An international consensus on gaps in mechanisms of forced-based manipulation research: findings from a nominal group technique

ABSTRACT

Force-Based Manipulation (FBM) including light touch, pressure, massage, mobilization, thrust manipulation, and needling techniques are utilized across several disciplines to provide clinical analgesia. These commonly used techniques demonstrate the ability to improve pain-related outcomes; however, mechanisms behind why analgesia occurs with these hands-on interventions has been understudied. Neurological, neuroimmune, biomechanical, neurovascular, neurotransmitter, and contextual factor interactions have been proposed to influence response; however, the specific relationships to clinical pain outcomes has not been well established. The purpose of this study was to identify gaps present within mechanism-based research as it relates to FBM. An international multidisciplinary nominal group technique (NGT) was performed and identified 37 proposed gaps across eight domains. Twenty-three of these gaps met consensus across domains supporting the complex multisystem mechanistic response to FBM. The strength of support for gaps within the biomechanical domain had less overall support than the others. Gaps assessing the influence of contextual factors had strong support as did those associating mechanisms with clinical outcomes (translational studies). The importance of literature investigating how FBM differs with individuals of different pain phenotypes (pain mechanism phenotypes and clinical phenotypes) was also presented aligning with other analgesic techniques trending toward patient-specific pain management (precision medicine) through the use of pain phenotyping.

KEYWORDS:

• Force-based manipulation
• manual therapy
• mechanisms research
• consensus research
• nominal group technique

Disclosure statement

Chad Cook is the Director of the Center of Excellence in Manual and Manipulative Therapy at Duke University and a portion of his salary is supported by that role. Chad published a book on OMT and a course with AGENCE EBP on Manual Therapy in which he receives royalties. He is also a consultant for the Hawkins Foundation, Zimmer Biomedical, and Akron Children’s.

All remaining authors have nothing to disclose

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Additional information

Funding

No funding sources to disclose.

Notes on contributors

Damian L. Keter

Damian L. Keter is a clinician and clinical researcher at the Cleveland VA Medical Center where he also serves as a mentor within their Physical Therapy Orthopaedic Residency program. He earned his Doctorate of Physical Therapy followed by his Philosophy Doctorate in Health Sciences where he investigated pain phenotyping in Orthopaedic Manual Therapy. He is a Board Certified Orthopaedic Clinical Specialist and holds certifications in dry needling and chronic pain rehabilitation. He serves as a member of the Department of Veterans Affairs National Biopsychosocial pain mentoring program and a National Institute of Health workgroup on force-based manipulation. He has published several peer-reviewed works on education and clinical topics related to pain and manual therapy.

Jennifer A. Bent

Jennifer A. Bent is a board-certified orthopedic physical therapist with over 10 years of experience in the management of acute and chronic musculoskeletal conditions at Duke University Healthcare System using a contemporary approach to rehabilitation. She completed her Bachelor of Science in Exercise Science with a minor in Sport Coaching from UNC-Greensboro, her Master’s degree in Physical Therapy from Winston Salem State University. She is a Fellow of the American Academy of Orthopedic Manual Therapists and a graduate of the Myopain Seminar Series.

Joel E. Bialosky

Joel E. Bialosky is a Clinical Professor in the Department of Physical Therapy at the University of Florida in Gainesville, Florida. He received a bachelor’s degree in physical therapy from Ithaca College in 1990 and a master’s degree in musculoskeletal physical therapy from the University of Pittsburgh in 1998. He graduated from the University of Florida with a PhD in Rehabilitation Science in 2008 with his research interests focused on the mechanisms of manual therapy in the treatment of musculoskeletal pain. His current research program is focused on 1.) contextual mechanisms of manual therapy and 2.) neuroplastic changes in pain associated with musculoskeletal disorders and their response to common rehabilitation interventions.

Carol A. Courtney

Carol A. Courtney is Professor at Northwestern University Department of Physical Therapy and Human Movement Science and serves as the Associate Chair for Clinical Post-Professional Studies. She received a Bachelor of Science in Physical Therapy from Washington University in St Louis, Master of Science from the University of South Australia and Louisiana State University, and a PhD from the University of Miami. Dr. Courtney is a licensed physical therapist and athletic trainer, and has been recognized as a Fellow of the American Academy of Orthopaedic Manual Physical Therapists. She was recently named a Catherine Worthingham Fellow of the American Physical Therapy Association.

Jorge E. Esteves

Jorge E. Esteves is an osteopath and cognitive scientist with a special interest in chronic musculoskeletal pain. He is currently professor of osteopathy and deputy director of Malta ICOM Educational, honorary professor at the University College of Osteopathy in London and researcher at the Collaboration for Osteopathic Medicine Research in Italy. His current research interests are focused on reconceptualizing osteopathic care under active inference and enactivist frameworks.

Martha Funabashi

Martha Funabashi is a clinical research scientist and associate professor at the Canadian Memorial Chiropractic College and an adjunct professor at the Universitè du Quèbec à Trois-Rivières and at Parker University. She has a bachelor’s degree is Physiotherapy, a master’s degree in Neurosciences and a PhD in Rehabilitation Sciences. She did a post-doctoral fellowship in patient safety. Martha’s research interests and passion include the biomechanics, underlying mechanisms and safety of manual therapies, with a focus on spinal manipulative therapy and spinal mobilization.

Samuel J. Howarth

Dr. Samuel J. Howarth is an Associate Professor, Director of Human Performance Research and holds the McMorland Family Research Chair in Mechanobiology at the Canadian Memorial Chiropractic College. He also holds adjunct positions at multiple Canadian universities. His current research is directed toward biomechanical analysis of human movement focusing on functional tasks used in daily life and clinical practice. Part of this work is dedicated to understanding how clinicians perform force-based manipulation, and how force-based manipulation affects physical function.

H. Stephen Injeyan

H. Stephen Injeyan is a professor for the Department of Research and Clinical Education at Canadian Memorial Chiropractic College (CMCC). He has a MSc and a PhD in the area of microbiology specializing in Parasitology from the Institute of Parasitology of McGill University. He has many years of teaching and research experience in the area of cell biology and microbiology. He received his qualification as a Doctor of Chiropractic in 1984 at CMCC. He has held a faculty position with duties and activities in research, teaching and Clinical Education for 42 years, at the same time holding a full-time clinical practice. His primary focus of research in the chiropractic area has been on the exploration of the effects of spinal manipulation on selected parameters of the immune response. Specifically, he has led the effort in understanding the effects of a manipulative intervention on inflammatory changes in patients with low back pain and his team has published several articles in this area. He has also collaborated with others on topics relevant to public health and chiropractic education.

Anna Maria Mazzieri

Anna Maria Mazzieri is a Soft Tissue Therapist and Educator with a special interest in the mechanisms of Massage, Manual Therapy and the contextual effects involved. She holds a Diploma in Soft Tissue Therapy followed by a Bachelor of Science with Honours in Sports Therapy by the University of St. Mark and St. John and waiting to start Master’s in Neuroscience. In clinical practice since 2002 and providing education since 2008 through The School of Soft Tissue Therapy which she founded. Anna Maria leads a team of tutors to deliver the BTEC Level 5 Diploma in Soft Tissue Therapy as well as creating and delivering post-graduate courses in evidence based manual and massage therapy approaches. She sits on the board of the Institute of Sports and Remedial Massage and has driven the introduction of Evidence Informed Practice into the Diploma curriculum and raised the benchmarks of education and practice. Anna Maria has been involved in several studies on mechanisms including a recent paper on Manual Therapy Framework for different pain phenotypes.

Casper Glissmann Nim

Dr. Casper Glissmann Nim holds the position of Assistant Professor at the Department of Sports Science and Clinical Biomechanics, as well as the Department of Regional Health Research at the University of Southern Denmark. Additionally, he is a Senior Researcher at the Spine Centre of Southern Denmark, University Hospital of Southern Denmark. His research interests revolve around manual therapy, with a particular emphasis on how the specificity of intervention impacts treatment outcomes.

Chad E. Cook

Chad E. Cook PT, PhD, FAPTA is a Professor in the Department of Orthopaedic Surgery in Duke University. He also has appointments in Population Health Sciences and the Duke Clinical Research Institute. Dr. Cook is an NIH and DoD funded researcher and is the Director of the Duke Center of Excellence in Manual and Manipulative Therapy.