Non Pharmacological Interventions

Non-Pharmacological Approaches[edit | edit source]

Non-pharmacological interventions (NPI) or non-pharmacological therapies (NPT) are any non-chemical intervention, which is theoretically supported and performed on a patient and has the capacity of benefitting the patient.

  • NPI have been employed as medical interventions (predating modern pharmacology), and are intended to improve quality of life, slow down deterioration or relieve pain.[1]
  • With NPI the side effects of medications are avoided, health costs reduced and there is minimal environmental impact.

Following a healthy lifestyle is possibly the best NPI, contributing to better health, increased quality of life, and at a small cost to health care.[1]

NPT include in physiotherapy include: massage, therapeutic exercise, manual techniques, yoga, meditation, acupuncture.

The following is a non-exhaustive list of non-pharmacological options both in and outside the scope of physiotherapy practice. The aim of this resource is to provide physiotherapists and other relevant health professionals with a baseline resource for complementary or alternative treatment options to consider when desiring to remedy clinical scenarios where overprescription is suspected. Clinical professional readers are advised to continually consider relevant and most recent available evidence in relation to their patients’ clinical situation and flagged medication. Additionally, non-prescribing clinical readers are reminded to stay within their scope of practice and always discuss any treatment options preferred as an alternative to drug therapies with the patient’s multidisciplinary team (MDT) or general practitioner (GP). Non-clinical readers are advised to discuss any preferable options with their GP before seeking treatment.

Physiotherapy interventions[edit | edit source]

Patient education[edit | edit source]

The importance of increasing a patient’s understanding of their condition and treatment plan is not only of benefit for improving a patient’s adherence to treatment, but can also improve health outcomes [2]. Self-management of chronic conditions as well as preventative health intents rely heavily on provision of contemporary information and communication practice [3]. Primary focus for long term conditions commonly involves promotion of informed lifestyle choices, risk-factor modification, and active patient self-management [3]. Education can be provided through a variety of health care professionals, preferably done by providers who have undertaken adequate training for education, and patient communication. Recognized physiotherapy programmes typically include a component of patient education within their training. [4].

Physical Activity[edit | edit source]

Physical activity prescription (a NPI) is an under-utilised tool for improving community health. In the right dose, physical activity can help to prevent, treat, and manage a range of chronic health conditions that increasingly impact the quality of life and physical function of individuals on a global scale.[5]

Electrotherapy modalities[edit | edit source]

Electrotherapy has a place within clinical practice. When used appropriately, the evidence supports its effectiveness.

  • Electrotherapy modalities, also referred to as electrophysical agents, are terms to describe electrical devices that are safely applied by trained professionals to an injury site in effort to enhance, expedite, or improve the treatment plan and recovery process. There are a wide range of electrotherapy modalities used in physical therapy.
  • Conventionally, they are used for pain management, reducing swelling, increasing local blood flow, and breaking down scar tissue and can be applied across various stages of injury recovery [6].
  • Common electrotherapy modalities used in pain management include transcutaneous electrical nerve stimulation (TENS), interferential current (IFC), ultrasound, and laser therapy.

More information on a wider variety of electrotherapy modalities and their multitude of uses can be found here.

Thermotherapy[edit | edit source]

Thermotherapy, involves use of heat or cold

  1. Heat can give relief in subacute and chronic inflammatory and traumatic disorders, Heat increases blood flow, helping reduce inflammation, oedema and exudates from connective tissue injuries.
  2. Cold helps relieve muscle spasms, myofascial or traumatic pain and acute inflammation.

Thermal modalities can also be used as adjuncts to exercise therapy and/or electrophysical modalities, for a variety of therapeutic purposes [7].

Manual Therapy[edit | edit source]

Manual therapy can be defined differently across health professionals but can be described as another non-pharmacological, non-surgical, conservative option for management of a range of musculoskeletal conditions. These skilled, hands on techniques can be applied to patients’ spine and extremities for purpose of assessment and treatment. There are a wide variety of techniques that can be grouped into four major categories: manipulation, mobilization, static stretching, and muscle energy techniques [8]. Commonly, manipulation and mobilization of the spine are used for treatment of low back pain by physiotherapists and other health professionals such as osteopaths and chiropractors [8]. Although the effectiveness of these techniques is dependent on the skills of the handling clinician, it is important to look at the available evidence when deciding to implement this option into a treatment plan. . Contemporary research reveals intricate neurophysiologic mechanisms are also at play and the beneficial psychological effects of providing hands-on examination and intervention have been substantiated.[9]

Therapeutic exercise[edit | edit source]

Therapeutic exercise techniques include passive movements, active assisted movements, active movements, resisted movements and assisted resisted movements with aims to correct impairment, improve musculoskeletal function or maintain well-being [10].

See also Exercise and Activity in Pain Management

Therapeutic exercise can be prescribed to accomplish the following aims [10]: Improve and enable ambulation; Release contracted muscles, tendons, and fascia; Mobilize joints; Improve circulation and respiratory capacity; Improve coordination; Reduce rigidity; Improve balance; Promote relaxation; Improve and maintain muscular strength and endurance; Improve exercise performance and functional capacity

Evidence supporting the use of therapeutic exercise is vast and dependent upon specific patient populations.eg stroke; multiple sclerosis; balance impairment; osteoarthritis; and mental health.

Meditation[edit | edit source]

Meditation

Mindfulness Meditation in Chronic Pain Management

Non-pharmacological options for referral and signposting[edit | edit source]

Therapeutic communities[edit | edit source]

Therapeutic communities come in many forms and each are tailored to address a variety of long term issues including personality disorders, mental health, learning disabilities, and substance abuse [11]. These communities are group-based with a participative approach in a residential or day unit setting. Since the target population for each therapeutic community varies, gaining access to one is best done by directly contacting the programme for a self-referral, however, in most cases you will require a referral from a doctor or social worker. In these cases, physiotherapists and other relevant health professionals would be wise to be aware of local therapeutic communities and their respective access procedures, in order to efficiently sign post patients that express long-term substance abuse concerns from overprescribed medications. Signposting these patients will likely require a discussion with the MDT or referring physician in order to determine if overprescription is an issue in the suspected addiction. A 2010 meta-analysis reviewing therapeutic communities’ effect for individuals with co-occurring substance abuse and mental disorders, found supporting evidence for significant treatment effects for substance use, mental health, crime, employment and housing [12]. More information about therapeutic communities can be found at The Consortium for Therapeutic Communities.

Mind-body therapies[edit | edit source]

While acute pain can resolve quickly with appropriate use of analgesics, medications and treatment of underlying causes, chronic pain can cause clinicians and patients significant concern. Human perception of pain is not purely somatic, it involves regions of the brain that register and modify pain signals including brain centres engaged with stress, emotion, attention, beliefs, conditioning, mood, and cognition [13]. Mind-body therapies can be described as interventions that change an individual’s mental and/or emotional state which aim to generate corresponding changes in the body, including pain perception. A variety of mind-body therapies can be used in the management of chronic pain as a sole treatment, however they may be better used as a complementary approach to other therapies [14]. When seeking a mind-body therapist for chronic pain, it is advisable to first consult a GP for a formal diagnosis, as many of these clinical practices are unregulated in the UK. The following is a summary of evidence on a few commonly used mind-body approaches for chronic pain management including: guided imagery; cognitive hypnotherapy; and cognitive behavioural therapy.

Guided imagery’s use in the management of chronic pain stems from relaxation, and distracting the individual’s mind from mental elaboration of pain, through use of therapeutic images. A systematic review revealed eight of nine randomized clinical trials found guided imagery results in significant reduction of musculoskeletal pain, however, the methodologies of included studies were graded medium to low and therefor the encouraging results were inconclusive [15]. Guided imagery is often paired with music therapy, and administered by Music Therapists who are required to be registered with the Health & Care Professions Council in the UK.

Cognitive hypnotherapy, also referred to as hypnosis, was one of the first mind-body therapies used for managing chronic pain. Exact definition of hypnosis can vary but it is considered a natural state of mind by those who practice it [16]. Using progressive relaxation techniques, service users can learn self-hypnosis for self-management as well. A 2012 review suggests there is evidence identified for chronic pain management in subjects with cancer, osteoarthritis, sickle cell disease, fibromyalgia, temporomandibular joint disorders, non-cardiac chest pain, and disability related chronic pain [17]. An earlier study found hypnotherapy may provide pain relief in irritable bowel syndrome with beneficial effects measured after 5 years [18]. Currently, hypnotherapy is not a regulated profession in the UK, however, the National Council for Hypnotherapy is one of the UK’s largest not-for-profit professional association, with fully insured members.

Cognitive behavioural therapy (CBT) is a talking therapy that can help manage issues beyond chronic pain by changing individuals’ perceptions and behaviours. Differing from other talking therapies, CBT focuses on individuals’ current problems rather than past problems, then uses practical ways to improve a daily state of mind [19]. There is a strong evidence base for CBT’s use in management of a variety of chronic pain conditions [20]. A 2012 narrative review also suggests that CBT is beneficial for treatment of nonspecific chronic low back pain and should be incorporated into MDT interventions for a more patient-centred approach [21]. Finally, a 2011 article published in Best Practice & Research Clinical Rheumatology, suggests CBT coupled with exercise should be integrated into a multi-component approach for chronic widespread pain conditions like fibromyalgia [22]. The article includes methods for how exercise and CBT can be combined using evidence-based guidelines. In the UK, CBT is free under the National Health Service (NHS) when referred from a GP. Although psychological therapies are unregulated at the moment in the UK, the British Association for Behavioural & Cognitive Psychotherapies keeps a register of accredited therapists.

Biofield Therapies[edit | edit source]

Biofield therapies is a term coined in 1992 in a United States National Institutes of Health Conference [23]. They can be described as non-invasive, non-pharmacological, practitioner-mediated therapies which utilize the biofield of the practitioner and service user to stimulate a response in the service user, sometimes referred to as a “healing response”. Common biofield therapies include Reiki, therapeutic touch, and healing touch, among many others. These therapies are not generally integrated into conventional clinical care, likely due to limited understanding of mechanisms and gaps in research base. While there may be pressure for these therapies to demonstrate plausible physiological mechanisms, an argument can be made that these mechanisms are important, however, not essential for conducting and analysing robust clinical trials. A systematic review on best evidence synthesis for biofield therapies published in 2010 found most studies were of medium quality and typically did not meet minimum standards for validity of inferences [24]. The review did report that there is strong evidence for reducing self-reported pain intensity in a variety of populations, including elderly patients with chronic pain. Another systematic review in 2009 explored the therapeutic effects of Reiki [25]. This review was unable to derive any definitive conclusions due to significant methodological and reporting limitations of existing studies investigating effectiveness of Reiki. While nine of the twelve included clinical trials found significant therapeutic effects using Reiki, the Jadad Quality score used in the review found eleven of the twelve studies were ranked as “poor”. It appears the consensus among relevant reviews in the area of various biofield therapies conclude that while the strongest evidence is found in symptom management of pain, there is a demand for high-quality studies for further investigation and recommendations [24][25][26].

Acupuncture[edit | edit source]

Acupuncture is a well-known and most prominent part of Chinese medicine in western medicine [27]. The aim of the practice is to affect body functions, as well as stimulate and restore the body’s own regulatory system through use of needles, pressure and/or heat on distinctive locations on the human body [27]. This non-pharmacological option is often incorporated in several clinical settings of conventional medicine, including qualified clinicians in physiotherapy [27]. There is extensive research exploring the use of acupuncture in the management of a variety of chronic pain conditions including low back pain, neck pain, and osteoarthritis, as well as tension-type and migraine headaches [28][29][30][31][32]. In 2015, an overview of systematic reviews for use of acupuncture on low back pain was published [28]. While overall methodological quality of reviews was low and external validity was weak, a number of conclusions were drawn. For acute low back pain, there was inconsistent evidence that acupuncture has a larger effect on pain relief and improved function compared to sham acupuncture. Conversely, for chronic low back pain, there was consistent evidence that acupuncture either used in isolation or with a conventional therapy, can provide short-term and clinically relevant improvements in pain and function. A recent systematic review with meta-analysis considering the effects of acupuncture on neck pain was published in 2017 [29]. Authors concluded that acupuncture for chronic neck pain has similar effects to conventional medicine for pain reduction and disability, when compared to each other, but is more effective for pain relief when both were used in combination. However, the review added that definitive conclusions were difficult to make due to high risk of bias and imprecision of the included studies. Research for use of acupuncture for osteoarthritis tends to focus around the knee joint. A systematic review regarding its effectiveness on knee joints suggest that acupuncture may play a role for treatment of this population, but currently there is insufficient evidence to determine its efficacy in comparison to conventional treatments [30]. Cochrane reviews have been published in 2016 for effects of acupuncture on both migraine attacks, and tension-type headaches [31][32]. The review for tension-type headaches found that acupuncture is an effective treatment for frequent episodic or chronic tension-type headaches, however due to the moderate quality of evidence, further trials are needed in comparing with conventional treatment options [31]. In regards to preventing migraine attacks, available evidence shows that acupuncture in combination with symptomatic treatment of migraine attacks, can reduce the frequency of migraine headaches, and may produce similar effects to pharmacological prophylactic treatment [32].

Overall, acupuncture is a valid and reasonable option to consider for individuals to manage certain chronic pain conditions, although, clinical guidelines are inconsistent regarding recommendations [28][29][30][31][32]. Acupuncture treatments for pain are mainly covered through private insurance companies in the UK, however, some treatments are also provided by the NHS [27]. A large professional and self-regulatory body for the practice of acupuncture is the British Acupuncture Council who are members of the Accredited Resister scheme run by the Professional Standards Authority. Clinical readers looking to ensure patients find a qualified professional in this area, can be directed to the British Acupuncture Council website. There are very few side effects from acupuncture when practiced by qualified practitioners, any minor side effects occurring are mild and self-correcting according to the British Acupuncture Council.

Massage Therapy[edit | edit source]

The terms massage and massage therapy have been defined and differentiated at a 2010 best practice symposium for the profession involving thirty-two experts in the field of massage therapy [33]. In general, massage is a patterned and purposeful soft tissue manipulation with or without emollients, liniments, thermal modalities or other external apparatus with aims of therapeutic change. Massage therapy includes the addition of non-hands-on components such as health promotion, and client education for self-care and maintenance [33]. Massage therapy is another non-pharmacological approach that has been extensively researched, although has been burdened by poor methodological studies. A 2006 systematic review of twenty studies evaluated the clinical effectiveness of therapeutic massage for symptomatic relief of musculoskeletal pain [34]. With positive results for massage compared to no treatment or sham treatment in many studies, the available evidence at the time was inconclusive due to small sample sizes, low methodological quality, and insufficient dosing [34]. Due to the large number of systematic reviews published on massage therapy’s effect on non-specific low back pain, a systematic review of nine systematic reviews was completed in 2013 [35]. The methodological quality of the reviews varied from poor to excellent, but the primary research informing the individual reviews was generally weak quality. Overall, the 2013 systematic review found that a small body of evidence emerged to support the use of massage therapy for short-term treatment of non-specific low back pain, although authors cautioned the interpretation of this conclusion due to the methodological limitations of the primary research [35]. Finally, a recent systematic review with meta-analysis was published in 2017, with fifteen studies exploring the efficacy of massage therapy for shoulder pain [36]. The author of the review suggested that massage therapy is effective for improving shoulder pain in the short-term, although, further research using randomized controlled trials with large sample sizes is required in order to make conclusive evidence-based recommendations. Massage therapy is another unregulated profession in the UK, however, the Complementary & Natural Healthcare Council is a UK voluntary regulator for various health practitioners including massage therapists. Their registered practitioners comply with the council’s standards of conduct, ethics and performance so service users can be confident the therapists are properly trained, qualified and insured.

Chiropractic[edit | edit source]

Chiropractic is also a non-pharmacological type of complementary and alternative treatment, as it is not considered conventional medical treatment. In these treatments, a chiropractor uses a hands-on approach to help relieve problems with bones, muscles and joints [37]. Similar to physiotherapists, the first visit entails an assessment to determine if the profession is suitable and which techniques may help. Techniques used by chiropractors include spinal manipulation, short and sharp thrusting movements, gradual joint movements and muscle stretches [37]. A variety of uses for chiropractic include pain for backs, necks, joint pains, tension-type headaches, migraine prevention and sports injury conditions [37]. A 2013 systematic review with meta-analysis explored the efficacy of manipulative therapy in adults with complaints of pain compared to sham manipulation, involving 19 studies [38]. Results included moderate level of evidence for manipulative therapy’s immediate effect on pain relief, but lower evidence at short-term follow up. Similar results were found in patients with musculoskeletal conditions [38]. Concluding statements were that manipulative therapy has a clinically relevant effect to reduce pain, but not disability. In regards to non-specific low back pain, a 2016 systematic review of six pragmatic studies found moderate evidence to support chiropractic care in producing similar results to other types of care, including physical therapy [39]. However, similar conclusions could not be made when compared to medical care and exercise therapy [39].

Chiropractic is generally very safe when receiving treatment from trained and registered clinicians. Besides minor adverse effects from the treatment such as aches and pains, stiffness or tiredness, a more serious risk is of stroke. Case reports and studies have suggested an association between chiropractic neck manipulation and cervical artery dissection, leading to stroke. However, a 2016 systematic review with meta-analysis performed on the subject has since concluded that the association of the two events is small and there is no evidence of direct causation [40].

All chiropractors in the UK are required by law to be registered with their regulatory body - The General Chiropractic Council. The council checks that registered chiropractors have current professional indemnity insurance, have met mandatory continuing professional development, and remain in good health and good character. Chiropractic is not widely available in the NHS, but is provided in some areas. Discussion with a patient’s GP can provide this information, or by contacting a local clinical commissioning group.

  1. ↑ 1.0 1.1 Herguedas AJ. Non-Pharmacological Interventions in Preventive, Rehabilitative and Restorative Medicine. InAlternative Medicine-Update 2020 Dec 21. IntechOpen. Available:https://www.intechopen.com/chapters/73680 (accessed 30.12.2022)
  2. ↑ Adams R. Improving health outcomes with better patient understanding and education. Risk Management and Healthcare Policy 2010;3:61-72
  3. ↑ 3.0 3.1 Wagner E.H, Austin B.T, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Affairs 2001;20:64-78.
  4. ↑ Forbes R, Mandrusiak A, Smith M, Russel T. Training physiotherapy students to educate patients: A randomized controlled trial. Patient Education and Counselling 2018;101:295-303.
  5. ↑ World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization Press, 2009 Available:https://www.who.int/publications/i/item/9789241563871 (accessed 30.12.2022)
  6. ↑ Watson T. Electrotherapy: Modalities. 2018 [online][viewed 12/04/2018]. Available from: http://www.electrotherapy.org/modalities
  7. ↑ Prentice W.E. Therapeutic Modalities in Rehabilitation. 4th ed. New York: McGraw-Hill Medical; 2011.
  8. ↑ 8.0 8.1 Clar C, Trertsvadze A, Court R, Hundt G.L, Clarke A, Sutcliffe P. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropractic & Manual Therapies 2014;22:12.
  9. ↑ Huijbregts PA. Manual therapy. InPain Procedures in Clinical Practice 2011 Jan 1 (pp. 573-596). Hanley & Belfus. Available from: https://www.sciencedirect.com/topics/medicine-and-dentistry/manual-therapy (last accessed 30.12.2022)
  10. ↑ 10.0 10.1 Lieberman J.A, Bockenek W.L. Physical Medicine and Rehabilitation: Therapeutic Exercise. 2016. [online] [viewed 15/04/2018]. Available from: https://emedicine.medscape.com/article/324583-overview#showall
  11. ↑ TCTC. Types of Therapeutic Communities. 2013. [online] [viewed 16/04/2018] Available from: https://www.therapeuticcommunities.org/what-is-a-tc/types-of-tcs/
  12. ↑ Sacks S, McKendrick K, Sacks J.Y, Cleland C.M. Modified Therapeutic Community for Co-Occurring Disorders: Single investigator meta analysis. Substance Abuse 2010;31:146-161.
  13. ↑ Zeidan F, Grant J.A, Brown C.A, McHaffie J.G, Coghill R.C. Mindfulness meditation-related pain relief: evidence for unique brain mechanisms in the regulation of pain. Neuroscience letters 2012;520:165-173.
  14. ↑ Astin J.A. Mind-body therapies for the management of pain. Clinical journal of pain 2004;20:27-32.
  15. ↑ Posadzki P, Ernst E. Guided imagery for musculoskeletal pain: a systematic review. Clinical journal of pain 2011;27:648-653.
  16. ↑ NCH. What is hypnosis? 2018. [online] [viewed 16/04/2018] Available from: https://www.hypnotherapists.org.uk/hypnotherapy/hypnotherapy-faq/
  17. ↑ Elkins G, Johnson A, Fisher W. Cognitive hypnotherapy for pain management. American journal of clinical hypnosis 2012;54:294-310.
  18. ↑ Gonsalkorale W.M, Miller V, Afzal A, Whorwell P.J. Long term benefits of hypnotherapy for irritable bowel syndrome. Gut 2003;52:1623-1629.
  19. ↑ NHS. Cognitive Behavioural Therapy. 2016 [online] [viewed 16/04/2018] Available from: https://www.hypnotherapists.org.uk/hypnotherapy/hypnotherapy-faq/
  20. ↑ Roland D, Prince J, Koppe H. Patient centred CBT for chronic pain. Australian family physician 2004;33:339-344.
  21. ↑ Sveinsdottir V, Eriksen H.R, Reme S.E. Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain. Journal of pain research 2012;5:371-380.
  22. ↑ Hassett A.L, Williams D.A. Non-pharmacological treatment of chronic widespread musculoskeletal pain. Best practice and research: Clinical rheumatology 2011;25:299-309.
  23. ↑ Rubik B, Pavek R, Greene E, Laurence D, Ward, R, Al E. Alternative medicine: expanding medical horizons: a report to the National Institutes of Health on alternative medical systems and practices in the United States. Washington, DC: US Government Printing Office; 1995.
  24. ↑ 24.0 24.1 Jain S, Mills P.J. Biofield therapies: helpful or full of hype? A best evidence synthesis. International journal of behavioral medicine 2010;17:1-16.
  25. ↑ 25.0 25.1 vanderVaart S, Jijsen V.M, de Wildt S.N, Koren G. A systematic review of the therapeutic effects of Reiki. Journal of alternative and complementary medicine 2009;15:1157-1169.
  26. ↑ Jain S, Hammerschlag R, Mills P, Cohen L, Krieger R, Vieten C, Lutgendorf S. Clinical studies of biofield therapies: summary, methodological challenges, and recommendations. Global advances in health and medicine 2015;4:58-66.
  27. ↑ 27.0 27.1 27.2 27.3 CAMDOC Alliance, ECH, ECPM, ICMART, IVAA. The regulatory status of complementary and alternative medicine for medical doctors in Europe. Brussels: 2010.
  28. ↑ 28.0 28.1 28.2 Liu L, Skinner M, McDonough S, Mabire L, Baxter G.D. Acupuncture for low back pain: an overview of systematic reviews. Evidence-Based Complementary and Alternative Medicine: eCAM 2015;2015 [online] [viewed 17/04/2018] Available from: http://doi.org/10.1155/2015/328196
  29. ↑ 29.0 29.1 29.2 Seo S.Y, Lee K.B, Shin J.S, Lee J, Kim M.R, Ha I.H, Ko Y, Lee Y.J. Effectiveness of Acupuncture and electroacupuncture for chronic neck pain: a systematic review and meta-analysis. American journal of Chinese medicine 2017;45:1573-1595.
  30. ↑ 30.0 30.1 30.2 Ezzo J, Hadhazy V, Birch S, Berman B. Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis & Rheumatology 2001;44:819-825.
  31. ↑ 31.0 31.1 31.2 31.3 Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin B.C, Vickers A, White A.R. Acupuncture for the prevention of tension-type headache. Cochrane Database for Systematic Reviews 2016;4.
  32. ↑ 32.0 32.1 32.2 32.3 Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Vertosick E.A, Vickers A, White A.R. Acupuncture for the prevention of episodic migraine. Cochrane Database for Systematic Reviews 2016;6.
  33. ↑ 33.0 33.1 Kennedy A.B, Cambron J.A, Sharpe P.A, Travillian R.S, Saunders R.P. Clarifying definitions for the massage therapy profession: the results of the best practices symposium. International journal of therapeutic massage & bodywork 2016;9:15-26.
  34. ↑ 34.0 34.1 Lewis M, Johnson M.I. The clinical effectiveness of therapeutic massage for musculoskeletal pain: a systematic review. Physiotherapy 2006;92:146-158.
  35. ↑ 35.0 35.1 Kumar S, Beaton K, Hughes T. The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. International journal of general medicine 2013;4:733-741.
  36. ↑ Yeun Y.R. Effectiveness of massage therapy for shoulder pain: a systematic review and meta-analysis. Journal of physical therapy science 2017;29:936-940.
  37. ↑ 37.0 37.1 37.2 GCC. About Chiropractic. 2013. [online] [viewed 17/04/2018]. Available from: http://www.gcc-uk.org/about-us/about-chiropractic/
  38. ↑ 38.0 38.1 Scholten-Peeters G.G, Thoomes E, Konings S, Beijer M, Verkerk K, Koes B.W, Verhagen A.P. Is manipulative therapy more effective than sham manipulation in adults?: a systematic review and meta-analysis. Chiropractic & manual therapies 2013;21 [online] [viewed 17/04/2018] Available from: http://doi.org/10.1186/2045-709X-21-34
  39. ↑ 39.0 39.1 Blanchette M.A, Stochkendahl M.J, Borges Da Silva R, Boruff J, Harrison P, Bussieres A. Effectiveness and economic evaluation of chiropractic care for the treatment of low back pain: a systematic review of pragmatic studies. PLOS ONE 2016;11 [online] [viewed 17/04/2018] Available from: https://doi.org/10.1371/journal.pone.0160037
  40. ↑ Church E.W, Sieg E.P, Zalatimo O, Hussain N.S, Glantz M, Harbaugh R.E. Systematic review and meta-analysis of chiropractic care and cervical artery dissection: no evidence for causation. Cureus 2016;8 [online] [viewed 17/04/2018] Available from: http://doi.org/10.7759/cureus.498
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