Manual and Body-Based Therapies
Core concepts
Manual therapies include spinal manipulation (chiropractic, osteopathic), massage, mobilization, and myofascial release. Understand the distinction between manipulation (high-velocity, low-amplitude thrust) and mobilization (low-velocity, passive movement). Know evidence: spinal manipulation has modest benefit for acute/chronic low back pain; massage has evidence for short-term pain and anxiety relief.
Traps in questions
- Overstating benefit-manual therapy is typically adjunctive, not curative, for musculoskeletal pain.
- Missing red flags: cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness), fracture, malignancy, infection-these are contraindications to manipulation and require urgent referral.
- Confusing massage (soft tissue) with manipulation (joint-directed thrust).
- Ignoring cervical manipulation risk: vertebral artery dissection is rare but serious; screen for warning signs (neck pain with neurological symptoms, recent trauma).
Worked example / rule of thumb
A patient with new low back pain and saddle numbness requests chiropractic adjustment. Rule of thumb: red flags trump preference. Saddle anesthesia plus bladder dysfunction suggests cauda equina syndrome-urgent imaging/referral, not manipulation. Document the red-flag screen.
Safety practice
Screen for osteoporosis, anticoagulation, malignancy, and recent trauma before manual therapy. Combine with active exercise and education, which have stronger evidence for long-term benefit than passive therapies alone.