Manual Therapy – Measuring Our Effectiveness

by Kevin Haussler, DVM, DC, PhD

If we are treating a patient with a specific goal in mind, then we will want to know how effective our therapy is for that individual patient’s condition. In this blog post, we explore the importance of establishing a baseline for each patient by performing a thorough pre-treatment assessment and then measuring the success of our work against specific performance indicators.

What is manual therapy?

Manual therapy involves the use of hands to assess and provide therapy to a patient. It typically consists of the application of mechanical forces to the patient’s skin, fascia, muscles, tendons, ligaments, and joints with the intent of relieving pain, increasing body awareness and mobility, and improving overall well-being. Psychological effects include relaxation, providing comfort, building trust, and bonding.

General categories of manual therapy techniques include touch therapies, soft tissue massage, stretching, joint mobilization and manipulation.

The use of hand-held tools, applied to the skin, fascia or muscles, may also be considered a type of manual therapy – these include cupping, instrument-assisted soft tissue mobilization tools, and vibrators.

Manual therapy can be beneficial for various conditions, which include behavioral issues, myofascial restrictions, musculoskeletal injuries, neurological disorders, and movement-related issues. While disease and disability are common clinical indications for treatment, optimizing health, maximizing performance, and preventing injuries are just as important from a wellness perspective.

Who are manual therapists?

Manual therapy treatments for animals are typically provided by practitioners with specific training and expertise. These include veterinarians, veterinary technicians, veterinary chiropractors, osteopaths, physical therapists, massage therapists and bodyworkers.

The effectiveness of manual therapy is influenced by the skill and experience of the practitioner, as well as by the specific needs and conditions of the individual patient. The various interventions are typically applied with a thorough understanding of animal anatomy, biomechanics, physiology, and pathology.

It is essential for individuals providing manual therapy treatments to animals to have appropriate training and certifications. Practitioners must adhere to legal and ethical standards and collaborate with licensed veterinarians to address any underlying medical issues and to ensure a comprehensive approach to animal health and well-being. Each case should be assessed individually, and the choice of manual therapy techniques needs to be tailored to the specific needs and conditions of the animal. This helps to ensure that the therapies are performed safely and effectively.

Which manual therapy to select?

Choosing the optimal modality or technique involves a thoughtful and individualized approach based on several factors, including the specific condition, the goals of treatment, and the expertise of the practitioner.

Here are some key considerations when selecting the most suitable manual therapy technique:

Clinical assessment: A thorough medical history, detailed observation, and clinical assessment are essential components in forming an accurate diagnosis or functional assessment of the patient’s condition. Identifying the specific pathoanatomic issue (e.g., myositis, osteoarthritis, tendinitis) or functional issue (e.g., pain, stiffness, muscle hypertonicity, poor posture) informs the choice of manual therapy.

Treatment goals: Clearly defining therapeutic goals helps to determine which manual technique might be most appropriate. Typical goals include pain management, improved joint mobility, postural stability, tissue healing, or enhancement of overall performance.

Practitioner expertise: Different techniques require specific training, and practitioners may specialize in certain areas. It is essential that the therapist has experience with the chosen modality or technique.

Individual horse factors: Age, overall health, and pre-existing conditions can influence the choice of therapy. For example, geriatric horses may require gentle techniques, while high-performance athletes may benefit from specific therapies aimed at optimizing performance.

Type of condition or injury: The nature of the musculoskeletal issue or injury plays a crucial role. For instance, joint mobilization may be suitable for osteoarthritis, while soft tissue massage may be more beneficial for muscle strains.

Red flags: Identifying relative or absolute contraindications is critical not only for determining if treatment is allowed or not – depending on the type, location, and severity of the issue of concern, one form of manual therapy may be preferential over another.

Comfort level of the patient: Closely observing the patient’s response to the applied therapy and constantly modifying the amount or direction of the applied pressure is essential. Some animals may be more receptive to certain modalities, while others may be sensitive or anxious. Choosing techniques that the animal tolerates well is essential for a safe, effective treatment and overall positive patient experience.

Integration with veterinary care: The patient’s assessment and planned course of action should always be in collaboration with the attending veterinarian. The chosen manual therapy should align with any existing overall veterinary care plan, and the practitioner should seek to communicate with the veterinarian to ensure a comprehensive approach to the horse’s health.

Research and evidence: All forms of assessment and therapy need to be based on evidence-based medicine principles. While some manual techniques have a robust body of evidence for clinical effectiveness in animals, others may have limited evidence or are largely extrapolated from human or basic science research. It is important to choose therapies that are both safe and effective.

Client preferences and values: Understanding the animal owner’s goals and preferences is critical to providing effective care. Some owners may prioritize holistic or alternative therapies, while others may prefer conventional approaches.

Monitoring and adjustments: The immediate and ongoing assessment of the patient’s response to the applied therapy is essential. Regular monitoring is required to determine if our treatment was effective or not. The use of outcome measures allows the practitioner to make continuous adjustments to the therapeutic plan as required. If the chosen modality is not yielding the desired results, the treatment approach may need to be modified.

Ultimately, the selection of the optimal modality or technique involves a comprehensive understanding of the individual animal, collaboration with veterinary professionals, and the application of evidence-based practices tailored to the specific needs and goals of the animal.

Key performance indicators

How can we know that we are making a difference in our patient’s condition unless we use some method to assess our therapeutic efficacy? Incorporating outcome measures, i.e., key performance indicators (KPIs), allows us to quantity and qualify the success of our work.

To achieve meaningful and measurable outcomes, a comprehensive pre-treatment assessment is paramount. This involves a meticulous examination of the horse’s behavior, movement, and physical attributes. Without a complete patient health and injury history and this initial assessment, it becomes challenging to establish a baseline, i.e., a reference point for comparison. This baseline is derived from a thorough understanding of the animal’s current condition, including the location and severity of any anatomical abnormalities, biomechanical issues, neurologic status, or existing pathologies. It serves as a point of reference to gauge the impact of manual therapies over time. (See https://vetcompendium.org/the-whole-body-assessment/)

Specific performance indicators can then be used to assess our treatment efficacy. These will vary depending on our intent, i.e., treatment goal, and the desired outcomes of the applied therapy. Also, manual therapy practitioners have a diverse array of training and experience, which means that there will be a wide range of clinical indicators applicable to the different treatment intents.

Here are some performance indicators to consider:

Pain reduction: Utilize pain assessment tools, both subjective and objective, to quantify any reduction in discomfort or pain levels experienced by the patient. Examples include assessing sensitivity to touch, facial grimace scales, ethograms, visual analog scales, and mechanical nociceptive thresholds.

Neurologic status: Assess changes in behavior, mental status, posture, and proprioception. Any improvements in these areas can be indicative of enhanced joint position sense, balance, and coordination. Examples include postural analysis, proprioceptive challenges, and navigating obstacles.

Biomechanical improvement: Assess changes in the horse’s gait and movement patterns. Any improvements in these areas can be indicative of enhanced flexibility, stability, and overall musculoskeletal function. Examples include subjective gait analysis for signs of altered movement patterns and objective measures using video analysis, inertial sensors, and artificial intelligence to quantify motion asymmetries and localize sources of lameness.

Functional range of motion: Measure and document improvements in the quality and quantity of soft tissue displacement and joint range of motion. Examples include assessing characteristics of active and passive movements, goniometers, and slow-motion videos.

Muscle function: Observe and palpate variations in muscle development, tone, and texture. Examples include flexible rulers to capture muscle contours, soft tissue palpation, tonometry, and electromyography.

Performance enhancement: If the intent of the treatment is to enhance athletic performance, monitor the horse’s performance metrics in relevant activities, such as jumping or racing. Other athletic disciplines have more subjective assessments of performance such as owner questionnaires, rider perceptions, esthetics of movement, judging scores, and vital parameters (heart rate, temperature) associated with endurance events.

By establishing baselines through systematic pre-treatment assessments and then employing appropriate performance indicators, manual therapists can effectively measure the success of their work. Performance indicators provide invaluable insights into the efficacy of treatment strategies.

How effective are manual therapies?

While there may be relatively limited research or evidence supporting the effectiveness of manual therapies in animals, this does not preclude the use of these techniques in clinical practice as long as they are applied in a safe manner and based on sound principles.

Therapeutic trials are a mainstay of medical practice – you never know how a particular patient is going to respond to a specific treatment. The effectiveness of manual therapies can vary depending on the modality or technique used, the nature of the patient’s condition, the skill and experience of the practitioner, and the individual response of the patient.

Here is a list of the current existing literature on the effectiveness of touch, massage, stretching, joint mobilization and manipulation in animals. It is hoped that continued efforts will increase the level of evidence across all forms of manual techniques used in animals, which will help improve and direct treatment plans.

Touch

  • Reduces stress behavior (Probst et al. 2012)
  • Reduces heart rate (Birt et al. 2015)
  • Alters skin temperature (Kanik et al. 2017)
  • Improves handling and restraint in foals (Spier et al. 2004)

Massage therapy

  • Scott & Swenson 2009; Corti 2014
  • Improves limb range of motion (Hill & Crook 2010)
  • Reduces stress (McBride et al. 2004)
  • Aids recovery (Scott 2003)
  • Improves gait abnormalities (Brockman 2017)
  • Increases lymph flow (Fedele & Berens von Rautenfeld 2007)
  • Reduces heart rate (Feh & de Mazieres 1993)
  • Improves race performance (Kowalik et al. 2017)
  • Reduces thoracolumbar pain (Sullivan et al. 2008)

Stretching exercises

  • Frick 2010; Marcellin-Little & Levine 2015
  • Alters posture (Giovagnoli et al. 2004)
  • Affects stride length (Rose et al. 2009)
  • Increases muscle size (Stubbs et al. 2011; de Oliveira et al. 2015)

Joint mobilization and manipulation

  • Haussler et al. 2021
  • Improves carpal range of motion (Olson 1987)
  • Reduces cervical pain and stiffness (Ahern 1994; Pusey et al. 1995; Colles et al. 2014)
  • Decreases acute thoracolumbar pain (Haussler et al. 2020)
  • Reduces chronic back pain (Haussler & Erb 2003; Sullivan et al. 2008; Acutt et al. 2019; Long et al. 2020)
  • Reduces epaxial muscle hypertonicity (Wakeling et al. 2006)
  • Decreases thoracolumbar stiffness (Haussler et al. 2007; Gomez Alvarez et al. 2008; Haussler et al. 2010; Taylor et al. 2019)
  • Alters thoracolumbar posture (Taylor et al. 2019)

Limitations

While manual therapies offer multiple benefits, there are certain limitations and aspects that they may not be able to address comprehensively. It is important to have realistic expectations and recognize the boundaries of manual therapies.

Surgical interventions: Manual therapies cannot replace the need for surgical interventions, such as fractures, severe joint injuries, or internal organ trauma.

Medical conditions: Manual therapies are not a substitute for medical treatments that involve medications. Certain health issues, like infections or metabolic disorders, may require pharmaceutical interventions prescribed by a veterinarian.

Diagnostic procedures: Manual therapies may provide valuable insights into musculoskeletal issues, but they cannot replace the accuracy of advanced imaging techniques (e.g., MRI, CT scans) or diagnostic procedures (e.g., blood chemistry, joint fluid analysis) for a comprehensive understanding of certain conditions.

Systemic disease: Manual therapies may address localized musculoskeletal issues, but they are not designed to treat systemic diseases affecting internal organs or physiological functions.

Emergency situations: In emergency situations where immediate and critical care is required, manual therapies are often contraindicated. Emergency cases often necessitate prompt medical attention and, if necessary, surgical intervention.

Chronic conditions: While manual therapies can contribute to the management of chronic conditions, they may not provide permanent solutions for certain issues. Long-term management may require a combination of therapies, medications, and lifestyle adjustments.

Unwanted behavior: Manual therapies may not be effective in addressing behavioral issues unrelated to pain or discomfort, such as training-related problems or certain psychological issues. In such cases, behavioral training and positive reinforcement may be more appropriate.

Disease prevention: While manual therapies can contribute to overall health and preventive care, they cannot guarantee the prevention of all health issues. Regular veterinary check-ups, vaccinations, and proper management practices are essential for preventive care.

It is crucial for animal owners and caregivers to work collaboratively with the attending veterinarian to develop a comprehensive healthcare plan for their animals. This plan may include a combination of manual therapies, medical treatments, preventive care, and, if needed, more advanced interventions to address specific health conditions.

In closing…

A proper assessment and a tailored treatment plan are crucial for maximizing the effectiveness of manual therapies.

The effectiveness of any manual therapy depends on factors such as the training and skill of the practitioner, the specific needs of the patient, and the nature of the condition being addressed.

Regular communication and knowledge exchange between owners, veterinarians, practitioners, and researchers are crucial to advancing our understanding of the application and benefits of manual therapies in animals.

Only through the use of objective performance indicators, i.e., outcome measures, will we ever know if we are truly making a difference in our patients’ lives.

See references here [PDF]

How do you ensure and maintain high standards in the training and clinical application of your manual therapy? What role does continuing education play in refining your techniques?

How do you balance the use of intuition and empirical evidence with established scientific approaches and published literature?

If you are a veterinarian, how has the integration of manual therapy enhanced your practice, and what challenges have you encountered in promoting this approach within a traditional veterinary context?

Do you have examples where a specific technique or protocol yielded notable results that were not achieved using other forms of therapy?

Dr. Haussler and his guests will be discussing this important topic at our March 28th free Community Gathering. Come join the conversation with Sandi Howlett, DC, CST-D, Veterinary Chiropractor; Celeste-Leilani Lazaris, LMT, LAMT; and Martina Neidhart, MRCVS, DVC, CVA, CERT, CEKTT.

Registration at vetspine.org/community-gatherings/

Interested in learning more?