Manipulative and Body-Based Practices: An Overview

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Manipulative and Body-Based Practices: An Overview

Therapeutic Massage and Chiropractic Care

Report excerpt

By: National Center for Complementary and Alternative Medicine

Date: October 2004

Source: National Center for Complementary and Alternative Medicine. "Manipulative and Body-Based Practices: An Overview." 〈〉 (accessed January 17, 2006).

About the Author: The National Center for Complementary and Alternative Medicine (NCCAM) is part of the National Institutes of Health (NIH), which is one of the agencies under the administrative umbrella of the Department of Health and Human Services (DHHS) in the Public Health Service (PHS). The NCCAM has a threefold task: to support, conduct, and fund training and research in the areas of complementary and alternative medicine, to educate healthcare professionals and the lay public regarding the utility and efficacy of complementary and alternative medicine, and to support education and professional development of future complementary and alternative medicine providers.


The first therapeutic massage probably occurred when a very early human sustained an injury and instinctively rubbed the area, noticed that it made the injury feel better, and repeated the process with the next wound. The American Massage Therapy Association (AMTA) defines massage therapy as that process in which a (trained) provider employs any of a number of specific manual techniques, causing soft tissue movement or manipulation, either with or without the use of complementary or additional methodologies, with the goal of improving the overall feeling of wellness of the client.

In the United States prior to the last few decades of the twentieth century, massage was considered to be primarily a relaxation and stress reduction technique, typically performed in the context of a health spa setting, or as an adjunct to a physical or sports conditioning program. Historically, massage has been utilized much more as a therapeutic modality in Europe, Asia, and the Middle Eastern countries than in the United States.

Two of the most common forms of therapeutic massage employed elsewhere in the world (and now in America as well) are shiatsu and Swedish massage. Shiatsu is predicated upon the Chinese concept of the movement of subtle energy, also called chi or qi. One of the main premises of energy movement theory is that the body is divided into segments, called meridians, that encircle the body both horizontally and vertically (two separate sets of meridians). Specific points (identical for shiatsu, acupuncture, and acupressure) along the meridians control the totality of the functioning of the body's systems. By applying either deep tissue pressure, stretching, or other techniques, it is thought that the health of the entire body-mind can be maintained, in addition to achieving a profound sense of comfort and relaxation. It is a philosophical and aesthetic process, as well as a physical one.

Swedish massage is much more physiologically centered than is shiatsu. There are a variety of strokes and soft tissue manipulations inherent in the practice, each of which has a discrete function. Overall, the goal is to improve circulation, assist stretched or over exercised muscles in rapid recovery, enhance the functioning of the immune and circulatory systems, and maintain the integrity and high functioning of the muscles, tendons, ligaments, and joints. Like shiatsu, it is used for optimizing the physical well-being of the body, as well as for relaxation of the mind.

The use of massage in a medical scenario in America is relatively recent. It has sometimes been used in conjunction with physical or occupational therapy in order to relax or stretch muscles, resolve swelling or tissue inflammation, maintain muscle tone in fractured limbs that must be immobilized for prolonged periods, or in the limbs and extremities of persons with various types of paralysis or peripheral neuropathies.

In addition to shiatsu, Swedish, and the various medical massage techniques, there are several other modalities used frequently in the massage therapy setting. The most well-known among them are: reflexology, craniosacral, deep tissue, trigger point, myofascial release, sports massage, and reflexology.

The following excerpt from a government report issued by the National Center for Complementary and Alternative Medicine discusses the prevalence and efficacy of chiropractic care and massage therapy.


Introduction Under the umbrella of manipulative and body-based practices is a heterogeneous group of CAM interventions and therapies. These include chiropractic and osteopathic manipulation, massage therapy, Tui Na, reflexology, rolfing, Bowen technique, Trager bodywork, Alexander technique, Feldenkrais method, and a host of others. Surveys of the U.S. population suggest that between 3 percent and 16 percent of adults receive chiropractic manipulation in a given year, while between 2 percent and 14 percent receive some form of massage therapy. In 1997, U.S. adults made an estimated 192 million visits to chiropractors and 114 million visits to massage therapists. Visits to chiropractors and massage therapists combined represented 50 percent of all visits to CAM practitioners. Data on the remaining manipulative and body-based practices are sparser, but it can be estimated that they are collectively used by less than 7 percent of the adult population….

Clinical Studies: Mechanisms Biomechanical studies have characterized the force applied by a practitioner during chiropractic manipulation, as well as the force transferred to the vertebral column, both in cadavers and in normal volunteers. In most cases, however, a single practitioner provided the manipulation, limiting generalizability. Additional work is required to examine interpractitioner variability, patient characteristics, and their relation to clinical outcomes.

Studies using magnetic resonance imaging (MRI) have suggested that spinal manipulation has a direct effect on the structure of spinal joints; it remains to be seen if this structural change relates to clinical efficacy.

Clinical studies of selected physiological parameters suggest that massage therapy can alter various neurochemical, hormonal, and immune markers, such as substance P in patients who have chronic pain, serotonin levels in women who have breast cancer, cortisol levels in patients who have rheumatoid arthritis, and natural killer (NK) cell numbers and CD4+ T-cell counts in patients who are HIV-positive. However, most of these studies have come from one research group, so replication at independent sites is necessary. It is also important to determine the mechanisms by which these changes are elicited.

Despite these many interesting experimental observations, the underlying mechanisms of manipulative and body-based practices are poorly understood. Little is known from a quantitative perspective. Important gaps in the field, as revealed by a review of the relevant scientific literature, include the following:

  • Lack of biomechanical characterization from both practitioner and participant perspectives
  • Little use of state-of-the-art imaging techniques
  • Few data on the physiological, anatomical, and biomechanical changes that occur with treatment
  • Inadequate data on the effects of these therapies at the biochemical and cellular levels
  • Only preliminary data on the physiological mediators involved with the clinical outcomes …

Utilization/Integration In the United States, manipulative therapy is practiced primarily by doctors of chiropractic, some osteopathic physicians, physical therapists, and physiatrists. Doctors of chiropractic perform more than 90 percent of the spinal manipulations in the United States, and the vast majority of the studies that have examined the cost and utilization of spinal manipulation have focused on chiropractic.

Individual provider experience, traditional use, or arbitrary payer capitation decisions—rather than the results of controlled clinical trials—determine many patient care decisions involving spinal manipulation. More than 75 percent of private payers and 50 percent of managed care organizations provide at least some reimbursement for chiropractic care. Congress has mandated that the Department of Defense (DOD) and the Department of Veterans Affairs provide chiropractic services to their beneficiaries, and there are DOD medical clinics offering manipulative services by osteopathic physicians and physical therapists. The State of Washington has mandated coverage of CAM services for medical conditions normally covered by insurance. The integration of manipulative services into health care has reached this level despite a dearth of evidence about long-term effects, appropriate dosing, and cost-effectiveness.

Although the numbers of Americans using chiropractic and massage are similar, massage therapists are licensed in fewer than 40 states, and massage is much less likely than chiropractic to be covered by health insurance. Like spinal manipulation, massage is most commonly used for musculoskeletal problems. However, a significant fraction of patients seek massage care for relaxation and stress relief….

Patient Satisfaction Although there are no studies of patient satisfaction with manipulation in general, numerous investigators have looked at patient satisfaction with chiropractic care. Patients report very high levels of satisfaction with chiropractic care. Satisfaction with massage treatment has also been found to be very high….


The use of therapeutic massage as a complementary medical modality has increased dramatically in recent years. One factor that led to its increase in the last two decades of the twentieth century was the prevalence of neuropathies; and tissue, muscle, and wasting syndromes associated with HIV and AIDS. Because the disease constellation was still quite new in America, little was known about the most effective ways in which to provide physical (and emotional) relief for patients experiencing a plethora of painful and debilitating symptoms throughout virtually their entire bodies. Because of the shortage of effective therapies, many people with HIV/AIDS turned to complementary and alternative treatments, including dietary manipulation, the use of herbal and botanical supplements, and the therapeutic use of massage—both for pain and symptom management and for stress reduction.

According to the AMTA and the NCCAM, research on the therapeutic benefits of massage has been going on for more than one hundred years. Based on both current and long-term research studies, massage has myriad medical and therapeutic benefits, among the most salient of which are to increase the flow of lymph and blood circulation, stimulate the release of endogenous endorphins (also referred to as the body's naturally occurring painkillers), lower heart rate and blood pressure, stretch and relax muscles, reduce the physical effects of stress on the body, increase a feeling of focus and alertness, and improve the range of motion in joints that are worked on. Among the myriad health benefits listed by consumers of therapeutic massage are improvements in chronic pain and degenerative joint syndromes (such as rheumatoid and osteoarthritis), decreased sinus and allergy symptoms, improved circulation, decrease in number and intensity of headaches, decreased feelings of stress associated with neck, shoulder, and back pain, more rapid healing of strains, muscle pulls, and many types of sports injuries, and improvements in signs and symptoms associated with the experience of stress, depression, and anxiety.

Many physician's offices and health clinics have begun to utilize on-site massage therapists as well as to refer their patients to them. Natural food and some specialty stores have begun to set up massage chairs. Even American shopping malls have begun to set up therapeutic massage kiosks (generally for chair massages only). Employers have started offering the use of therapeutic massage as a standard health benefit, and some utilize on-site massage therapists in the workplace. Among those who do so, preliminary data have indicated an increase in productivity, a decrease in job site accidents, and a decrease in sick leave. However, it is still early in this research, and the results are not yet considered conclusive.



Gordon, James S. Manifesto for a New Medicine: Your Guide to Healing Partnerships and the Wise Use of Alternative Therapies. Reading, MA: Perseus Publishing, 1996.


American Massage Therapy Association. "Manipulative Research Confirms Massage Therapy Enhances Health." 〈〉 (accessed January 17, 2006).

American Massage Therapy Association. "Massage Therapy Tips for Consumers." 〈〉 (accessed January 17, 2006).

National Certification Board for Therapeutic Massage and Body work. "Consumers' Guide to Therapeutic Massage and Bodywork." 〈〉 (accessed January 17, 2006).