Manual Therapy: An Important Overlooked Treatment for Work-Related Musculoskeletal Disorders

Work-related musculoskeletal disorders (WMSDs) affect millions of persons in the United States annually. Many of these disorders result gradually from repeated trauma to muscles, tendons, or nerves due to overuse or performance of high-repetition tasks.

Studies have shown that people with WMDs have inflammation, fibrosis, and degeneration in their tissues, contributing to pain and physical impairments. Although numerous approaches can be used to treat WMSDs, healing can take a considerable amount of time and complete recovery is not always possible; thus, better approaches for treating WMSDs are needed, with preventive strategies being ideal.

During the APS 35th Annual Scientific Meeting, Geoffrey M. Bove, DC PhD, professor, University of New England College of Osteopathic Medicine, Biddeford, Maine; Mary F. Barbe, PhD, professor, Temple University School of Medicine, Philadelphia, Pennsylvania; and Susan Chapelle, RMT, Squamish Integrated Health, Squamish, British Columbia, Canada, gave a workshop that examined the use of manual therapy (MT) for WMSDs, particularly repetitive strain injuries, such as carpal tunnel syndrome and thoracic outlet syndrome.¹ Dr. Barbe also reported the results of an animal study that she and Dr. Bove recently conducted that examined the efficacy of MT in preventing the fibrosis and reduced function that occur from overuse.²

MT uses skilled passive movement of joints and soft tissues to improve range of motion, mobility, and function; decrease pain or discomfort; reduce or eliminate soft-tissue inflammation; and induce relaxation and healing. It can include many techniques, such as massage, stretching, and chiropractic interventions.

Drs. Bove and Barbe, and Ms. Chapelle shared their experiences with MT for WMSDs with Clinical Pain Advisor.

Can you provide an overview of how MT would be applied in practice?

Dr. Bove: Patients might directly seek care from a manual therapist or be referred from another healthcare provider, such as a pain treatment specialist. Upon consultation, a good manual therapist will listen carefully to his/her patient and understand prior to even examining the patient what is likely to be the problem. Combined with a thorough physical examination, including standard and specific palpation methods, a clear diagnostic picture usually appears. Treatment typically includes mobilization of the muscles and joints that seem to be the cause of the symptoms. This almost always includes the neck, which is often overlooked in cases that present as carpal tunnel syndrome. Lifestyle and postural habits are often addressed as well. Modification of these factors is essential because they are typically the cause of the problem. Active participation from the patient is necessary to avoid symptoms from recurring.

Ms. Chapelle: MT is mobilization of tissues and joints, and, as Dr. Bove has stated, is started with a thorough case history. I specifically rely on palpation to differentiate tissue quality. Case history most often reveals an understanding of the anatomy involved. In the case of repetitive strain injuries, Dr. Barbe’s studies reveal a change in fibrosis between tissues. Evaluation of neural pathways and possible contributing factors to the injury help to inform specific treatment. Diagnosis and treatment of common injuries tend to focus on the obvious; thus, these injuries may not resolve if the correct pathology is not addressed. For instance, carpal tunnel surgeries are only 50% effective. Often there is forearm or neck involvement and this can be assessed with a thorough orthopedic examination. In my clinic, I often see patients who have had cortisone injections without resolution. Additionally, cortisone use risks tissue degradation, which can cause more fibrosis.

What type of providers perform MT?

Dr. Bove: There are four primary professions who perform MT.  These include massage therapists (>200K practitioners, most do MT), chiropractors (>60K, all do MT), physical therapists (>200K, I don’t know how many do MT), and osteopaths (>100K, 3-4% perform MT).

Are there any special considerations when selecting an MT?

Ms. Chapelle: Depending on licensing, I would choose to see the therapist who has obtained the best education in neurology, physiology, and anatomy. Many practices follow belief systems or apply techniques like recipes, instead of following individualized anatomical and physiological assessments. In the end, each practice mobilizes tissue. The education of the patient and the therapist’s thorough understanding of pathophysiology seem to be relevant to good outcomes. I tend to avoid therapists who advertise long lists of named techniques and outcomes.

When should pain treatment specialists consider referring a patient for MT?

Dr. Bove: Always! Pain treatment specialists are not necessarily versed in anatomy and mechanics, and we all know that pain physiology is historically not taught in a comprehensive manner in medical training, including that of specialists. After ruling out factors within individual knowledge bases, referrals to trusted colleagues should be considered. Actually, MTs would be best included in the primary assessment process.

What kind of results have you seen as a manual therapist?

Ms. Chapelle: We all think that we have fantastic outcomes. I see a lot of cases of repetitive strain disorders that have failed to improve using traditional approaches. I do not know what the differences really are, but they could include spending a lot of time palpating, acknowledging, and listening.

Your animal study used a rat model to examine MT with massage as a secondary prevention approach and sought to emulate the clinical setting, where a patient seeks care after developing symptoms. What were some of the key findings from your study?

Dr. Barbe: We had 3 key findings:

1. Provision of modeled MT for 5 days/week for the duration of a 12-week task paradigm reduced discomfort-related behaviors, improved grip strength, and enhanced task performance in rats performing a high-repetition, high-force task.
2. The aforementioned modeled MT regimen also attenuated task-induced increases in collagen and transforming growth factor-beta1 (TGF-β1) deposition in nerve and connective tissues of the forearm.
3. Our observations support the investigation of MT as a preventative for hand and wrist work-related musculoskeletal disorders, including median nerve fibrosis.

How does MT help prevent repetitive motion disorders?

Dr. Barbe: In our rat model, it reduced discomfort-related behaviors and enhanced motor outcomes, including grip strength and the ability to successfully perform the task. This occurred in parallel with the reduction in adhesion changes (fibrosis) in the forelimb and forepaw tissues.

In humans, studies have reported benefits. Two recent pilot studies examining the effects of massage therapy on carpal tunnel syndrome also reported reduced symptoms and increased strength post-treatment.^3,4 There is also a case report of two patients with lateral epicondylopathy who had reduced pain symptoms after 4 to 6 weeks of MT.⁵ Reviews of massage therapy (sports massage) for post-exertional muscle soreness show contradictory results, yet overall clinical utility is supported for reduction of delayed-onset muscle soreness, stiffness, and fatigue.^6-11 It is important to note that most of the published literature examines short-term massage therapy treatment (a single bout at <1 week after onset of muscle soreness) for repetitive motion disorders, which typically develop over weeks or even years. Therefore, it is difficult to say for sure how effective it is in humans. Long-term treatment studies would be needed for more definitive answers.

We could not identify any studies using MTs as a preventive approach for the development of chronic upper extremity repetitive motion disorders, but one animal study did show that active stretching of the back (10 min/day for 12 days) improved gait and lowered mechanical hypersensitivity in a mouse model of induced low back pain.¹² Findings from several animal models show that passive movement allows tendons to heal with less fibrosis,^13,14 and that stretching after microsurgical injury reduces subcutaneous collagen formation.¹⁵ Studies using instrumented massage of skeletal muscle (single bout or ≤4 days) after nerve stimulation–induced maximum eccentric exercise showed increased muscle viscoelastic properties, and reduced muscle stiffness and muscle fiber damage.^16-19 Findings from these studies combined with our current study support further investigations of MT for WMSDs.

Are there any potential side effects of MMT?

Dr. Barbe: In our rat model, we carefully examined this question. We monitored the rats for spontaneous signs of discomfort during the treatment and after they returned to the home cage (tracked for 1 hour each day). There was a small increase in limb withdrawal in both the preferred reach limb and in the opposite limb during the MT itself. However, these differences were not significant between the limbs. No negative behavioral changes were observed in the rats during the 1-hour tracking period. These observations indicate that the treatment was well tolerated. That said, a clinician will need to note what makes a particular patient have more pain than less over several hours, and avoid that as necessary.

Ms. Chapelle:  Overzealous and unfocused treatment seems to increase symptoms. It would be interesting to understand if overapplied MTs could increase fibrosis secondary to the inflammation that it causes.

Is there anything you would like to add about your study or about MT in general?

Dr. Bove: MT is complex and multidimensional. The practice is incredibly variable, and it is impossible to know what the training and treatment approach is for a given practitioner until one has experience with him or her. As I quoted in the workshop introduction, “life is like a box of chocolates, you never know what you’re gonna get….” Therefore, it is important to learn, ideally from personal experience, what to expect from any particular therapist.

Dr. Barbe: Dr. Bove and I are now funded by the National Center for Complementary and Integrative Health to continue our research. We are exploring which particular submodalities are best, which tissues respond to which submodalities best, and possible changes in angiogenesis and vascular function reported to occur with massage therapy.

References

1. Bove GM, Barbe MF, Chapelle SL. Movement good, stasis bad: manual therapy approaches to two common painful problems. Workshop presented at: 35th Annual Scientific Meeting of the American Pain Society; May 11-14, 2016; Austin, Texas.
2. Bove GM, Harris MY, Zhao H, Barbe MF. Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. J Neurol Sci. 2016;361:168-80.
3. Moraska A, Chandler C, Edmiston-Schaetzel A, Franklin G, Calenda EL, Enebo B. Comparison of a targeted and general massage protocol on strength, function, and symptoms associated with carpal tunnel syndrome: a randomized pilot study. J Altern Complement Med. 2008;14:259-267.
4. Elliott R, Burkett B. Massage therapy as an effective treatment for carpal tunnel syndrome. J Bodyw Mov Ther. 2013;17:332-338.
5. Papa JA. Two cases of work-related lateral epicondylopathy treated with Graston Technique® and conservative rehabilitation. J Can Chiropr Assoc. 2012;56:192-200.
6. Hilbert JE, Sforzo GA, Swensen T. The effects of massage on delayed onset muscle soreness. Br J Sports Med. 2003;37:72-75.
7. Wilson JJ, Best TM. Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005;72:811-818.
8. Zainuddin Z, Newton M, Sacco P, Nosaka K. Effects of massage on delayed-onset muscle soreness, swelling, and recovery of muscle function. J Athl Train. 2005;40:174-180.
9. Ogai R, Yamane M, Matsumoto T, Kosaka M. Effects of petrissage massage on fatigue and exercise performance following intensive cycle pedaling. Br J Sports Med. 2008;42:834-838.
10. Han JH, Kim MJ, Yang HJ, Lee YJ, Sung YH. Effects of therapeutic massage on gait and pain after delayed onset muscle soreness. J Exerc. Rehabil. 2014;10:136-140.
11. Urakawa S, Takamoto K, Nakamura T, et al. Manual therapy ameliorates delayed-onset muscle soreness and alters muscle metabolites in rats. Physiol Rep. 2015;3:e12279.
12. Corey SM, Vizzard MA, Bouffard NA, Badger GJ, Langevin HM. Stretching of the back improves gait, mechanical sensitivity and connective tissue inflammation in a rodent model. PLoS One. 2012;7:e29831.
13. Gelberman RH, Menon J, Gonsalves M, Akeson WH. The effects of mobilization on the vascularization of healing flexor tendons in dogs. Clin Orthop Relat Res. 1980;153:283-289.
14. Gelberman RH, Woo SL, Lothringer K, Akeson WH, Amiel D. Effects of early intermittent passive mobilization on healing canine flexor tendons. J Hand Surg Am. 1982;7:170-175.
15. Bouffard NA, Cutroneo KR, Badger GL, et al. Tissue stretch decreases soluble TGF-beta1 and type-1 procollagen in mouse subcutaneous connective tissue: evidence from ex vivo and in vivo models. J Cell Physiol. 2008;214:389-395.
16. Crawford SK, Haas C, Butterfield TA, et al. Effects of immediate vs. delayed massage-like loading on skeletal muscle viscoelastic properties following eccentric exercise. Clin Biomech. 2014;29:671-678.
17. Haas C, Best TM, Wang Q, Butterfield TA, Zhao Y. In vivo passive mechanical properties of skeletal muscle improve with massage-like loading following eccentric exercise. J Biomech. 2012;45:2630-2636.
18. Haas C, Butterfield TA, Abshire S, et al. Massage timing affects postexercise muscle recovery and inflammation in a rabbit model. Med Sci Sports Exerc. 2013;45:1105-1112.
19. Haas C, Butterfield TA, Zhao Y, Zhang X, Jarjoura D, Best TM. Dose-dependency of massage-like compressive loading on recovery of active muscle properties following eccentric exercise: rabbit study with clinical relevance. Br J Sports Med. 2013;47:83-88.