Clinical Techniques
Review of Manual Therapy Techniques in Equine Practice

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Abstract

The realm of manual therapy includes diverse techniques such as chiropractic, osteopathy, physical therapy, massage therapy, and touch therapies, which have been developed for use in human beings and the techniques transferred to horses. All forms of manual therapy have reported levels of effectiveness for treating musculoskeletal issues in human beings, but mostly only anecdotally evidence exists in horses. The purpose of this review is to explore the scientific literature for potential common mechanisms of action and evidence of efficacy and safety for different forms of manual therapies, with a specific focus on joint mobilization and manipulation techniques. A description of a detailed musculoskeletal and spinal examination using manual therapy techniques is also presented. In humans, there is an extensive published data base for most forms of manual therapies; however, the methodological quality of most studies is poor, which often prevents definitive conclusions and recommendations. In horses, there are too few controlled studies to support most anecdotal claims of effectiveness. However, there is limited evidence suggesting effectiveness of spinal manipulation in reducing pain and muscle hypertonicity and increasing joint range-of-motion. Further research is needed to assess the efficacy of specific manual therapy techniques or combined treatments for management of documented back problems and specific lameness conditions in horses. Additional studies are also needed to define specific treatment parameters required for optimal management of select disease processes, such as the amount of force applied, and the frequency and duration of treatment.

Introduction

Manual therapy involves the application of the hands to the body, with a therapeutic intent.1 Chiropractic, osteopathy, physical therapy, massage therapy, and touch therapies are all considered forms of manual therapy techniques that have been developed for treatment of musculoskeletal disorders in humans and transferred for use in horses. Each technique has unique origins and different proposed biomechanical or physiological effects; however, all forms of manual therapy are characterized by applying variable gradations of manual force and degrees of soft-tissue or articular displacement.2 The goal of all manual therapies is to influence reparative or healing processes within the neuromusculoskeletal system. Therapeutic effects may be generalized to the entire body by inducing relaxation or altering behavior, regional effects may include alterations in pain perception or neuromuscular control, or effects may be localized to specific tissues and cellular responses.1 The challenge is in selecting the most appropriate and effective form of manual therapy to produce the desired physiological effect within an individual patient, such as increasing joint range of motion, reducing pain, or promoting general body relaxation. Anecdotally, all forms of manual therapy have reported levels of effectiveness in humans and horses. However, most claims are not supported by high levels of evidence such as randomized, controlled trials or systematic reviews of the published data. The purpose of this review article is to provide a brief overview of the scientific literature on the mechanisms of action and effectiveness of the different forms of manual therapy techniques used routinely in humans and to assess how effective and safe these techniques may be in horses, with a specific focus on joint mobilization and manipulation techniques applied to the proximal limbs and axial skeleton.

The physical act of touching someone can induce physiologic responses and is often considered therapeutic.3 In human beings, therapeutic touch is used by nurses for nurturing premature infants, for supportive care in cancer or terminally-ill patients, and for support of the bereaved.4 Some well-known touch therapies in human beings include Healing Touch, Therapeutic Touch, and Reiki techniques.5 These techniques are considered a form of energy-based therapy in which practitioners move their hands over the body but do not touch the patient, or use a gentle touch over certain areas of the body with the goal of facilitating physical, emotional, mental, and spiritual health. People use touch therapies for relaxation, stress reduction, and symptom relief. Reviews of controlled studies in evaluating effectiveness of touch therapies in human beings show promising results for pain relief, but further rigorous studies are needed to define clinical applications and mechanisms of action.5, 6 Interestingly, trials conducted by more experienced practitioners seemed to yield greater effects in pain reduction. In horses, touch therapies have been primarily developed and promoted by Linda Tellington-Jones in a collection of techniques named the Tellington Touch Equine Awareness Method (TTEAM) or Tellington TTouch.7 Anecdotally, therapeutic touch is considered to improve behavior, performance, and well-being of horses and enhance the relationship between horse and rider, but no controlled studies exist to support these claims. Similar touch therapy techniques have been used in foals at birth to assess the effects of touch or imprint-training on behavioral reactions during selected handling procedures.8 Conditioned foals were significantly less resistant to touching the front and hind limbs and picking up the hind feet at 3 months of age. More controlled studies are needed to determine the effectiveness of touch theories in managing behavioral or musculoskeletal issues in horses.

Massage therapy is defined as the manipulation of the skin and underlying soft tissues either manually (e.g., rubbing, kneading, or tapping) or with an instrument or machine (e.g., mechanical vibration) for therapeutic purposes. Massage techniques include many well-known methods such as Swedish massage, sports massage, trigger point therapy, cross-fiber friction massage, myofascial release, lymphatic drainage, and acupressure. Clinically, massage and soft-tissue mobilization are believed to increase blood flow, promote relaxation, relax muscles, increase tissue extensibility, reduce pain, and speed return to normal function; however, few controlled studies exist to support these claims.9 There are many anecdotal reports of the beneficial effects of massage on athletic performance; however, strong evidence in the form of controlled studies does not exist which proves the effects of massage on preventing injuries, recovery from exercise, or enhancing performance.10 Review of randomized, controlled trials in human beings suggests that massage may be beneficial for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education programs.11, 12 Massage is also a popular adjunct to cancer palliation, and systematic reviews suggest that it can alleviate a wide range of symptoms like pain, nausea, anxiety, depression, anger, stress, and fatigue.13, 14However, the methodological quality of most massage studies is poor, which prevents definitive conclusions and recommendations. In horses, massage therapy has been shown to be effective for reducing stress-related behavior and pain thresholds within the thoracolumbar spine.15, 16 A noncontrolled, clinical trial using eight horses measured increased stride lengths at the walk and trot compared pre and post-massage, but changes were not significant because of a small sample size.17 Manual lymph drainage has been described for use in the management of lymphedema in horses; however, no controlled studies exist evaluating its effectiveness.18 In a clinical trial in dogs, massage was significantly more effective in increasing lymph flow than passive flexion and extension of the forelimb or electrical stimulation of the forelimb musculature.19 More high-quality, scientific-based evidence is needed to support the use of massage therapy in horses.20

Passive stretching consists of applying forces to a limb or body segment in order to lengthen muscles or connective tissues beyond their normal resting lengths, with the intent of increasing joint range of motion and flexibility.21 The amplitude of motion and length of time that an individual stretch is held are gradually increased over time according to patient tolerance and ability. Stretching exercises are thought to increase joint range of motion, enhance flexibility, improve coordination and motor control, increase blood flow to muscles, and help to prevent injuries. Systematic reviews of the human literature suggest that stretching may have beneficial effects on increasing joint range of motion, reducing pain, and preventing work-related musculoskeletal disorders in different occupations.22, 23 Randomized studies suggest that regular stretching increases joint range of motion (average of 8 degrees) for more than 1 day after cessation of stretching and that the effects of stretching are possibly greater in muscle groups with limited extensibility.24 Regular stretching has been shown to improve performance by increasing force, jump height, and speed.25 Other systematic reviews report that there is insufficient evidence to endorse or discontinue routine stretching before or after exercise to prevent injury among competitive or recreational human athletes.26, 27, 28 Because of the relatively low methodological quality of most studies, further research is needed to determine the proper role of stretching in human sports. Stretching combined with strengthening provides the largest improvement in nonspecific chronic neck or low back pain in human beings.29, 30 In horses, passive stretching exercises of the limbs and axial skeleton have anecdotal effects of increasing stride length and joint range of motion and improving overall comfort.31 In a noncontrolled study, passive thoracic limb stretching lowered wither height as a result of possible relaxation of the fibromuscular thoracic girdle.32 However, a randomized controlled trial in riding school horses evaluating the effect of two different 8-week passive stretching programs reported no significant changes in stride length at the trot, but reported actual decreases in joint range of motion within the shoulder, stifle, and hock articulations.33 The authors concluded that daily stretching may be too intensive in normal horses and may actually cause negative biomechanical effects. Additional studies on the effects of different stretching techniques and frequency for specific disease processes using objective outcome measures need to be completed before any further claims of performance enhancement in horses can be made.

Mobilization is defined as manually-induced movement of articulations or soft tissues for therapeutic purposes. Soft-tissue mobilization focuses on restoring movement to the skin, connective tissue, ligaments, tendons, and muscles with the aim of modulating pain, reducing inflammation, improving tissue repair, increasing extensibility, and improving function.9 Joint mobilization is characterized as nonimpulsive, repetitive joint movements induced within the passive range of joint motion with the purpose of restoring normal and symmetric joint range of motion, to stretch connective tissues, and to restore normal joint end-feel.34 Manipulation is a manual procedure that involves a directed impulse which moves a joint or vertebral segment beyond its physiological range of motion, but does not exceed the anatomical limit of the articulation.35 Therefore, the primary biomechanical difference between joint mobilization and manipulation is the presence of a high-speed thrust or impulse. Spinal manipulation involves the application of controlled impulses to articular structures within the axial skeleton with the intent of reducing pain and muscle hypertonicity and increasing joint range of motion.36

Manual techniques used by physical therapists consist primarily of soft tissue and joint mobilization to assess the quality and quantity of joint range of motion and as a primary means of treating musculoskeletal disorders. Physical therapists often focus on functional assessment and diagnosis of neurophysiological processes as they relate to neuromotor control and the sensorimotor system, such as proprioception.37 Subjective assessment of the ease of joint motion, joint stability, and joint end-feel provides insights into the biomechanical and neurologic features of an articulation. Goniometry is often used to objectively quantify and document the amount of flexion or extension present at an articulation. Manually-applied physical therapy techniques also provide an adjunct to therapeutic exercises and rehabilitation of neuromotor control, where manual forces are used to induce passive stretching, weight-shifting, and activation of spinal reflexes, which help to increase flexibility, stimulate proprioception, and strengthen core musculature.38 Peripheral nerve and nerve root mobilization techniques and exercises are also used by physical therapists for postoperative rehabilitation of low back pain.39 Few formal studies exist to support the use of active joint or spinal mobilization techniques in horses.40 Most mobilization studies in horses involve a period of induced joint immobilization by a fixture or cast, followed by allowing the horse to spontaneously weight bear and locomote on the affected limb, without evaluation of specific soft-tissue or joint mobilization techniques.41

The chiropractic and osteopathic professions have many overlapping philosophies, techniques, and potential mechanisms of action related to joint mobilization and manipulation. Manual osteopathic techniques use a combination of mobilization and manipulation methods to address impaired or altered function of the musculoskeletal system (i.e., somatic dysfunction). From an osteopathic perspective, somatic dysfunction relates to impaired or altered function of skeletal, articular, myofascial, and related vascular, lymphatic, and neural elements.42 Human osteopathic techniques also include highly controversial methods associated with mobilizing cranial bones and abdominal viscera, which have questionable application to horses.43, 44 Chiropractic treatment is characterized primarily as the application of high-velocity, low-amplitude (HVLA) thrusts to induce therapeutic effects in articular structures, muscle function, and neurological reflexes.35 From a chiropractic perspective, the basic elements of joint or spinal dysfunction include altered articular neurophysiology, biochemical alterations, pathologic changes within the joint capsule, and articular degeneration. Clinical signs of somatic or spinal dysfunction in horses include asymmetric or restricted joint motion, pain, and muscle hypertonicity.36 Human research has demonstrated reductions in pain and muscle hypertonicity and increased joint range of motion after chiropractic treatment.45, 46, 47

Anecdotal evidence and clinical experience suggest that manipulation is an effective adjunctive modality for the conservative treatment of select musculoskeletal-related disorders in horses.48 Therapeutic trials of spinal manipulation are often used because there is currently limited formal research available about the effectiveness of osteopathic or chiropractic techniques in equine practice. Equine osteopathic evaluation and treatment procedures have been described in textbooks and case reports, but no formal hypothesis-driven research exists.44, 49, 50 The focus of recent equine chiropractic research has been on assessing the clinical effects of spinal manipulation on pain relief, improving flexibility, reducing muscle hypertonicity, and restoring spinal motion symmetry. Obvious criticism has been directed at the physical ability to even induce movement in the horse's back. Pilot work has demonstrated that manually-applied forces associated with chiropractic techniques are able to produce substantial segmental spinal motion.51 Two randomized, controlled clinical trials using pressure algometry to assess mechanical nociceptive thresholds (MNTs) in the thoracolumbar region of horses have demonstrated that both manual and instrument- assisted spinal manipulation can reduce back pain (or increase MNTs).16, 52 Additional studies have assessed the effects of equine chiropractic techniques on increasing passive spinal mobility (i.e., flexibility) and reducing longissimus muscle tone.40, 53 The effect of manipulation on asymmetrical spinal movement patterns in horses with documented back pain suggests that chiropractic treatment elicits slight but significant changes in thoracolumbar and pelvic kinematics, and that some of these changes are likely to be beneficial.54, 55

Section snippets

Joint Mechanics

The use of palpation techniques to qualitatively and quantitatively assess joint motion requires an understanding of joint mechanics.56 Joint motion can be categorized into three zones of movement: physiologic, paraphysiologic, and pathologic (Fig. 1A). The physiological zone of movement consists of both active and passive joint motion within all possible directions of movement (e.g., flexion, extension, lateral bending, and axial rotation). Passive movement of an articulation from a neutral

Mechanisms of Action

Manual therapy is considered to produce physiological effects within local tissues, on sensory and motor components of the nervous system, and at a psychological or behavioral level.1 It is likely that specific manual therapy techniques are inherently more effective than others in addressing each of these local, regional, or systemic components.71 The challenge is in choosing the most appropriate form of manual therapy or a combination of techniques that will be efficacious for an individual

Spinal Examination

The principle goal of the manual therapy examination is to identify whether a musculoskeletal problem exists and to localize the injury to either soft tissue, articular, or neurologic structures. Orthopedic and neurologic evaluations are important adjunctive assessments used to identify common causes of limb lameness, spinal injuries, and neurological disorders that are more appropriately and effectively treated with traditional medical or surgical approaches. Manual therapy evaluation and

Indications for Joint Mobilization and Manipulation

Back pain is a common cause of poor performance in equine athletes. Unfortunately, medical and surgical treatment options are often limited for affected horses. Manual therapy has the potential to provide important diagnostic and therapeutic approaches for addressing equine axial skeleton problems that are not currently available in veterinary medicine. Most of the current knowledge about equine manual therapies has been borrowed from human techniques, theories, and research and is applied to

Joint Mobilization and Manipulation Techniques

Stretching exercises vary according to the direction, velocity, amplitude, and duration of the applied force or induced movement. However, it is difficult to identify which combination of positions, techniques, and durations of stretching are most effective to induce increased joint range of motion.106 Active stretching involves using the patient's own movements to induce a stretch, whereas passive stretches are applied to relaxed muscles or connective tissues during passive soft tissue or

Direction of Future Studies

A thorough knowledge of equine anatomy, soft tissue and joint biomechanics, musculoskeletal pathology, and tissue-healing processes is required to understand the basic principles of the various forms of manual therapies and to properly apply the associated techniques. There is a severe deficiency in evidence for using touch, massage, stretching exercises, and joint mobilization in horses. Spinal manipulation has been shown in several studies to be effective for reducing pain, improving

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