Active versus Passive: Is Exercise more Effective than Manual Therapy?

Review and Commentary on Research Comparing Outcomes following Manual Therapy and Exercise

by Dr. Brent Brookbush, DPT, PT, MS, CPT, HMS, IMT

Introduction

This article has been developed from a comprehensive systematic research review included in the course: Joint Mobilization and Manipulation: Introduction

Time for a little MYTH BUSTING:

Recently, the phrase "active is better than passive" has been published in articles, memes, and thrown around in chat boards as if it's some undeniable truth. But I am not sure how this myth got started. There is absolutely no support in the research for this statement. So, let's start by stating the facts.

• Based on the available research, active interventions are NOT better than passive interventions.

For the record, we are big fans of both active and passive interventions. The Brookbush Institute actually started as a corrective exercise education company and then added manual therapy and strength and performance courses. You may have already seen our Certified Personal Trainer (CPT) , Human Movement Specialist (HMS) , and Integrated Manual Therapist (IMT) certifications . As discussed below, research and objective outcome measures in practice demonstrate that an optimal approach would include the integration of manual therapy, specific/corrective exercise, and strength training.

What the Research Has to Say

If we consider all studies and base our conclusion on a simple method of adopting the conclusion implied by most of them, then manual therapy is generally more effective than exercise, especially during the initial phases of treatment. In summary, the majority of randomized controlled trials (RCTs) comparing manual therapy to exercise demonstrate that manual therapy is more effective than exercise, there is a minority of RCTs demonstrating that both interventions are equally effective, and it is challenging to find research that implies exercise is more effective. If I were to guess at the percentages of each of these categories, I would estimate that 70% suggest manual therapy is more effective, 25% suggest that manual therapy and exercise are equally effective, and only 5% suggest that exercise is more effective. Of course, there is a more accurate and nuanced conclusion to be developed from the research if our goal is to optimize practice (discussed below). But, this article was written to address a single statement that is little more than misinformation.

Again, the review below is an excerpt from the course Joint Mobilization and Manipulation: Introduction . To improve clarity, this review only includes the Randomized Controlled Trials (RCTs) that could be located comparing manual joint mobilizations and manipulations to exercise interventions. All of the available research investigating manual therapy techniques, including additional comparative studies, has been thoroughly reviewed in our Joint Mobilization Courses , Joint Manipulation Courses , and Static Manual Release courses. This includes studies comparing manual therapy techniques to each other, to conventional interventions, to physician care, to other modalities, and to the combination of interventions.

Summary of Research Findings:

Summary Statement: There is no evidence to suggest that exercise should be prioritized over manual or self-administered joint mobilizations and manipulations. In fact, research suggests that manual joint mobilizations and manipulations are more effective than exercise during the initial phase of therapy. Further, these comparative studies likely imply that manual mobilization and manipulation techniques are among the most effective techniques available to movement professionals.

• Cervical Spine: Cervical mobilizations and manipulations are likely more effective than exercise for treating cervical pain and potentially equally effective for treating shoulder pain. Further, both cervical manipulation and exercise are more effective for treating cervical dysfunction than pharmacological interventions and physician care.
• Thoracic Spine: Thoracic manipulations are more effective than therapeutic exercise or physician care for the improvement of neck and shoulder range of motion (ROM), function, and pain, both short-term and long-term.
• Lumbar Spine and Sacroiliac Joint: Results of exercise and lumbar manipulations may be similar for low back pain; however, there is some evidence of a more complex relationship that includes lumbar manipulations being more effective for pain reduction and the combination of specific intervention and manipulations resulting in superior short-term outcomes when compared to general exercise. Unlike studies comparing manipulations to exercise, studies comparing mobilizations to exercise demonstrate a clear trend toward mobilizations resulting in superior outcomes for pain and function, especially during the initial 2 months of treatment.
• Shoulder: shoulder mobilization may be more effective than exercise for the treatment of adhesive capsulitis, with the exception of a daily home exercise program. Further, there is some evidence of specificity, implying shoulder mobilizations will improve the ROM and strength ot the joint ROM that was addressed.
• Elbow and Wrist: For the treatment of lateral epicondylalgia, based on pain, function, and grip strength scores, the combination of elbow mobilization and soft tissue therapy is at least as effective as exercise, and wrist manipulation is likely more effective than conventional therapies including exercise, ultrasound, and friction massage.
• Lower Extremity: Mobilizations are as effective or more effective than exercise for the treatment of hip and/or knee osteoarthritis and/or stiffness based on pain, stiffness, ROM, proprioception, and/or function scores.

Caption: Explanation of hand position during a sacroiliac joint mobilization using a pisiform (saddle) grip hand position.

A False Dichotomy

Perhaps what is most disheartening about the "active vs. passive" myth is it will not result in the best approach for patients based on outcomes. Asking whether active or passive interventions are better is a false dichotomy; that is, it is an unnecessary comparison. Although it is beyond the scope of this article, but is addressed in a separate research review in the same course mentioned above, research almost unanimously demonstrates that the combination of manual therapy and exercise is better than either alone. A truly outcome-driven approach would include an integrated intervention plan of effective manual therapy techniques, supervised exercise, some modalities, and a home exercise plan with the goal of self-management. For example:

1. Start with more manual therapy, some supervised exercise, and 1 - 2 home exercises.
2. Progress to equal amounts of manual therapy and supervised exercise, and 2 - 4 home exercises.
3. Discharge with an effective self-management program that includes 3 - 6 home exercises.

A New Business Model for Rehab Professionals?

Self-administered exercise is great; however, manual therapy is likely more effective during the initial phases of treatment, and some manual interventions do not have good self-administered substitutions (e.g. first rib mobilization, cervicothoracic junction manipulation, extensor digitorum release, etc.). An incredibly effective strategy for the treatment of dysfunction and improving optimal motion includes an initial cluster of manual therapy and supervised exercise sessions to greatly reduce dysfunction, followed by a combination of self-administered exercise and occasional follow-up visits. The follow-up visits can be used for re-assessment, another boost from manual therapy interventions, and progression of the exercise program. This approach may reduce the need for a large number of initial visits, perhaps down to just 1 - 6 initial sessions, which would reduce the jarring upfront cost for patients. Conversely, semi-regular return visits provide the practitioner with a steady stream of recurrent, high-value, 1-3 session clusters. Because a reduction in initial sessions and the total cost of 1-3 session follow-up significantly decreases the financial burden to patients, this allows the rehab professional to increase per-session pricing. This, in turn, allows professionals to provide higher-value sessions. For example, 1-on-1 60-minute treatments with educational materials and videos of home exercises, telehealth/video appointment follow-ups, and perhaps access to additional support lines (e.g. patient chat boards, group therapy sessions, etc.). This new model can begin a virtuous cycle of continuous improvement of per-session value, practitioner hourly rate, and quality of life for the patient and practitioner.

Some Additional Practical Tips

• Stop thinking “either/or” and start thinking “and.” We should be looking to integrate effective modalities, not compare and dismiss them.
• Use manual therapy as a method for giving patients an initial boost in outcomes. It is unlikely that a patient will perform a comparable self-administered exercise during their initial sessions with the same level of skill that an experienced manual therapist can perform a manual technique.
• Nobody should be denied manual therapy and the opportunity to feel better sooner simply because it cannot be used in a home exercise program.
• Every program should progress toward developing a self-administered home exercise program that mimics the effects achieved by the manual techniques and exercises performed during sessions.
• Ideally, patient education would include motivation to start a fitness and/or strength training program. Better fitness and strength training reduce the risk of future injury and orthopedic pain.

Caption: The pictured exercise, Prone Ball Combo (Trapezius Activation) is being performed in a prone position on a stability ball.

Research Review:

• From the course: Joint Mobilization and Manipulation: Introduction

Summary Statement: There is no evidence to suggest that exercise should be prioritized over manual or self-administered joint mobilizations/manipulations. In fact, research suggests these techniques may be more effective than exercise during the initial phase of therapy. Further, these comparative studies likely imply that manual mobilization and manipulation techniques are among the most effective techniques available to movement professionals.

Summary of Research Findings

• Cervical Spine: Cervical mobilizations and manipulations are likely more effective than exercise for treating cervical pain and potentially equally effective for treating shoulder pain. Further, both cervical manipulation and exercise are more effective for treating cervical dysfunction than pharmacological interventions and physician care.
• Thoracic Spine: Thoracic manipulations are more effective than therapeutic exercise or physician care for the improvement of neck and shoulder range of motion (ROM), function, and pain, both short-term and long-term.
• Lumbar Spine and Sacroiliac Joint: Results of exercise and lumbar manipulations may be similar for low back pain; however, there is some evidence of a more complex relationship that includes lumbar manipulations being more effective for pain reduction and the combination of specific intervention and manipulations resulting in superior short-term outcomes when compared to general exercise. Unlike studies comparing manipulations to exercise, studies comparing mobilizations to exercise demonstrate a clear trend toward mobilizations resulting in superior outcomes for pain and function, especially during the initial 2 months of treatment.
• Shoulder: shoulder mobilization may be more effective than exercise for the treatment of adhesive capsulitis, with the exception of a daily home exercise program. Further, there is some evidence of specificity, implying shoulder mobilizations will improve the ROM and strength ot the joint ROM that was addressed.
• Elbow and Wrist: For the treatment of lateral epicondylalgia, based on pain, function, and grip strength scores, the combination of elbow mobilization and soft tissue therapy is at least as effective as exercise, and wrist manipulation is likely more effective than conventional therapies including exercise, ultrasound, and friction massage.
• Lower Extremity: Mobilizations are as effective or more effective than exercise for the treatment of hip and/or knee osteoarthritis and/or stiffness based on pain, stiffness, ROM, proprioception, and/or function scores.

Cervical Spine:

Several RCTs have demonstrated that mobilizations and manipulations are more effective than exercise (and physician care) for cervical and shoulder dysfunction. An RCT by Galindez-Ibarbengoetxea et al. demonstrated that the immediate effects of cervical manipulation were larger than exercise for chronic cervical pain and cervical ROM (1). An RCT by Cho et al. demonstrated that upper cervical and upper thoracic spine mobilizations were more effective than deep cervical flexor (DCF) exercise  for individuals with forward head posture, including a larger reduction in pain, craniovertebral angle, increase in DCF activity, and better functional outcome scores (2). An RCT by Bronfort et al. demonstrated superior outcomes following spinal manipulation when compared to home exercise; however, both were superior to medication for subacute neck pain (3). An RCT by El-Sodany et al. demonstrated that cervical manipulation and cervical SNAG mobilization resulted in larger improvements in ROM, pain, and Neck Disability Index scores when compared to exercise alone (4). In two RCTs by Hoving et al. investigating the treatment of neck pain, it was demonstrated that cervical manipulations and therapeutic exercise resulted in better outcomes than pharmacological intervention and care from a general practitioner; further, cervical manipulations resulted in better outcomes than therapeutic exercise for the first 7-weeks of treatment (5, 6). Korthals-de Bos et al. performed an economic analysis and RCT to determine the most effective and economical approach for neck pain, demonstrating that a manual therapy group (which included manipulation) outperformed physical therapy (which included exercise), which outperformed general practitioner care (which included medication) (7). Last, a single-blind RCT by Coronado et al. demonstrated that cervical manipulation, thoracic manipulation, and exercise resulted in similar outcomes for shoulder pain (8). This study may be evidence that the difference between spine manipulation and exercise decreases when comparing interventions for orthopedic issues involving the extremities. In summary, these studies imply that cervical mobilizations and manipulations are likely more effective than exercise for the treatment of cervical pain, and potentially equally effective for the treatment of shoulder pain. Further, both cervical manipulation and exercise are more effective for treating cervical dysfunction than pharmacological intervention and physician's care.

Thoracic Spine

Thoracic manipulation has also demonstrated superior efficacy when compared to exercise and physician care. Note that thoracic spine mobilization/manipulation was included in 3 of the studies above and 1 additional study. The one additional study was an RCT by Savolainen et al. demonstrating that neck/shoulder pain patients exhibited better outcomes during 6- and 12-month follow-ups following 4 thoracic manipulations compared to instructions to perform therapeutic exercises (9). As mentioned above, an RCT by Korthals-de Bos et al. demonstrated manual therapy (including manipulation) resulted in faster improvements (up to 26 weeks) and lower cost than either physiotherapy or physician care for neck pain (7). Also mentioned above, an RCT by Cho et al. demonstrated that upper cervical and upper thoracic spine mobilizations were more effective than deep cervical flexor (DCF) exercise  for individuals with forward head posture, including a larger reduction in pain, craniovertebral angle, increase in DCF activity, and better functional outcome scores (2). Last of the previously mentioned studies, a single-blind RCT by Coronado et al. demonstrated that cervical manipulation, thoracic manipulation, and exercise resulted in similar outcomes for shoulder pain (8). These studies suggest that thoracic manipulations are likely more effective than therapeutic exercise or physician care for the improvement of neck and shoulder range of motion (ROM), function, and pain, both short-term and long-term.

Lumbar Spine and Sacroiliac Joint (SIJ)

Studies comparing lumbar manipulations and specific exercises suggest outcomes may be similar. An RCT by Dougherty et al. could not validate the use of a previously developed clinical prediction rule (CPR) that was intended to aid in deciding between therapeutic exercise (for lumbar instability) and mobilization/manipulation (for hypomobility), demonstrating that both therapeutic exercise and manipulations resulted in similar outcomes for groups differentiated by the CPR (10). An RCT by Ferreira et al. demonstrated that manipulation and specific exercise were superior to general exercise for improving function and pain in low back patients in the short-term; however, results during 6 and 12-month follow-ups were similar (11). A prospective RCT by Bronfort et al. demonstrated that supervised exercise was superior to home exercise for all outcomes during both short-term and long-term follow-ups and was better than manipulations for improving strength and endurance. However, manipulation resulted in larger improvements in pain (12). These studies may indicate that results of exercise and lumbar manipulations may be similar for low back pain; however, there is some evidence of a more complex relationship that includes lumbar manipulations being more effective for pain reduction and the combination of specific interventions and manipulations resulting in superior short-term outcomes when compared to general exercise.

Research has demonstrated that lumbar spine and sacroiliac joint mobilizations are likely more effective than exercise. An RCT by Krekoukias et al. demonstrated that for the treatment of low back pain with disk degeneration, 5 sessions of mobilizations resulted in larger improvements in pain and disability than conventional physiotherapy (CP) (stretching exercises, transcutaneous electrical nerve stimulation, and massage) (13). An RCT by Visser et al. demonstrated that SIJ-related leg pain was successfully treated with physiotherapy in 3 out of 15 patients (20 %), intra-articular injection in 9 of 18 patients (50 %), and manual therapy (mobilization and soft tissue) in 13 of the 18 patients (72 %) (14). An RCT by Ulger et al. compared treatments for low back pain, demonstrating that SIJ mobilizations resulted in similar quality of life scores and superior improvements for pain and functional outcomes when compared to stabilization exercise (15). And, an RCT by Schneider et al. demonstrated that manual therapy and specific exercises were more effective than medical care and group exercise for the first two months of treatment for spinal stenosis, although outcomes were similar at 6 months (16). Unlike studies comparing manipulations to exercise, studies comparing mobilizations to exercise demonstrate a clear trend toward mobilizations resulting in superior outcomes for pain and function, especially during the initial 2 months of treatment.

Shoulder

There are a limited number of RCTs comparing shoulder mobilization to exercise, and most include participants with adhesive capsulitis, which may limit the generalizability of results. An RCT by Yeole et al. demonstrated that mobilization with movement (MWM) improved pain and ROM more than supervised exercise following one week of treatment for patients with adhesive capsulitis (17). An RCT by Panchal et al. demonstrated the combination of end-range mobilization and interferential current resulted in larger improvements in ROM than the combination of stretching and heat; however, both combinations were equally effective for reducing pain in individuals with adhesive capsulitis (18). An RCT by Doner et al. compared the combination of hot pack, TENS, and either mobilization or passive stretching exercise for adhesive capsulitis, demonstrating that the mobilization group exhibited larger improvements in pain, ROM, dysfunction, and patient satisfaction (19). Conversely, an RCT by Tanaka et al. demonstrated that home exercise may be more important than mobilization frequency in a hospital setting for the treatment of adhesive capsulitis (20). Last, some specificity may be implied by an RCT by Neelapala et al. that demonstrated an MWM with posterior glide resulted in larger improvements in external rotator strength and shoulder pain when compared to active external rotator strengthening ; however, neither technique improved internal rotator strength or scapular motion (21). These studies suggest that shoulder mobilization may be more effective than exercise for the treatment of adhesive capsulitis, with the exception of a daily home exercise program. Further, there is some evidence of specificity, implying shoulder mobilizations will improve the ROM and strength ot the joint ROM that was addressed.

Elbow and Wrist

Studies comparing mobilization/manipulation to exercise for the treatment of lateral epicondylalgia suggest that elbow mobilizations are at least as effective as exercise. Nagrale et al. compared Cyriax physiotherapy (Mill's manipulation and transverse cross-friction massage soft-tissue therapy) to phonophoresis and exercise, demonstrating that both groups improved pain, pain-free grip strength, and functional status; however, the Cyriax group improved more (22). An RCT by Stasinopoulos et al. compared Cyriax physiotherapy, supervised exercise, and polarized polychromatic non-coherent light, demonstrating that all interventions had a positive effect on pain, pain-free grip strength, and function; however, supervised exercise resulted in the best outcomes, followed by Cyriax physiotherapy, and last polychromatic non-coherent light (23). An RCT by Drechsler et al. compared a group receiving radius and radial nerve mobilizations to a group receiving ultrasound, transverse friction massage, and wrist extensor stretching and strengthening for the treatment of lateral epicondylitis. After 6 - 8 weeks of 2 sessions per week, data was collected 3 months post-treatment, demonstrating that the mobilization group exhibited less pain, disability, and better function (24). Conversely, An RCT by Viswas et al. demonstrated that exercise may result in superior outcomes when compared to Cyriax physiotherapy (Mill's manipulation and transverse cross-friction massage soft-tissue therapy) for the treatment of lateral epicondylalgia; however, both treatments demonstrated efficacy (25). Considering the mixed results of these studies, the conservative conclusion is likely that elbow mobilization/manipulation and exercise are similarly effective, and both are likely more effective than polarized polychromatic non-coherent light.

Wrist manipulation may result in larger effect sizes than exercise for individuals with lateral epicondylalgia. An RCT by Moitra et al. compared phonophoresis, flexibility, and endurance training to phonophoresis and wrist manipulation for the treatment of lateral epicondylalgia, demonstrating that both groups exhibited improvements in pain and grip strength (26). An RCT by Joshi et al. compared manipulation of the wrist to conventional therapy (ultrasound, friction massage, and muscle stretching and strengthening exercises) for the treatment of lateral epicondylalgia, demonstrating that during 3 weeks of treatment, the wrist manipulation group exhibited earlier and higher success rates based on pain and function scores (27). Similarly, An RCT by Struijs et al. compared a group receiving wrist manipulation to a group receiving ultrasound, friction massage, muscle stretching, and strengthening exercises. Both groups improved based on pain and dysfunction scores; however, the wrist manipulation group improved more on pain and function scores (28). These studies imply that for the treatment of lateral epicondylalgia, based on pain, function, and grip strength scores, the combination of elbow mobilization and soft tissue therapy is at least as effective as exercise, and wrist manipulation is likely more effective than conventional therapies including exercise, ultrasound, and friction massage.

Lower Extremity

Studies comparing lower extremity mobilizations to exercise demonstrate mobilizations are at least as effective as exercise interventions. An RCT by Hoeksma et al. compared manual therapy to an exercise protocol for the treatment of hip osteoarthritis. Following 9 sessions in 5 weeks, success rates (patient report of improvement) were 81% in the manual therapy group and only 50% in the exercise group; further, patients in the manual therapy group had significantly better outcomes for pain, stiffness, hip function, and ROM, and the difference between groups was still present during a 29-week follow-up (29). A double-blind RCT by Raghav et al. investigated the treatment of post-traumatic stiffness of the knee joint, comparing continuous passive motion and flexibility exercises to MWM for the knee, demonstrating that MWM for the knee resulted in better pain and ROM scores following 4 weeks of treatment (30). An RCT by Lalit et al. compared Maitland mobilizations, MWM, and exercise for knee osteoarthritis following 3 sessions in 5 days, demonstrating that all interventions were equally effective for improving pain, proprioception, and weight-bearing ability (31). These studies demonstrate that mobilizations are as effective or more effective than exercise for the treatment of hip and/or knee osteoarthritis and/or stiffness based on pain, stiffness, ROM, proprioception, and/or function scores.

Bibliography

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3. Bronfort, G., Evans, R., Anderson, A. V., Svendsen, K. H., Bracha, Y., & Grimm, R. H. (2012). Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of internal medicine, 156(1_Part_1), 1-10.
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   • Active vs. Passive: Thoracic
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   • Active vs. Passive: Lumbar Spine and Sacroiliac Joint
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    • Active vs. Passive: Shoulder
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    • Active vs. Passive: Elbow Mobilization
22. Nagrale, A. V., Herd, C. R., Ganvir, S., & Ramteke, G. (2009). Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial. Journal of Manual & Manipulative Therapy, 17(3), 171-178.
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    • Active vs. Passive: Wrist Manipulation
26. Moitra, M., Sharma, S., Kumar, S. P., & Samuel, A. J. (2015). Efficacy of Wrist Manipulation and Phonophoresis on Pain and Grip Strength in Lateral Epicondylitis: A Randomized Clinical Trial.
27. Joshi, S., Metgud, S., & Ebnezer, C. (2013). Comparing the effects of manipulation of wrist and ultrasound, friction massage and exercises on lateral epicondylitis: a randomized clinical study. Indian Journal of Physiotherapy and Occupational Therapy, 7(3), 205.
28. Struijs, P. A., Damen, P. J., Bakker, E. W., Blankevoort, L., Assendelft, W. J., & van Dijk, C. N. (2003). Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Physical therapy, 83(7), 608-616.
    • Active vs. Passive: Lower Extremity
29. Hoeksma, H. L., Dekker, J., Ronday, H. K., Heering, A., Van Der Lubbe, N., Vel, C., ... & Van Den Ende, C. H. (2004). Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Care & Research: Official Journal of the American College of Rheumatology, 51(5), 722-729.
30. Raghav, S., Singh, A., Tyagi, G. P., & Rastogi, K. The Effect of Mobilization with Movement versus Conventional Treatment on Range of Motion in Patients with Post-Traumatic Stiffness of Knee Joint: A Randomized Clinical Trial.
31. Lalit, S. Y., Suhas, M. B., & Amita, M. (2012). Effect of Manual Therapy Techniques on knee Proprioception in Patients with Osteo-arthritis of knee. Indian Journal of Physiotherapy and Occupational Therapy, 6(3), 285.

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