases of chronic pain and not neuromusuculoskeletal disorders, such as pregnancy-related back and pelvic pain, and postpartum-related low back, pelvic girdle, or combination pain, and photophobia and phonophobia. Chronic pain supposes that many factors affect symptoms. No evidence/no report was related indirect approach of disorders, including thoracic manipulation for acute neck pain, cervicothoracic spinal thrust/non-thrust for shoulder impingement syndrome, and primarily and secondary prevention of disease.

Conclusion

Evidence of manual PT was searched by PEDro and summarized in two periods of year, such as before 2010and after 2011. Before 2010, searched articles were 71 that indicated two strong evidence, 35 moderate evidence, 27 weak evidence/unclear, and 7 no evidence/no report. In contrast, after 2011, searched articles were 170 that indicated 19 strong evidence (increasing ratio: 9.5 times) and 95 moderate evidence (increasing ratio: 2.7 times), 46 weak evidence/unclear (increasing ratio: 1.7 times), and 12 no evidence/no report (increasing ratio: 3.1 times). It is easy to access evidence when we apply manual PT. Manual physical therapists should be continue to increase evidence in the future.

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Citation: Fujinawa O (2023) Evidence of Manual Physical Therapy, the Trend of the Last Twenty Years. J Altern Complement Integr Med 9: 333.

Copyright: © 2023  Osamu Fujinawa, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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