Abstract ID: 2226

Primary Topic: Manual medicine/body work (including chiropractic and massage)
Secondary Topic: Basic Science

Neural Mechanisms of Manual Therapies for Chronic Pain
Merav Sabri, PhD; Partap S Khalsa, DC, PhD, DABCO, National Center for Complementary and Integrative Health (NCCIH), Bethesda, MD, United States; Mark D Bishop, PT, PhD, University of Florida, Gainesville, FL, United States; Helene M Langevin , MD, Osher Collaborative for Integrative Medicine, Boston, MA, United States; William R Reed, DC, PhD, University of Alabama at Birmingham, Birmingham, AL, United States; Laura Case, PhD, National Center for Complementary and Integrative Health (NCCIH), Bethesda, MD, United States

Late Breaker: No

Overview

Manual therapies (MT) are a class of non-pharmacological approaches that can be used for treatment and management of chronic pain. MT (e.g., massage, mobilization, spinal manipulation) could be an alternative to, or used to reduce need for, prescription opioids. This is especially important given the current, national prescription opioid epidemic. However, the mechanisms by which MT reduce pain are insufficiently understood, and this lack of understanding impedes their optimal utilization. Further, there is little consensus on the extent to which MT modulate and/or modify neurophysiological responses in the peripheral and/or central nervous system (i.e., brain and spinal cord), nor how neurophysiological responses might reciprocally affect peripheral tissues and/or immunological processes. This proposed NCCIH-sponsored symposium will explore theoretically-based research directions that focus on elucidating the peripheral and central neural mechanisms of MT, with the goal to achieve individualized mechanism-based pain management. The symposium will begin with a brief overview by the Co-Chair, Dr. Merav Sabri, on the NCCIH priorities for manual therapies. The first speaker, Dr. Mark Bishop, will introduce a theoretical and testable framework of the mechanisms of MT. The second speaker, Dr. Helene Langevin, will discuss the evidence and importance of peripheral mechanisms of MT. The third speaker, Dr. William Reed will present evidence and the importance of central mechanisms of MT. The forth speaker, Dr. Laura Case, will present research related to the sensory-affective neural mechanisms of massage. The symposium will conclude with a discussion moderated by the Co-Chair, Dr. Partap Khalsa.

Rationale

Manual therapies (MT; e.g., massage, mobilization, spinal manipulation) are a class of non-pharmacological approaches that can be used for treatment and management of chronic pain. Based on data from CDC/NCHS National Health Interview Surveys (2002 and 2012), there is a significant increase in adult use of MT for pain management (Nahin et al., 2016). MT could be an alternative to, or used to reduce need for, prescription opioids. This is especially important given the current, national prescription opioid epidemic.

The mechanisms by which MT reduces pain are not well established. Consequently, clinicians are often challenged in selecting the most efficacious therapeutic approach for individuals with chronic pain. Mechanistic understanding of MT effects could facilitate the development and implementation of mechanism-based, individualized pain management, and identification of responders from non-responders. Historically, local and segmental responses (e.g., in tissue, structure) to MT were considered responsible for clinical benefit. This biomechanical approach could not explain the presence of non-segmental hypoalgesia and autonomic function changes (e.g., heart rate), bringing attention to neurophysiological responses to MT. However, there is little consensus on the extent to which MT modulate and/or modify neurophysiological responses in the peripheral and/or central nervous system (i.e., brain and spinal cord), nor how such responses might reciprocally affect peripheral tissues and/or immunological processes. There is evidence that MT affect the interaction between inflammatory mediators and peripheral nociceptors in response to injury (Vernon et al., 1986; McPartland et al., 2005; Teodorczyk-Injeyan et al., 2006). In addition, changes in spinal excitability following MT, as indicated by decreased nociceptive flexion reflexes (Courtney et al., 2010) and reduced temporal summation (Bishop et al., 2011), represent evidence for reduced facilitation and increased inhibition of nociceptive input as mediated by central descending pain modulatory systems. Still, direct evidence for spinal or cortical changes are weak and whether central nervous system plays a dominant or secondary role is unknown.

The proposed NCCIH-sponsored symposium will explore theoretically-based neuroscience research that focus on elucidating the potential peripheral and central mechanisms of MT, to facilitate the development of individualized mechanism-based pain management. The goals of this symposium are to: 1) stimulate discussion among clinicians, physiologists, and neuroscientists; 2) facilitate collaborations on research of the neural pathways by which MT exert beneficial effects; and 3) promote optimization of MT.

Citations:

Bishop, M. D., Beneciuk, J. M., & George, S. Z. (2011). Immediate reduction in temporal sensory summation after thoracic spinal manipulation. Spine J, 11(5), 440-446. doi:10.1016/j.spinee.2011.03.001

Courtney, C. A., Witte, P. O., Chmell, S. J., & Hornby, T. G. (2010). Heightened flexor withdrawal response in individuals with knee osteoarthritis is modulated by joint compression and joint mobilization. J Pain, 11(2), 179-185. doi:10.1016/j.jpain.2009.07.005

McPartland, J. M., Giuffrida, A., King, J., Skinner, E., Scotter, J., & Musty, R. E. (2005). Cannabimimetic effects of osteopathic manipulative treatment. J Am Osteopath Assoc, 105(6), 283-291.

Nahin, R. L., Barnes, P. M., & Stussman, B. J. (2016). Insurance Coverage for Complementary Health Approaches Among Adult Users: United States, 2002 and 2012. NCHS Data Brief(235), 1-8.

Teodorczyk-Injeyan, J. A., Injeyan, H. S., & Ruegg, R. (2006). Spinal manipulative therapy reduces inflammatory cytokines but not substance P production in normal subjects. J Manipulative Physiol Ther, 29(1), 14-21. doi:10.1016/j.jmpt.2005.10.002

Vernon, H. T., Dhami, M. S., Howley, T. P., & Annett, R. (1986). Spinal manipulation and beta-endorphin: a controlled study of the effect of a spinal manipulation on plasma beta-endorphin levels in normal males. J Manipulative Physiol Ther, 9(2), 115-123.

Objectives

  1. Discuss the theoretical framework of MT mechanisms.
  2. Assess the peripheral and central mechanisms underlying MT.
  3. Identify research gaps and discuss future research directions of the mechanisms by which MT work to alleviate pain.

Methods/Session Format

-Overview (5 min): Dr. Merav Sabri, Co-Chair, NIH-NCCIH

-Presenter 1 (15 min talk; 3 min Q&A): Dr. Mark Bishop, University of Florida

-Presenter 2 (15 min talk; 3 min Q&A): Dr. Helene Langevin, Harvard Medical School and Brigham and Women's Hospital

-Presenter 3 (15 min talk; 3 min Q&A): Dr. William Reed, University of Alabama at Birmingham

-Presenter 4 (15 min talk; 3 min Q&A): Dr. Laura Case, Intramural Research, NIH-NCCIH

-Discussion Q&A (13 min): Dr. Partap Khalsa, Co-Chair, NIH-NCCIH

Total time: 90 min

Outline

The proposed NCCIH-sponsored symposium will explore theoretically-based research directions that focus on elucidating the peripheral and central neural mechanisms of MT, with the goal to achieve individualized mechanism-based pain management. The goals of this symposium are to: 1) stimulate discussion among clinicians, physiologists, and neuroscientists; 2) facilitate collaborations on research of the neural pathways by which MT exert beneficial effects; and 3) promote optimization of MT.