Report on The Conference on the Biology of Manual Therapies: A Historic Collaboration between the Canadian Institutes of Health Research and the United States National Institutes of Health

Dr. John J. Triano, DC, PhD, FCCS

On June 9–10, 2005 the first in what is hoped to be a trend of collaborations occurred between the Canadian and United States institutes charged with improving the knowledge base of health care. The Conference on the Biology of Manual Therapies was held with joint sponsorship at the Natcher Conference Center of the National Institutes of Health in Bethesda, Maryland. The purpose of the conference was to review the state of the art and progress in the knowledge base underlying manipulation and other manual therapies and to set research priorities for the next era of studies. The CIHR-NIH co-organized conference was announced in the February 2005 edition of Brain Brief. It is the outcome of several discussions between CIHR, under its international cooperation initiative, the Institute of Musculoskeletal Health and Arthritis (IMHA) and the National Centre for Complementary and Alternative Medicine (NCCAM). The event sponsors from both countries are listed in Table 1.

Table 1.

International Sponsorship for the Biology of Manual Medicine Therapies

Canadian Institutes of Health Research
	Institute of Musculoskeletal Health and Arthritis (IMHA)
	Institute of Neuroscience, Mental Health and Addiction (INMHA)
	International Relations Branch
National Institutes of Health
	National Center for Complementary and Alternative Medicine (NCCAM)
	National Institute of Neurological Disorders and Stroke (NINDS)
	National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
	National Institute of Child Health and Human Development (NICHHD)
	National Institute of Biomedical Imaging and Bioengineering(NIBIB)

For the purposes of this conference, the definition of manual therapies included a host of techniques that focus primarily on the structures and systems of the body, including the bones and joints, the soft tissues, and the circulatory and lymphatic systems. The most popular include chiropractic; massage therapy; and osteopathic manipulation. The conference sought to survey the existing knowledge underlying the biology of these methods. Experts from the NIH and CIHR were joined by academic, patient advocacy, and professional organizations to discuss the state of the art.

Early governmental focus on manual treatments began with the development of the original Office of Alternative Medicine in the United States in 1991. Over the intervening time, funding was made available for the development of research collaboration and infrastructure with particular focus on randomized clinical trials. Early results from these and earlier trials proved helpful in establishing a scientific foundation for patient benefit, particularly from manipulation, mobilization and massage (e.g. {Evans, Bronfort, et al. 2002 2418 /id}{Bronfort, Haas, et al. 2004 3489 /id}{Giles & Muller 2003 1754 /id}{Ernst 1999 1614 /id}). However, more recent studies have been less clear. At the 2004 NCCAM advisory meeting, the director Dr. Stephan Strauss acknowledged similar difficulties with investigations throughout complementary medicine and attributed it to a prematurely narrow focus on randomized trials to the exclusion of mechanistic studies. The conference of 2005 sought to remedy that concern and reprioritize research emphasis.

The Biology of Manual Therapies Conference, the first focused meeting in 30 years since the historic governmental conference on spinal manipulation in 1975{Goldstein 1975 477 /id}, was organized in three sections 1) an overview of the use of manual procedures in Canada and the United States; 2) a survey of evidence on mechanisms of neuroscience, immunology/endocrinology, biomechanics and imaging; and 3) concurrent audience participation breakout sessions for providing public input from practitioners and scientists from the various disciplines who were in attendance. Scientific experts invited to present and the topic areas covered are listed in Table 2.

Table 2.

Topics and invited speakers for the Biology of Manual Therapies Conference (* indicates abstracts available through the nccam.nih.gov/news/upcomingmeetings/agenda)

Section	Speaker & Affiliation	Topic Area
Introduction & Overview	Dr. Richard Nahin, NIH	NCCAM
	Dr. Juliette Cooper, CIHR	IMHA
	Dr. Remi Quirion, CIHR	INMHA
	Dr. Stephen Straus, NCCAM	NIH, NCCAM history
	Dr. Murray Goldstein, United Cerebral Palsy Research and Educational Foundation	Historical perspective: the 1975 Research Status of Spinal Manipulative Therapy meeting*
	Dr. Michael Smith, Health Canada	Chairman, Current use of manual therapies
	Dr. Maria Verhoef, University of Calgary	Overview of manual therapy in Canada*
	Dr. Janet Kahn, Integrative Consulting	Overview of manual medicine in the U. S.*
Neuroscience	Dr. Partap Khalsa, SUNY Stony Brook	Mechanical states encoded by mechanoreceptors and mechanonocicetors*
	Dr. Joel Pickar, Palmer Center for Chiropractic Research	Sensory input elicited by manual therapies*
	Dr. Min Zhuo, University of Toronto	Genetic and synaptic studies of sensory-related central sensitization*
	Dr. Kerstin Uvnas-Moberg, Karolinska Institute	Antistress effects in response to non-noxious sensory stimulation*
Immunology/Endocrinology	Dr. Jon Levine, University of Ca San Francisco	Manipulating pain and inflammation*
	Dr. Claude Cote’, University of Laval	Biological mechanism underlying the inflammatory and healing phases in trauma of the muscle-tendon unit*
	Dr. Firdaus Dhabhar, Ohio State University	A hassle a day may keep the doctor away: enhancing vs. suppressive effects of stress on immune function*
Biomechanics & Imaging	Linda Woodhouse, PT, PhD (candidate), McMaster University	Biomechanics and medical imaging helping to unravel biological effects*
	Dr. John Triano, Texas Back Institute & University of Texas	Manual therapies: A biomechanical continuum*
	Dr. David Wilder, Iowa Spine Research Center	Timing is everything in a column and segment that can buckle*
	Dr. Helene Langevin, University of Vermont	Connective tissue mechanotransduction response to stretch and acupuncture*
	Dr. Hermano Krebs, MIT	Rehabilitation robotics and movement therapy: implications for manual procedures*
	Dr. Norman Kettner, Logan College	Functional neuroimaging techniques in manual therapy research*

The second day of the conference was devoted to comments from attendees that included chiropractors, medical physicians, osteopaths, massage therapists and body workers using various approaches. Once comments were collected, the co-chairman and panel members for each of the three sections collapsed them into common topic areas. Results from the meeting will provide guidance to investigators and funding agencies to prioritize research efforts in manual methods for the next 5 years. Summaries of those results are listed in Table 3. Answers to these questions on how manual methods work are likely to place manual therapies on solid foundation for future growth.

Table 3.

Summary of recommendations resulting from the Biology of Manual Therapies Conference.

GENERAL QUESTIONS	Determine effects on normal animals and in animal models of tissue injury
	Compare effects in different body regions
	Study effects on the nervous system
	Examine similarities/differences of different methods in terms of biomechanical characteristics and biochemical/molecular effects.
	Develop imaging techniques to capture in vivo dynamics
	Characterize effects on immune/endocrine outcomes
Peripheral manual therapy mechanisms	Effects of superficial stimulation vs. deep stimulation
	Compare dorsal vs. ventral effects of massage
	Examine short vs. long term effects of HVLA on biomechanics and neurophysiology
	Examine peripheral vs. paraspinal reflex function
	Examine sensory neuron response to HVLA
	Examine relationship of microvasculature and mechanonociceptor peripheral sensitization
	Examine peripheral nerve biomechanics
	Determine the path applied loads take through the body
Central mechanisms	Define central neuron activity responses
	Examine spinal cord gating mechanisms and synaptic plasticity
	Determine therapy effects on experimental models of pain
	Identify indicators for spinal manipulation
	Investigate spinovisceral and viscerospinal reflexes