Manual therapy refers, in general, to treatment approaches involving the hands, including massage and chiropractic therapy. Some manual therapy providers incorporate a tool or instrument to aid their work. Although manual therapies are most commonly used to treat somatic pain or other musculoskeletal maladies, other indications may include lymphedema, immunosuppression, or visceral discomfort.
Medical massage techniques vary widely, ranging from light- to heavy-pressure techniques and from slow, relaxing strokes to invigorating activation before sporting events. The term "medical massage" refers to a multimodal, soft-tissue therapy approach that incorporates a wide range of techniques and styles. Such styles may include Swedish massage, osteopathic manual therapy techniques, or trigger point deactivation. A selected style may follow the determination of a diagnosis and aim to address problems pertaining to the patient's diagnosis by means of integrated soft-tissue treatment.
Swedish massage, also called "classic muscular massage," incorporates several maneuvers, including effleurage (stroking and gliding), tapotement (percussion), petrissage (kneading), and friction massage.
Effleurage, a superficial, gliding technique, compresses, slightly stretches, and warms tissue. Tapotement vibrates tissue through vigorous percussion. Petrissage releases adherent fibrous tissue through passive stretching, kneading, pushing, and pulling. Friction mobilizes connective tissue to reduce contractures.
Soft-tissue techniques adapted from osteopathic manual medicine include direct and indirect myofascial release, ligamentous articular strain, lymphatic pump, and craniosacral therapy, described below. The difference between osteopathic manual therapy approaches and Swedish massage pertains largely to the physiologic end-goals of the former, as opposed to the technique itself with the latter.
Several ways to relax tense and tender foci of myofascial dysfunction (loosely called trigger points) exist. These methods include sustained compression of the tissue to cause a temporary local ischemia, acupuncture needling (also called "dry needling"), and photonic stimulation by means of laser therapy or LEDs. Typically, practitioners of integrative medicine and rehabilitation incorporate more than one technique in an effort to alleviate soft-tissue restriction and signs of pain.
When the terms“animal chiropractic,” “veterinary manual therapy,” or “animal adjusting” are used, it is usually in reference to a technique also known as "high velocity, low amplitude thrusting." The technique is claimed to alleviate pain and, commonly, spinal dysfunction. These interventions draw from human chiropractic techniques. As such, persons performing chiropractic therapy on animals might solely use the force of their hands or might alternatively rely on mechanical devices that serve as "adjusting tools," eg, an "activator." This handheld device, which resembles a metal syringe with a rubber knob at the end, delivers a rapid “thump” to the patient when the plunger is depressed. In this way, the activator supposedly mimics the action of a person applying a thumb thrust to the body. More violent and less sophisticated methods applied to horses may incorporate mallets and blocks of wood. The treatment provider may claim to “drive protruding spines into line”; all such methods have, as yet, little to no evidence supporting their efficacy.
Indications for Manual Therapy in Veterinary Patients
Indications may include neck or back pain or stiffness, inability to sit normally, reduced flexibility, muscle spasms, poor performance, difficulty going up or down stairs, inability to walk or run in a straight line, and abnormal tail carriage. However, limited or no data from well-designed scientific studies supports the utility of such interventions in applicable patients; notably dogs, cats and horses. The evidence for massage in human infants and adults suggests applications in animals with stress, pain, edema, arthritis, sluggish digestion, postoperative ileus, and intervertebral disc disease.
Although some animal chiropractors have advocated chiropractic therapy for a gamut of problems, including idiopathic lameness, intervertebral disc disease, Wobbler syndrome/cervical vertebral malformation, spondylosis, cauda equina syndrome, urinary incontinence, neuropathies, postsurgical rehabilitation, trauma, and various organ pathologies; many of these may actually constitute contraindications.
Contraindications for Manual Therapy in Veterinary Patients
For massage, patients who are especially fragile or ill generally require briefer and gentler treatments with less digital pressure and compression. Soft-tissue techniques should never be directly applied over areas of infection, acute inflammation, tumors, recent surgical sites/incisions, or thromboses. Similarly, massage may not be ideal in areas of acute inflammation, skin infection, bone fractures, burns, deep vein thromboses, or in patients with cancer.
Contraindications for chiropractic therapy; not withstanding the lack of evidence supporting this modality, include conditions that weaken bone or other structural elements such that applying a thrust to a vulnerable spine or limb could lead to serious injury or even death, as has been reported in the human medical literature. Examples of deossifying or destabilizing conditions include hyperadrenocorticism, cancer, secondary renal hyperparathyroidism, degenerative joint disease, and disc disease.
Adverse Effects of Manual Therapy in Veterinary Patients
Excessive pressure from massage and forceful thrusts from chiropractic therapy both have the potential to injure organs, vessels, neural tissue, or bones. Deep massage of the abdomen may damage organs (rupture/bleeding) and nerves (from direct pressure onto nerves); intense pressure could dislodge a stent or catheter or embolize thrombi. With chiropractic manipulation, thrusts are not always innocuous. A heavy-handed individual can seriously harm or even kill an animal. Even milder thrusts can injure animals weakened by age, joint pathology, osteopenia, or neoplasia.
Injuries from chiropractic therapy usually result from trauma to the spinal cord or brain, arising from impacted blood vessels, discs, or nervous tissue. Reports in human patients have found a concerning association between stroke and chiropractic upper cervical manipulation. In addition to high velocity techniques, deep massage or other pressing techniques in the suboccipital region have damaged vessels and caused neurologic impairment and death in people. Although rare, stroke from cervical chiropractic manipulation of human patients is well recognized and may be underreported. The mechanism of injury typically involves arterial dissection or spasm.
In a study of human patients with neck pain, 25% of patients reported increased neck pain or stiffness after chiropractic treatment, and adverse reactions were more likely after the use of higher-force techniques. The authors concluded that because high-force techniques did not demonstrate superior effectiveness compared with low-force maneuvers, chiropractors should consider conservative manipulative procedures. Especially in geriatric or otherwise fragile animals, soft tissue manual therapy techniques are likely to be safest.
Controversies of Manual Therapy in Veterinary Patients
From a mechanical standpoint, extrapolating human chiropractic theories to animals raises questions. Biomechanical forces on the spine of a quadruped differ from those in bipeds. Furthermore, the vertebrae of horses are at least the size of a human fist and are surrounded by muscle, tendon, and ligament layers several inches thick, suggesting that thrusting motions applied to equine vertebrae cannot actually reposition bones at all.
Furthermore, claims that spinal joints or other bones move “out of place” remain unsubstantiated. Even if such lesions exist, the diagnostic measures commonly used to detect them are not reproducible or reliable. The overall utility of manipulative therapy may reside in its ability to mobilize joints and their surrounding soft tissues, rather than put bones "back into place."
Finally, additional controversy arises from the fact that manual therapies may be performed by non-veterinarians. Manual therapies pose grave potential risks. When these are practiced by overzealous therapists with insufficient education regarding anatomy and pathophysiology, the risk of injury to the patient, practitioner and bystanders is greatly increased. Additionally, lack of familiarity with animal behavior, zoonotic illnesses, and proper restraint and techniques can further increase risks. Nonprofessionals may also not have suitable liability insurance for potential accidents or incidents.
State laws may or may not allow non-veterinarians to treat animals. Some may allow a human chiropractor or massage therapist to treat animals but require a defined level of supervision by a veterinarian. Because state laws differ, veterinarians should check state laws and regulations regarding this before referring or delegating care.
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Also see pet health content regarding complementary and alternative therapies for pain.
