CLINICAL TECHNIQUES
Review of Manual Therapy Techniques
in Equine Practice
Kevin K. Haussler, DVM, DC, PhD
ABSTRACT
The realm of manual therapy includes diverse tech-
niques such as chiropractic, osteopathy, physical ther-
apy, massage therapy, and touch therapies, which have
been developed for use in human beings and the tech-
niques transferred to horses. All forms of manual ther-
apy 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 po-
tential common mechanisms of action and evidence of
efficacy and safety for different forms of manual thera-
pies, with a specific focus on joint mobilization and ma-
nipulation 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 evi-
dence suggesting effectiveness of spinal manipulation
in reducing pain and muscle hypertonicity and increas-
ing joint range-of-motion. Further research is needed
to assess the efficacy of specific manual therapy tech-
niques or combined treatments for management of
documented back problems and specific lameness con-
ditions in horses. Additional studies are also needed to
define specific treatment parameters required for opti-
mal management of select disease processes, such as
the amount of force applied, and the frequency and
duration of treatment.
Keywords: Manual therapy; Chiropractic; Osteopathy;
Mobilization; Manipulation
From the Gail Holmes Equine Orthopaedic Research Center, Department of Clinical
Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State
University, Fort Collins, CO.
Reprint requests: Kevin K. Haussler, DVM, DC, PhD, Gail Holmes Equine
Orthopaedic Research Center, Department of Clinical Sciences, College of Veterinary
Medicine and Biomedical Sciences, Colorado State University, 300 West Drake Road,
Fort Collins, CO 80523.
0737-0806/$ - see front matter
2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.jevs.2009.10.018
Journal of Equine Veterinary Science  Vol 29, No 12 (2009)
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 dis-
orders in humans and transferred for use in horses. Each
technique has unique origins and different proposed bio-
mechanical or physiological effects; however, all forms of
manual therapy are characterized by applying variable gra-
dations of manual force and degrees of soft-tissue or artic-
ular displacement.2 The goal of all manual therapies is to
influence reparative or healing processes within the neuro-
musculoskeletal system. Therapeutic effects may be gener-
alized 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 lo-
calized to specific tissues and cellular responses.1 The chal-
lenge 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 system-
atic 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 rou-
tinely 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 physi-
ologic responses and is often considered therapeutic.3 In
human beings, therapeutic touch is used by nurses for nur-
turing 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 tech-
niques.5 These techniques are considered a form of en-
ergy-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
849
850
spiritual health. People use touch therapies for relaxation,
stress reduction, and symptom relief. Reviews of controlled
studies in evaluating effectiveness of touch therapies in hu-
man beings show promising results for pain relief, but fur-
ther 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, therapeu-
tic touch is considered to improve behavior, performance,
and well-being of horses and enhance the relationship be-
tween 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 pick-
ing 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., rub-
bing, kneading, or tapping) or with an instrument or
machine (e.g., mechanical vibration) for therapeutic pur-
poses. Massage techniques include many well-known
methods such as Swedish massage, sports massage, trigger
point therapy, cross-fiber friction massage, myofascial re-
lease, lymphatic drainage, and acupressure. Clinically, mas-
sage and soft-tissue mobilization are believed to increase
blood flow, promote relaxation, relax muscles, increase tis-
sue 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 ben-
eficial 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 in-
juries, recovery from exercise, or enhancing perfor-
mance.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 ed-
ucation 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, anxi-
ety, depression, anger, stress, and fatigue.13,14However,
the methodological quality of most massage studies is
poor, which prevents definitive conclusions and recom-
mendations. In horses, massage therapy has been shown
to be effective for reducing stress-related behavior and
pain thresholds within the thoracolumbar spine.15,16
KK Haussler  Vol 29, No 12 (2009)
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 lymphe-
dema in horses; however, no controlled studies exist evalu-
ating 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 elec-
trical 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 flexibil-
ity, improve coordination and motor control, increase
blood flow to muscles, and help to prevent injuries. Sys-
tematic 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 occupa-
tions.22,23 Randomized studies suggest that regular
stretching increases joint range of motion (average of 8 de-
grees) 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.2628
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 com-
bined with strengthening provides the largest improve-
ment 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 de-
creases 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
KK Haussler  Vol 29, No 12 (2009)
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 fur-
ther 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 inflam-
mation, improving tissue repair, increasing extensibility,
and improving function.9 Joint mobilization is character-
ized 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 in-
volves 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 re-
ducing 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 in-
sights into the biomechanical and neurologic features of an
articulation. Goniometry is often used to objectively quan-
tify and document the amount of flexion or extension pres-
ent 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 in-
crease flexibility, stimulate proprioception, and strengthen
core musculature.38 Peripheral nerve and nerve root mobi-
lization 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 allow-
ing the horse to spontaneously weight bear and locomote
851
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 mech-
anisms of action related to joint mobilization and manipu-
lation. 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 perspec-
tive, somatic dysfunction relates to impaired or altered
function of skeletal, articular, myofascial, and related vascu-
lar, lymphatic, and neural elements.42 Human osteopathic
techniques also include highly controversial methods asso-
ciated with mobilizing cranial bones and abdominal vis-
cera, which have questionable application to horses.43,44
Chiropractic treatment is characterized primarily as the ap-
plication 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 dysfunc-
tion include altered articular neurophysiology, biochemical
alterations, pathologic changes within the joint capsule,
and articular degeneration. Clinical signs of somatic or spi-
nal 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 chi-
ropractic treatment.4547
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 manipula-
tion are often used because there is currently limited formal
research available about the effectiveness of osteopathic or
chiropractic techniques in equine practice. Equine osteo-
pathic evaluation and treatment procedures have been de-
scribed 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 move-
ment in the horses 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 noci-
ceptive thresholds (MNTs) in the thoracolumbar region
of horses have demonstrated that both manual and instru-
ment- 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
852 KK Haussler  Vol 29, No 12 (2009)

longissimus muscle tone.40,53 The effect of manipulation A Neutral joint

on asymmetrical spinal movement patterns in horses with position
documented back pain suggests that chiropractic treat- Physiologic zone
ment elicits slight but significant changes in thoracolumbar
Elastic barrier
and pelvic kinematics, and that some of these changes are Paraphysiologic
likely to be beneficial.54,55 space Anatomical
limit of joint
Pathologic zone
JOINT MECHANICS
The use of palpation techniques to qualitatively and quan-
titatively assess joint motion requires an understanding of
joint mechanics.56 Joint motion can be categorized into
three zones of movement: physiologic, paraphysiologic, B Neutral joint
position Limit of voluntary
and pathologic (Fig. 1A). The physiological zone of move- joint movement
ment consists of both active and passive joint motion Active range of motion
within all possible directions of movement (e.g., flexion, Passive range of motion Elastic barrier
extension, lateral bending, and axial rotation). Passive
Anatomical
movement of an articulation from a neutral joint position limit of joint
first involves evaluating the range of joint motion that
has minimal, uniform resistance. Then as the articulation
is moved toward the end range of passive joint motion,
there is a gradual increase in the resistance to movement
which terminates at an elastic barrier (i.e., joint end feel).
The end range of motion begins with any palpable change C Active movements
in resistance to passive joint mobilization. Joint end feel is and exercise
often evaluated by bringing an individual articulation to Mobilization and
tension and applying rhythmic oscillations to qualify the stretching exercises
resistance to movement.57 Normal joint end feel is initially
soft and resilient but gradually becomes more restrictive as
the limits of joint range of motion are reached. A patho- Manipulation
logic or restrictive end range of motion is palpable earlier
in passive joint movement and has an abrupt, hard end
feel when compared with normal joint end feel. Each artic-
ulation within the body has unique palpatory end feels for
each of the directions of joint motion (e.g., flexion, exten-
Figure 1. Graphic representations of joint mechanics as
sion, lateral bending, etc.). The goal of palpating passive
it relates to joint mobilization and manipulation. (A)
joint movement is to evaluate each articulation of interest
Zones of joint motion. (B) Active and passive joint
for quality of joint motion, the initiation of resistance to
ranges of motion. (C) Sites of active joint movement,
motion and type of end feel, and the amount of motion
mobilization, and manipulation.
within each of the principle directions of movement. The
paraphysiologic space is bordered by the elastic and ana-
tomical limits of an individual joint. Joint motion into
the paraphysiologic space occurs only with the application Vertebral range of motion in left and right lateral bending
of high velocity forces associated with joint manipulation. or axial rotation is typically distributed symmetrically about
The anatomical barrier of the joint marks the junction a neutral joint position; however, joint ranges of motion in
between the paraphysiologic and pathologic zones of flexion versus extension at certain vertebral levels or limb
movement. The pathologic zone is characterized by the ap- articulations may be quite asymmetrical.58,59 Passive joint
plication of excessive forces or joint motion which causes range of motion can be assessed only with the application
an articulation to move beyond its anatomical limits and of external articular forces. The limit of passive joint mo-
results in mechanical disruption of intra- and periarticular tion occurs beyond the range of voluntary joint move-
structures and subsequent joint instability or luxation. ments and is the site where joint mobilization and
Active range of motion is characterized by the amplitude stretching exercises are applied (Fig. 1C). Joint mobiliza-
of voluntary joint movements (e.g., flexion and extension) tion and manipulation are two types of induced articular
produced by active muscle contractions (Fig. 1B). movements used in musculoskeletal rehabilitation to
KK Haussler  Vol 29, No 12 (2009)
restore joint mobility and reduce pain. Mobilization is
characterized as repetitive joint movements induced within
the normal physiological range of joint motion. Joint ma-
nipulation involves the application of force to bring an ar-
ticulation to end range of motion (i.e., pre-tension), and
then applying a thrust or impulse to move the joint of in-
terest beyond the elastic barrier and into the paraphysio-
logical zone with the intent of stimulating both
mechanical and neurophysiologic mechanisms.
Joint mobilization and manipulation are thought to pro-
duce different physiologic effects; however, the evidence in
human beings is mixed. Manipulation has been shown to
immediately reduce spontaneous myoelectrical activity,
whereas mobilization has not.60 For neck pain in human
beings, manipulation produces significant reductions in
pain and disability as compared with mobilization.61 How-
ever, both joint mobilization and manipulation increase
cervical range of motion to a similar degree.47 Other stud-
ies report that neither manipulation nor mobilization is
beneficial or significantly different for mechanical neck dis-
orders.62 For acute low back pain in human beings, there is
moderate evidence that spinal manipulation provides more
short-term pain relief than does mobilization.45 It has been
theorized that spinal manipulation preferentially influences
a sensory bed which, in terms of anatomical location and
function, is different from the sensory bed influenced by
spinal mobilization techniques.63 Manipulation may par-
ticularly stimulate receptors within deep intervertebral
muscles, whereas mobilization techniques most likely af-
fect more superficial axial muscles. Only one study has
compared mobilization to manipulation in horses, and spi-
nal manipulation induced a 15% increase in displacement
and a 20% increase in applied force as compared with
mobilization.40 At most vertebral sites studied, manipula-
tion increased the amplitudes of dorsoventral displacement
and applied force, indicating of increased spinal flexibility
and tolerance to pressure in the thoracolumbar region of
the equine vertebral column.
Joint manipulation often induces a palpable release or
movement of the restricted articular end feel. An audible
cracking or popping sound may also be heard during Mechanical effects can also influence the vasculature, lym-
joint mobilization or manipulation because the applied
force overcomes the elastic barrier of resistance.64,65 Rapid
articular separation produces a cavitation of the synovial
fluid.66 In human beings, radiographic studies of synovial
articulations after manipulation have shown a radiolucent
cavity within the joint space (i.e., vacuum phenomenon)
that lasts for 1520 minutes. A second attempt to recavi-
tate the joint with a high-velocity thrust will be unsuccess-
ful and potentially painful until the intra-articular gas has
been reabsorbed (i.e., refractory period). Joint mobiliza-
tion has no refractory period because synovial fluid cavita-
tion is not produced during most mobilization procedures.
The presence of joint cavitation induced during
853
manipulation has mixed clinical significance. Some authors
suggest that joint cavitation is highly important and is re-
quired for successful joint manipulation64 whereas other
studies state that joint cavitation is absolutely unimpor-
tant.67 The published data suggest that any stimulus that
activates high-threshold receptors within the periarticular
tissues has the potential to initiate unique neurologic re-
flexes associated with joint manipulation.68,69 The me-
chanical sensation and audible produced by joint
cavitation has been used by some individuals to support
the misconception of articular malpositioning or the con-
cept of a bone out of place, which is an outdated theory
and not supported by current spinal research.70 Palpatory
changes in osseous symmetry after manipulation are often
associated with soft-tissue alterations and not actual reduc-
tion of an articular misalignment.56
MECHANISMS OF ACTION
Manual therapy is considered to produce physiological ef-
fects within local tissues, on sensory and motor compo-
nents 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 com-
ponents.71 The challenge is in choosing the most appropri-
ate form of manual therapy or a combination of techniques
that will be efficacious for an individual patient with specific
musculoskeletal disabilities. If soft-tissue restriction and
pain are identified as the primary components of a musculo-
skeletal injury, then massage, stretching and soft-tissue
mobilization techniques are indicated for increasing tissue
extensibility.72 However, if the musculoskeletal dysfunc-
tion is localized to articular structures, then stretching,
joint mobilization, and manipulation are the most indi-
cated manual therapy techniques for restoring joint range
of motion and reducing pain.45
Local tissue effects produced by manual therapy tech-
niques relate to direct mechanical stimulation of skin, fas-
cia, muscles, tendons, ligaments, and joint capsules.73
phatics, and synovial fluid.74 Direct mechanical loading of
tissues can alter tissue healing, the physical properties of tis-
sues (e.g., elongation), and local tissue fluid dynamics asso-
ciated with extracellular or intravascular fluids. Normal
tissue repair and remodeling relies on mechanical stimula-
tion of cells and tissues to restore optimal structural and
functional properties, such as tensile strength and flexibil-
ity. Nonspecific back pain is most likely related to a func-
tional impairment and not a structural disorder;
therefore, many back problems may be related to muscle
or joint dysfunction, with secondary soft-tissue irritation
and pain generation.56 Soft-tissue contractures and adhe-
sions are unwanted effects associated with musculoskeletal
854
injuries and postsurgical immobilization.41 Stretching ex-
ercises or direct mechanical mobilization of the affected tis-
sue can be used to elongate contracted or fibrotic
connective tissues to improve soft-tissue extensibility and
increase joint range of motion.72 Tissue viability is highly
dependent on its vascular and lymphatic supply which is of-
ten compromised because of mechanical disruption or is-
chemia. Soft-tissue or joint mobilization may facilitate
flow to and from the affected tissues, help to reduce pain
and edema, and decrease joint effusion.74 Joint manipula-
tion can improve restricted joint mobility and may reduce
the harmful effects associated with joint immobilization
and joint capsule contractures. Limb and joint mobiliza-
tion can also have direct mechanical effects on nerve roots
and the dura mater, which may have clinical application in
the treatment of perineural adhesions and edema.75
Tissue manipulation has an additional effect of stimulat-
ing regional or systemic changes in neurologic signaling
related to pain processing and motor control. Manual ther-
apy can provide effective management of pain and neuro-
muscular deficits associated with musculoskeletal injuries,
alterations in postural control, and locomotory issues re-
lated to antalgic or compensatory gait.1 In response to
chronic pain or stiffness, new movement patterns are devel-
oped by the nervous system and adopted in an attempt to
reduce pain or discomfort. Long after the initial injury
has healed, adaptive or secondary movement patterns
may continue to persist, which predispose adjacent articu-
lations or muscles to injury.56 Activation of proprioceptors,
nociceptors, and components of the muscle spindles pro-
vides afferent stimuli that have direct and widespread influ-
ences on components of the peripheral and central nervous
systems that directly regulate muscle tone and movement
patterns.56 The various forms of manual therapy are
thought to affect different aspects of joint function
through diverse mechanical and neurologic mechanisms.2
Alterations in articular neurophysiology from mechanical
or chemical injuries can affect both mechanoreceptor and
nociceptor function through increased joint capsule ten-
sion and nerve ending hypersensitivity.76 Mechanorecep-
tor stimulation induces reflex paraspinal musculature
hypertonicity and altered local and systemic neurologic re-
flexes. Nociceptor stimulation results in a lowered pain
threshold, sustained afferent stimulation (i.e., facilitation),
reflex paraspinal musculature hypertonicity, and abnormal
neurologic reflexes. Touch and light massage preferentially
stimulate superficial proprioceptors, whereas any tech-
nique that involves deep tissue massage, stretching, muscle
contraction, or joint movement has the potential to stimu-
late deep proprioceptors.1 Massage, stretching, and joint
mobilization are also considered to affect more superficial
epaxial muscles, such as the longissimus muscle, and to
have a multisegmental effect. In contrast, manipulation
preferentially stimulates mechanoreceptors within deep
KK Haussler  Vol 29, No 12 (2009)
multifidi muscles and has a more segmental focus.63 Joint
manipulation can affect mechanoreceptors (i.e., Golgi ten-
don organ and muscle spindles) to induce reflex inhibition
of pain and muscle relaxation and to correct abnormal
movement patterns.77 Because of somatovisceral innerva-
tion, mobilization and manipulation within the trunk
have possible influences on the autonomic system and vis-
ceral functions; however, the clinical significance and
repeatability of these effects are largely unknown.78
The effects of touch or massage on psychological issues
such as behavior or emotion are often dismissed as an insig-
nificant component of the overall healing process in
patients.1 Promoting general body relaxation and reducing
anxiety may be significant components of some treatment
protocols.79 Behaviors related to pain, depression, or fear
are associated with patterned somatic responses, which
may be manifested as generalized changes in muscle
tone, autonomic activity, or altered pain tolerance. Other
psychological factors associated with manual therapies
include placebo effects and patient satisfaction. However,
the role of placebo effects in horses and their owners is
currently unknown.
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 neuro-
logic structures. Orthopedic and neurologic evaluations
are important adjunctive assessments used to identify com-
mon causes of limb lameness, spinal injuries, and neurolog-
ical disorders that are more appropriately and effectively
treated with traditional medical or surgical approaches.
Manual therapy evaluation and treatment is not a substitute
for a thorough lameness examination and diagnostic imag-
ing. However, horses with conditions that are not readily
diagnosed using traditional modalities or with concurrent
lameness and spinal dysfunction may benefit from a thor-
ough manual therapy evaluation. Some horses present
with vague or overlapping signs of neurologic disease and
musculoskeletal pain, which may be differentiated with
a detailed axial skeleton evaluation. The spinal examination
also helps to identify and differentiate signs of acute and
chronic spinal dysfunction and to localize stiffness, pain,
or muscle hypertonicity to a few vertebral segments or an
entire vertebral region.
Examination of the neuromusculoskeletal system begins
with a thorough medical history, detailed discussion of the
chief complaint, and observation of the patient from a dis-
tance for evaluation of conformation, posture, and signs of
lameness. The horses general attitude and behavior are
monitored for signs of pain or discomfort. Many owners
will report a change in behavior (i.e., pinned ears, swishing
tail) because a horse with back pain anticipates being
KK Haussler  Vol 29, No 12 (2009)
touched or having the saddle placed on its back. Vertebral
column conformation is evaluated for proper alignment
and symmetry, with special attention to the top line, shape
and height of the withers, and osseous pelvic symmetry. A
short-coupled horse is believed to have a higher incidence
of osseous disorders, whereas a long-backed horse is more
prone to soft-tissue injuries.80 The horse is made to stand
squarely on a hard, level surface and posture is evaluated
for a preferred or shifting stance, head and neck carriage,
vertebral curvatures, and muscular development and
symmetry.
Evaluation of spinal mobility during gait analysis focuses
on observing the overall balance and fluidity of movement
from head to tail, in addition to assessing thoracic and pel-
vic limb stride length, foot placement, and signs of lame-
ness. Gait analysis and lameness examination are typically
used to identify and localize limb lameness and to rule
out signs of vertebral dysfunction, although limb lameness
has been reported in 74% of horses with back problems.81
Neck or back motion asymmetries, restricted vertebral or
pelvic mobility, not tracking straight, or lack of propulsion
are a few spinal function characteristics that are evaluated.
Tape on the tubera coxae or vertebral column midline
may assist in visualization of subtle motion asymmetries.
Normal vertebral column motion during the walk consists
of small cumulative amounts of segmental motion, which
produce an overall smooth curve or movement of the ver-
tebral column. Evaluation of the response to placing a sad-
dle on the horse, tightening of the girth, and riding
exercise is important for a complete assessment of horses
with potential back problems. Inspection of the tack for
proper fit and use are always suggested on the initial exam-
ination of a horse with back pain or complaints of poor per-
formance. Saddles and restraint devices should be
evaluated for proper fit, positioning, and padding.82
A thorough physical examination, coupled with orthope-
dic and neurologic evaluation, is used to identify common
causes of lameness or neurological disorders. A detailed
spinal examination helps to identify compensatory or con-
current musculoskeletal issues not readily diagnosed or
treated with traditional medical or surgical approaches.
The spinal evaluation focuses on evaluating and localizing
segmental vertebral dysfunction, which is characterized
by localized pain, muscle hypertonicity, and reduced joint
motion. The challenge, as with any musculoskeletal injury,
is to identify the specific musculoskeletal structures that are
affected and to quantify the associated disability or altered
function present. Palpation is used to localize and identify
soft tissue and osseous structures for changes in texture,
tissue mobility, or resistance to pressure.80,83 The horses
response to being approached and its anticipation of palpa-
tion is often used as a behavioral indication of potential
back pain or hypersensitivity. Soft-tissue layers are evalu-
ated from superficial to deep by increasing digital pressure
855
and by focusing attention to specific tissues or structures
with discrete palpatory movements. Shapes of structures,
transitions between structures, and attachment sites are
also palpated.56 Soft-tissue texture and mobility can be
compared between the skin, subcutaneous tissue, thoraco-
lumbar fascia, and muscle; similar to layers of an onion
(Fig. 2). Assessing patient response to palpation is espe-
cially important in evaluating tenderness or hypersensitiv-
ity. The epidermis should be evaluated for scabs, scrapes,
lacerations, fly bites (ventral dermatitis), sarcoids, and der-
matophilosis (rain scald), which can be primary causes of
back pain or sources of irritation with saddle or girth place-
ment. The dermis is palpated over the trunk region for the
presence of eosinophilic granulomas or other dermal
masses. The subcutaneous tissues are palpated for edema
or cellulitis, masses, fat deposits, and for mobility of the cu-
tis over the underlying loose connective tissues. The skin
and subcutaneous tissues are gently mobilized by a firm,
broad manual contact. Chronic scar tissue, adhesions,
and fibrosis may produce pain or mechanical restrictions
if affected tissues are restrained during locomotion or trunk
movements. The superficial fascia is assessed for smooth-
ness and uniform tonicity or compliance, and typically
forms an external covering over muscles, whereas the
deep fascia forms folds of connective tissue between muscle
bellies and attaches to deeper osseous structures. The dense
connective tissue that forms the deep fascia is systematically
evaluated for masses, rents, scar tissue, and tonicity. Severe
or deep trauma to the myofascial tissues (e.g., kicks, deep
lacerations, abscesses, or hematomas) can produce residual
fibrosis that limits adjacent muscular movements and fas-
cial extensibility. The thoracolumbar fascia is the most
prominent fascia of the trunk and is particularly evident
at the thoracolumbar junction as it blends medially with
the supraspinous ligament. In the lumbar region, the
caudal aponeurotic portion of the thoracolumbar fascia
attaches to the cranial aspect of the tuber sacrale and iliac
wing, deep to the overlying middle gluteal muscle. The
tendon of the thoracolumbar fascia is palpable cranial and
medial to the tubera sacralia as it inserts on the second
sacral spinous process in conjunction with the dorsal sacro-
iliac ligament.84 Other connective tissue structures, such as
tendons and ligaments, are systematically evaluated for
signs of acute or chronic injury.
The spinal ligaments are systematically palpated for pain,
swelling, thickening, fibrosis, and fiber disruption. Firm
digital pressure is applied dorsally and laterally to the nu-
chal and supraspinous ligaments as they attach to the dorsal
apices of the thoracolumbar spinous processes (Fig. 3).
Fascial insertions from the thoracolumbar fascia are also
palpated as they attach laterally to the supraspinous liga-
ment. However, most pelvic ligaments are inaccessible to
palpation because of their location deep to the gluteal
musculature. The dorsal portion of the dorsal sacroiliac
856
Figure 2. Image of the cross-sectional spinal anatomy
at the level of the fourth lumbar vertebra. Anatomical
features and thickness of the skin, subcutaneous tissue,
thoracolumbar fascia, and spinal musculature are
illustrated. The epaxial spinal musculature (e.g.,
longissimus and multifidi muscles) lies dorsal to the
transverse processes, and the psoas major and minor
muscles are located ventrally.
ligament and the caudal portion of the sacrotuberous liga-
ment are the only palpable ligaments within the pelvic re-
gion. The dorsal sacroiliac ligaments are palpable in the
croup region as two large round ligaments that originate
from the caudal aspect of the tuber sacrale and converge
caudally to insert on the dorsal aspect of the sacral
spinous processes. Firm digital pressure is applied dorsally
and laterally to the dorsal sacroiliac ligaments, both indi-
vidually and bilaterally to localized pain or swelling, indic-
ative of desmitis. Specific mobilization forces applied to the
pelvic prominences (i.e., tuber sacrale, tuber coxae, or
ischial tuberosity) or the sacral apex can provide an indirect
method of assessing the structural and functional status of
the bony pelvis and the supporting sacroiliac ligaments.85
The evaluation of muscle begins with observation and
palpation of the neck, trunk, and proximal limb muscula-
ture for development and symmetry. Muscle atrophy can
be due to partial or complete denervation, disuse, malnu-
trition, metabolic, or immune-mediated disorders.86
Obese or out-of-condition horses often have accumula-
tions of adipose tissue, poor muscle development, and in-
distinct myofascial borders, which make myofascial
palpation difficult. Epaxial muscle development within
the neck, trunk, and pelvis is assessed by laying a hand
transversely across the spinal or gluteal musculature
(Fig. 4). Horses with exceptional spinal muscle develop-
ment have a palpable uniform convexity or outward curva-
ture of the muscles along the entire length of the vertebra
column from the poll to the scapula, along the trunk, and
KK Haussler  Vol 29, No 12 (2009)
Figure 3. Palpation of the supraspinous ligament and
midline attachment of the thoracolumbar fascia. Firm
digital pressure is applied laterally along individual
spinous processes in an effort to localize and grade the
severity of pain responses within the connective tissue
structures.
over the croup and down the caudal aspect of the thigh.
Deconditioning or poor flexibility may contribute to epax-
ial muscles with the thoracolumbar that are palpably flat
between the dorsal spinous processes medially and the
ribs laterally. Horses with chronic back pain or poor fitting
saddles will have a palpable concavity or inward curvature
of the epaxial muscles at the withers or along the trunk.
Asymmetries in epaxial muscle development may be palpa-
ble cranial-to-caudal, medial-to-lateral, or left-to-right
within the axial skeleton. The epaxial and pelvic muscula-
ture is further evaluated from superficial to deep, with
detailed palpation to identify areas of abnormal muscle to-
nicity, pain, or fasciculations. Muscle palpation is made
with light but firm pressure applied by a broad contact
with the entire hand and not only the finger tips, which
may unduly localize the applied pressure and precipitate
a false positive pain response. Muscles are evaluated for
masses, fibrosis, swellings, or depressions, and affected sites
or muscles are identified. Regional muscle tone of the neck,
KK Haussler  Vol 29, No 12 (2009)
Figure 4. Palpation of muscle development and tone
within the thoracic portion of the spinalis muscle
located over the lateral withers. The presence and
severity of left-right muscle asymmetries, muscle
hypertonicity, and pain responses are documented.
trunk, and proximal limb musculature is assessed and com-
pared left-to-right. Detailed palpation and a thorough
knowledge of muscular anatomy will help to identify which
muscle or group of muscles are primarily affected, and
which distant muscles are likely to have secondary guarding
because of common biomechanical or neurological inciting
factors. Muscle tone is categorized as hypotonic, normal,
or hypertonic. General muscle tone varies between horses
and breeds. Nervous or excited horses will have overall in-
creased muscle tone, whereas stoic, depressed, or systemi-
cally-ill horses will have reduced or sometimes flaccid
muscle tone. Arabians tend to carry more muscle tone,
whereas most warmbloods or draft breeds will allow deep
palpation of their generally relaxed muscles. Muscle tone
is an indirect measure of muscle activity or contraction. Di-
agnostic and kinesiologic electromyography provides
a more direct assessment of muscle activity; however, it is
not readily available in most clinical situations and it is of-
ten difficult to perform and interpret.86 Muscle hypotonic-
ity or flaccidity is indicative of neuropathies, such as disuse
or denervation atrophy. Muscle hypertonicity is the most
commonly palpable abnormality in horses with acute or
chronic back problems, and can have either neural or myo-
pathic origins.86 Muscle hypertonicity may affect a small
portion of a muscle (i.e., trigger point), an entire muscle
belly, or a regional group of muscles. In general, localized
muscle hypertonicity is considered indicative of an acute or
primary back problem, whereas regional or generalized
longissimus muscle hypertonicity is often associated with
chronic pelvic limb lameness or systemic disease.86 Muscle
857
Figure 5. Palpation of the width of the retromandibular
space between the caudal ramus of the mandible and the
lateral wing of the atlas. Left-right asymmetry is
indicative of possible atlanto-occipital joint dysfunction
or structural vertebral abnormalities.
fasciculations are usually indicative of profound muscle
weakness, electrolyte imbalance, or primary muscle pathol-
ogy. However, muscles may also fasciculate at characteristic
locations distant to an area of palpation, which is indicative
of referred pain in human beings. Referred pain is difficult
to truly assess in horses because of the lack of verbal feed-
back.87 Muscle spasms are characterized as an acute, severe
form of muscle hypertonicity, with substantial pain, spas-
ticity, and loss of muscle function.
Osseous palpation involves evaluating bony structures
for pain, morphology, asymmetries, and alignment. Horses
with pain localized to the temporomandibular joints and
hypertonicity of the adjacent muscles of mastication should
be evaluated for potential dental malocclusion or oral pain.
Osseous asymmetry in the space between the caudal ramus
of the mandible and the lateral wing of the atlas can be
identified in horses with upper cervical congenital malfor-
mations or occipitoatlantal trauma caused by pulling back
in cross ties or flipping over backwards (Fig. 5). Individual
cervical transverse processes, articular processes, and thor-
acolumbar and sacral spinous processes are palpated for
a painful response to firm digital pressure (Fig. 6).88 Typi-
cal signs of discomfort include avoidance reactions such as
rapid elevation of the head, extension of the back or withers
858 KK Haussler  Vol 29, No 12 (2009)

away from the applied pressure, or localized secondary

muscle spasms, indicative of local injury or impinged spi-
nous processes. Pressure algometry of osseous landmarks
provides an objective measure of MNTs and allows moni-
toring of the efficacy of treatment protocols.89 During in-
duced kyphosis, the abaxial borders of each individual
thoracolumbar spinous process and the overlying supraspi-
nous ligament are palpated for pain, thickening, or devia-
tion from midline. Palpable deviations of individual
spinous processes are common, but are typically not associ-
ated with spinous process fracture or vertebral malposition
(i.e., bone out of place), as is commonly believed.90 Paired
bony pelvis prominences are palpated for dorsoventral and
craniocaudal asymmetries and pain response to manual
compression. Small amplitudes of unilateral or bilateral
prominence of the tuber sacrale are common and not con-
sidered clinically significant unless associated with clinical
signs of localized pain, inflammation, or positive findings
on diagnostic imaging (e.g., scintigraphy). The apex of
the second sacral spinous process is a reliable landmark
used to evaluate relative dorsal or ventral tuber sacrale dis-
placement. Fractures of tuber coxae typically produce pal-
pable bony asymmetries and ventral displacement of
fracture fragments, which are readily diagnosed on oblique
radiographs of the pelvis.91 The tail and caudal vertebrae
are evaluated for tone, fractures, and osseous deviations.
A complete musculoskeletal examination includes assess- Figure 6. Palpation of dorsal spinous processes within
ment of active and passive joint ranges of motion for all ax- the thoracolumbar region. Firm digital pressure is
ial and appendicular articulations of interest. Active joint applied dorsally along individual spinous processes in an
range of motion of the axial skeleton is evaluated during effort to localize and grade the severity of the osseous
normal daily activities (e.g., lying, standing movements, pain responses.
or locomotion) or during induced vertebral movements
while using a carrot or other treat to produce active move-
ments of the head, neck, or trunk (Fig. 7). Similar proce- muscle spasms. Joint hypermobility is usually indicative
dures can be used therapeutically as active stretching of articular instability that often requires immediate medi-
exercises to increase neck or trunk range of motion or for cal or surgical evaluation and stabilization and is generally
developing coordination and strength of the muscles re- a contraindication for most forms of manual therapy.
sponsible for trunk stabilization.38 Normal vertebral move- Passive joint range of motion is evaluated by measuring
ments consist of varying amounts and combinations of the amount and characteristics of joint motion beyond
flexion, extension, left and right lateral bending, and left the active range of joint motion (Fig. 1B). Assessing passive
and right axial rotation. Active joint motion within most range of motion requires patient cooperation and muscular
equine limb articulations consists almost exclusively of flex- relaxation because each articulation is moved passively
ion-extension, with occasional joints capable of undergo- throughout its unique ranges and directions of motion.
ing small amounts of internal or external rotation. The goal of palpating joint movement is to evaluate the
Abnormal active joint motion is characterized by weakness, quality of joint motion, the initiation of resistance to mo-
incoordination, asymmetry, restricted, or excessive joint tion and joint end feel, and the amplitude of joint motion
movements. The willingness, coordination, and amount present. Similar palpatory findings can be identified in soft
of vertebral or limb segment motion is compared bilater- tissues, such as skin, connective tissue, muscles, or liga-
ally, and left-to-right range of motion asymmetries are ments.83 Passive joint range of motion is evaluated to de-
documented. Local or regional causes of active vertebral tect whether a particular movement is normal, restricted,
movement restrictions or altered movement may include or hypermobile. Passive joint mobility can be assessed ei-
peripheral or central neuropathies, myopathies, intra-artic- ther segmentally through palpation of individual vertebral
ular pathology (i.e., osteoarthritis), periarticular soft-tissue motion segments or limb articulations or evaluated region-
adhesions, musculotendinous contractures, or protective ally via passive mobilization of vertebral regions or entire
KK Haussler  Vol 29, No 12 (2009)
Figure 7. Evaluation of active cervical range of motion
in left lateral bending. A carrot or similar treat is directed
toward the elbow to assess quality and quantity of
overall cervical range of motion. The treat can also be
directed toward the ipsilateral stifle to assess lateral
bending of the trunk, which is compared bilaterally.
limbs. Causes of restricted articular movement include soft
tissue (e.g., capsular fibrosis, muscle spasms, or contrac-
tures) and osseous pathologies (e.g., malformations, oste-
oarthritis, or ankylosis). Restricted vertebral segment
motion can occur with or without localized muscle hyper-
tonicity or pain. Diagnostic interpretations of joint func-
tion can be implied by combining evaluation of joint
range of motion and pain at the extremes of joint mo-
tion.92 Normal joint motion is painless, suggesting that ar-
ticular structures are intact and functional. Normal joint
mobility that has a painful end range of movement suggests
a minor sprain of periarticular tissues or muscle. Painless
joint hypomobility suggests a soft-tissue contracture or ad-
hesion, whereas painful joint hypomobility an acute strain
or intra-articular injury with secondary muscle guarding.
Painless hypermobility of an articulation may indicate
a complete rupture, whereas painful hypermobility sug-
gests a partial tear of an intra- or periarticular structure.
Evaluation of passive joint range of motion within the ax-
ial skeleton begins at the head and continues to the tip of
the tail. In a relaxed horse, left-right lateral excursion of
859
Figure 8. Evaluation of the quality and quantity of
passive range-of-motion of the mandible during left and
right lateral excursions. The presence and severity of
joint motion asymmetry and pain responses are noted.
the mandible is assessed for amplitude, quality, and sym-
metry (Fig. 8). Palpation of mandibular range of motion
and audible contact of the cheek teeth are compared bilat-
erally. The dorsal and lateral excursion of the lingual
process and basihyoid bone of the hyoid apparatus are as-
sessed for restricted motion and pain, indicative of possible
temporohyoid osteoarthropathy. The atlanto-occipital
(Occ-C1) articulation is evaluated in full ranges of flexion,
extension, and lateral bending for signs of pain or resisted
motion (Fig. 9). The atlantoaxial (C1-C2) articulation is
evaluated for altered or asymmetrical ranges of axial rota-
tion. The intervertebral articulations of the second to sev-
enth cervical vertebrae (C2-C7) are assessed individually
for altered joint range of motion and joint end feel during
combined lateral bending and rotation (Fig. 10). Articula-
tions of the mid-cervical region (C4-C6) are commonly
restricted and painful in performance horses, presumably
because of locally altered biomechanical influences. The
individual spinous processes of the third to twelfth thoracic
vertebrae (T3-T12) are manually deviated from midline,
while monitoring for signs of reduced vertebral motion,
localized or generalized pain response, and induced muscle
hypertonicity (Fig. 11). Horses with poorly fitting saddles
(i.e., tree is too narrow) resent palpation and passive
motion of the affected cranial thoracic vertebrae. The re-
maining thoracolumbar region (T13-L6) is evaluated in
lateral bending and flexion and extension for similar signs
of spinal dysfunction. Normal lateral bending range of
motion is maximal at the mid-thoracic region and gradually
diminishes toward the lumbosacral junction.59 Conversely,
flexion and extension are minimal within the thoracic
860
Figure 9. Evaluation of the quality and quantity of
passive lateral bending at the atlanto-occipital
articulation. The presence and severity of left-right joint
motion asymmetries and pain responses are
documented.
region and gradually increase toward the lumbosacral junc-
tion, which is the site of maximal flexion and extension
range of motion within the trunk region. Evaluation of
segmental vertebral motion in flexion and extension re-
quires the clinician to be on an elevated surface to induce
ventrally-directed rhythmic oscillations over the individual
thoracolumbar intervertebral articulations (Fig. 12).
Horses with impinged dorsal spinous processes strongly re-
sent any induced extension of the affected vertebral seg-
ments. The pelvis and sacroiliac joints are evaluated for
motion restrictions and pain during induced joint motion
with ventrally-directed forces applied over the tuber coxae
(Fig. 13) or during abaxial compression of the tubera sa-
cralia (Fig. 14). The caudal vertebrae are assessed by passive
range of motion of each intervertebral articulation and by
applying axial traction to the tail. The passive range of mo-
tion of all thoracic and pelvic limb articulations is also eval-
uated in flexion and extension, internal and external
rotation, abduction and adduction, and circumduction
for signs of restricted joint motion, pain, inflammation,
and muscle hypertonicity. Comparisons of the quality
and quantity of passive range of motion are evaluated
pre- and post-stretching exercises or joint manipulation
to assess potential therapeutic responses within limb artic-
ulations or vertebral motion segments.93
KK Haussler  Vol 29, No 12 (2009)
Figure 10. Evaluation of the quality and quantity of
passive lateral bending and axial rotation at the C5-C6
articulation. The presence and severity of left-right joint
motion asymmetries, muscle hypertonic and pain
responses are documented for each individual
intervertebral articulation within the cervical spine.
INDICATIONS FOR JOINT MOBILIZATION AND
MANIPULATION
Back pain is a common cause of poor performance in
equine athletes. Unfortunately, medical and surgical treat-
ment 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 veter-
inary medicine. Most of the current knowledge about
equine manual therapies has been borrowed from human
techniques, theories, and research and is applied to horses.
Therapeutic trials of joint mobilization or manipulation are
often used because of limited knowledge about the effects
of manual therapy in horses. The indications for joint mo-
bilization and manipulation are similar and include re-
stricted joint range of motion, muscle spasms, pain,
fibrosis, or contracted soft tissues.34 The principal indica-
tions for spinal manipulation are neck or back pain, local-
ized or regional joint stiffness, poor performance, and
altered gait that is not associated with overt lameness. A
thorough diagnostic workup is required to identify soft tis-
sue and osseous pathology, neurologic disorders, or other
lameness conditions that may not be responsive to manual
therapy. Clinical signs indicative of a primary spinal disor-
der include localized musculoskeletal pain, muscle
KK Haussler  Vol 29, No 12 (2009)
Figure 11. Evaluation of the quality and quantity of
passive lateral bending and axial rotation of individual
thoracic spinous process that form the withers. The
presence and severity of left-right joint motion
asymmetries, muscle hypertonicity, and pain responses
are documented for each spinous process.
Figure 12. Evaluation of the quality and quantity of
passive thoracolumbar extension at each individual
intervertebral articulation. The presence and severity of
restricted motion, muscle hypertonicity, and local or
generalized pain responses are documented.
hypertonicity, and restricted joint motion. This triad of
clinical signs can also be found in a variety of lower limb
disorders; however, they are most evident in horses with
neck or back problems. Clinical signs indicative of chronic
or secondary spinal disorders include regional or diffuse
pain, generalized stiffness, and widespread muscle hyperto-
nicity. In these cases, further diagnostic evaluation or imag-
ing should be done to identify the primary cause of
861
Figure 13. Evaluation of the quality and quantity of
passive lumbosacral, coxofemoral and pelvic motion
induced during a ventrally-applied force over the tuber
coxae. The presence and severity of restricted motion,
muscle hypertonicity, and pain responses are
documented.
lameness or poor performance. Manual therapy may help
in the management of muscular, articular, and neurologic
components of select musculoskeletal injuries in perfor-
mance horses. Musculoskeletal conditions that are chronic
or recurring, not readily diagnosed, or are not responding
to conventional veterinary care may be indicators that man-
ual therapy evaluation and treatment is needed. Manual
therapy is usually more effective in the early clinical stages
of disease processes versus end-stage disease where repara-
tive processes have been exhausted. Joint manipulation is
usually contraindicated in the acute stages of soft-tissue in-
jury; however, mobilization is safer than manipulation and
has been shown to have short-term benefits for acute neck
or back pain in human beings.94 Manipulation is probably
more effective than mobilization for chronic neck or back
pain and has the potential to help restore normal joint mo-
tion, thus limiting the risk of reinjury.56
Contraindications for mobilization and manipulation are
often based on clinical judgment and are related to the
technique applied and skill or experience of the practi-
tioner.34 Few absolute contraindications exist for joint mo-
bilization if techniques are applied appropriately. Manual
therapy is not a cure all for all joint or back problems
and is generally contraindicated in the presence of
862
Figure 14. Evaluation of a pain response to abaxial
compression of the tubera sacralia. A normal response
consists of mild extension of the lumbosacral joint and
contraction or mild fasciculations of the longissimus and
middle gluteal muscles. A positive pain response occurs
when horses unlock their stifles and exhibit dramatic
dropping of the pelvis.
fractures, acute inflammatory or infectious joint disease,
osteomyelitis, joint ankylosis, bleeding disorders, progres-
sive neurological signs, and primary or metastatic tu-
mors.34 Joint mobilization and manipulation cannot
reverse severe degenerative processes or overt pathology.
Acute episodes of osteoarthritis, impinged dorsal spinous
processes, and severe articular instability, such as joint sub-
luxation or luxation, are often contraindications for manip-
ulation. Inadequate physical or spinal examination and
poorly developed manipulative skills are also contraindica-
tions for applying manual therapy.95 All horses with neuro-
logic diseases should be evaluated fully to assess the
potential risks or benefits of joint mobilization or manipu-
lation. Cervical vertebral myelopathy occurs because of
both structural and functional disorders.96 Static compres-
sion caused by vertebral malformation and dynamic lesions
caused by vertebral segment hypermobility are contraindi-
cations for cervical manipulation; however, adjacent
regions of hypomobile vertebrae may benefit from mobili-
zation or manipulation to help restore joint motion and
reduce biomechanical stresses in the affected vertebral seg-
ments. Serious diseases requiring immediate medical or
surgical care need to be ruled out and treated by conven-
tional veterinary medicine before any routine manual
therapy is initiated, although, manual techniques may
KK Haussler  Vol 29, No 12 (2009)
Figure 15. Application of a spring-loaded instrument
(Activator, Activator Methods International Ltd.,
Phoenix, AZ) to bony or soft-tissue landmarks, with the
aim of inducing high-velocity impulses during
manually-assisted, mechanical-force procedures.
contribute to the rehabilitation of most postsurgical cases
or severe musculoskeletal injuries by helping to restore
normal joint motion and function. Horses that have con-
current hock pain (e.g., osteoarthritis) and a stiff, painful
thoracolumbar or lumbosacral vertebral region are best
managed by addressing all areas of musculoskeletal dys-
function. A multidisciplinary approach entails combined
medical treatment of the hock osteoarthritis and manual
therapy evaluation and treatment of the back problem.
In human beings, adverse effects or risks of complications
associated with joint mobilization are minimal. Mobiliza-
tion is considered safer than manipulation.94 Some authors
suggest that given the higher risk of adverse reactions and
lack of demonstrated effectiveness of manipulation over
mobilization, manual therapists should consider conserva-
tive mobilization, especially in human patients with severe
neck pain.97 In human beings, most adverse events associ-
ated with spinal manipulation are benign and self-
limiting.98 Potential mild adverse effects from properly
applied manipulations include transient stiffness or wors-
ening of the condition after treatment. Data from prospec-
tive studies suggest that minor, transient adverse events
occur in approximately half of all patients during a course
of spinal manipulative therapy.99,100 However, these mild
adverse effects do not cause patients to stop seeking manip-
ulative care. Mild adverse effects usually last less than 12
days and resolve without concurrent medical intervention.
KK Haussler  Vol 29, No 12 (2009)
Severe complications after spinal manipulation are typically
uncommon and estimates of the incidence of range from 1
in 200,000 to 1 per 100 million manipulations in human
beings.94,101,102 The most common serious adverse events
in humans are vertebrobasilar accidents, disk herniation,
and cauda equina syndrome.99 Although there is no evi-
dence of increased risk of vertebrobasilar artery stroke asso-
ciated with chiropractic care compared to primary medical
care.103 Even though the complication rate of spinal ma-
nipulation is small, the potential for adverse outcomes
must be considered because of the possibility of permanent
impairment or death.94 The benefits of chiropractic care in
human beings seem to outweigh the potential risks.104 The
risk of adverse effects associated with joint mobilization or
spinal manipulation is unknown in horses. The apparent
safety of spinal manipulation, especially when compared
with other medically accepted treatments for neck or
low back pain in human beings, should stimulate its use
in the conservative treatment of spinal-related prob-
lems.102,105 If an exacerbation of musculoskeletal dysfunc-
tion or lameness is noted after spinal manipulation, then
a thorough re-examination and appropriate medical treat-
ment should be pursued. If the condition does not improve
with conservative care, referral for more extensive
diagnostic evaluation or more aggressive medical treat-
ment is recommended.
JOINT MOBILIZATION AND MANIPULATION
TECHNIQUES
Stretching exercises vary according to the direction, veloc-
ity, amplitude, and duration of the applied force or induced
movement. However, it is difficult to identify which com-
bination of positions, techniques, and durations of stretch-
ing are most effective to induce increased joint range of
motion.106 Active stretching involves using the patients
own movements to induce a stretch, whereas passive
stretches are applied to relaxed muscles or connective tis-
sues during passive soft tissue or joint mobilization. In
horses, active stretches of the neck and trunk are often in-
duced with baited (i.e., carrot) stretches with the aim to in-
crease flexion, extension, or lateral bending of the axial
skeleton (Fig. 7). It is very difficult to make horses do active
stretching of the limbs; therefore, passive stretches are
most commonly prescribed in horses.31 Stretching should
be performed slowly to maximize tissue elongation because
of creep and stress relaxation within fibrotic or shortened
periarticular soft tissues.72 Sustained, low-load stretching
is more effective than rapid, high-load stretching for alter-
ing viscoelastic properties within soft tissues.107 Rapid
stretching may exceed the tissues mechanical properties
and produce additional trauma within injured tissues.108
The force applied during stretching exercises should be tai-
lored to specific phases of tissue repair.72 During the acute
863
inflammatory phase, stretching should be mostly avoided
due to the increased risk of tissue injury. During the regen-
erative and remodeling phases of healing, tissues progres-
sively regain tensile strength and applied manual forces
can be gradually increased. The amount of force applied
during passive stretching is largely based on the patients
response and signs of pain. Musculoskeletal injuries are
characterized by multiple tissue involvement, each of
which has a different healing rate and unique mechanical
response to stretching. Therefore, effective stretching pro-
grams are best tailored to address specific soft-tissue
injuries and do not only focus on restoring joint motion.
The duration of the applied stretch is dependent on the
force applied, affected tissue shape and size, the amount
of damage or fibrosis present, and the stage of tissue heal-
ing.72 In human beings, the recommended duration for
stretching the musculotendinous unit varies from 6 to 60
seconds.108 Stretching for 30 seconds has been shown to
be significantly more effective than 15-second stretches;
however, structural and functional differences within
each affected tissue makes general recommendations for
stretching a particular articulation or limb difficult to estab-
lish.109 The mode of loading during an applied stretch
varies from continuous to cyclic. Continuous or static load-
ing during stretching exercises can be uncomfortable for
some patients and is not recommended.72 Cyclic or rhyth-
mic stretching is more comfortable and physiologic as it
provides periods of tissue loading and unloading, which
has biomechanical and neurological benefits. Cyclic load-
ing also has cumulative effects on soft tissues as a result
of incremental elongation and stress relaxation within
each stretch cycle; however, these effects are maximized
approximately within the first four cycles of loading.108
Therefore, recommendations for optimal passive stretch-
ing include applying four to five repetitions of slow, low-
load forces held at the end range of motion of the affected
tissues, with each stretch applied and released in 30-second
cycles, without inducing pain. If performed inappropri-
ately, stretches may cause or aggravate injuries.22 There-
fore, thorough patient evaluation and proper stretching
program design are required before implementing
stretches. With minimal training, horses and their owners
can be taught how to do simple but effective passive joint
mobilization and active stretching exercises (i.e., carrot
stretches) to improve both limb and axial skeleton
flexibility.
Selection factors for considering mobilization versus ma-
nipulation include the technical training and skill of the
practitioner, perceived risks versus benefits, the presence
of acute pain and inflammation, and pathoanatomic con-
siderations.63 Joint mobilization is easier to apply, requires
less psychomotor skills, has minimal risks, and can be used
in the presence of acute pain and inflammation, as com-
pared to manipulation. Manual therapy procedures are
864
also dependent on the ability of the patient to relax and the
patent response to the applied force. Characteristics of
joint mobilization and manipulation include factors related
to specificity, leverage, velocity, amplitude, direction, and
prestress of the applied force.2 Additional factors are re-
lated to joint position and frequency or oscillation of the
applied forces.34 Levers are used to increase mechanical ad-
vantage and assist in applying force to an articulation or
body segment to induce joint motion. Long levers include
using the limbs or head and neck as levers to induce spinal
motion, instead of inducing motion at one or two individ-
ual vertebrae by using transverse or spinous processes as
short lever contacts. Velocity relates to the speed of the im-
pulse applied to move a vertebra or body segment, and dis-
placement is the distance over which the applied thrust is
applied. Amplitude refers to the amount of force applied.
With long-lever techniques, lower amplitudes of force are
required to induce similar joint motion as short-lever con-
tacts. However, the rationale for using short-lever tech-
niques is to increase the specificity of the applied thrust
because a single vertebral process is contacted on the verte-
bra of interest with short-lever techniques. With long
levers, it is likely that multiple articulations are included be-
tween the doctors contact and the body segment of inter-
est, which produces a more generalized treatment effect.
Using a specific contact is theorized to address a single
articulation; however, studies on treatment effects indicate
that specific contact techniques produce local, as well as, re-
gional and systemic effects.46 The therapeutic dosage of
joint mobilization or manipulation is also determined by
the number of vertebrae or body segments treated and
the frequency of the applied treatments.
Biomechanical characteristics of joint mobilization
include low peak forces, slow application, low velocity
movements, and large displacements. Mobilization of the
thoracic spine produces 2-3 cm displacements, whereas
manipulation induces 6-12 mm displacements.63 Mobili-
zation is typically applied with long lever-arm, low velocity,
oscillatory forces within or at the limits of physiological
joint range of motion without imparting a thrust or im-
pulse. Mobilization is also performed within the patients
ability to resist the applied motion and therefore requires
cooperation and relaxation of the patient. Mobilization is
usually applied in a graded manner, with each grade
increasing the range of joint movement. Grade 1 and 2 mo-
bilizations are characterized by slow oscillations within the
first 25% to 50% of the available joint motion, with the goal
of reducing pain. Grade 3 and 4 mobilizations involve slow
oscillations at or near the end of available joint motion,
which are used to increase joint range of motion. Some
mobilization techniques may include a hold and stretch
at the end range of motion. Distraction or traction refers
to applying manual or mechanical forces to induce separa-
tion of adjacent joint surfaces, which causes stretching of
KK Haussler  Vol 29, No 12 (2009)
the joint capsule, reduced intra-articular pressure, and is of-
ten used to reduce joint luxations.
Manipulation is characterized by short lever-arm, high
velocity, and low-amplitude forces applied outside of the
physiological zone of joint motion. Therefore, it is often
difficult for patients to resist or guard against the applied
impulse. Chiropractic techniques are often characterized
as HVLA thrusts delivered to a specified vertebral process
(short-lever arm) in a specific direction.2 Osteopathic tech-
niques also include similar HVLA thrusts applied to single
or multiple articulations with the goal of increasing joint
range of motion and reducing pain.44 Mobilization and
manipulation forces can both be focused on a specific joint
or anatomical region in a specific direction; however,
mobilization is often considered a general technique and
manipulation is theoretically considered more specific.
The therapeutic dosage of applied mobilizations or manip-
ulations is modified by the number of vertebrae or articu-
lations treated, the amount of force applied, and the
frequency and duration of treatment. However, there is
a lack of good scientific evidence on which optimal dosage
recommendations for continued care can be based; there-
fore, therapeutic trials are often used on an individual ba-
sis.110 The goal of manual therapy is to restore normal
joint motion, stimulate neurological reflexes, and reduce
pain and muscle hypertonicity. Comparisons of sensitivity
to palpation, muscle tone, and joint motion are made be-
fore and after treatment to evaluate the response to and ef-
fectiveness of manual therapy.
In human beings, the application of manual forces can be
combined with a wide diversity of therapeutic or medical
techniques to produce varying effects. Hand-held,
spring-loaded or electromechanical devices can be used
to apply single or multiple impulses to articulations or
tissues in a series of techniques named manually-assisted,
mechanical-force procedures (Fig. 15). It has been
reported that approximately 40 N of force is required to
activate mechanical and neurologic responses associated
with spinal manipulation.111 Manually-applied impulses
applied to the human cervical and lumbar spine range
from 40400 N and occur over 30150 milliseconds.
Similar amplitudes of force have been measured with in-
strument-assisted manipulations (i.e., 72 N230 N); how-
ever, the impulse occurs over a much shorter time (i.e.,
0.15.0 milliseconds). It is hypothesized that the velocity
of the applied force may be more important than the ampli-
tude of the applied force.111 Randomized studies have
shown similar effectiveness using either manual or instru-
ment-assisted treatment techniques.112,113 Using a stick
and mallet or similar percussive device to apply sharp,
mechanical forces to dorsal spinous processes has been re-
ported in horses to reduce back pain and increase spinal
range of motion, but controlled studies are lacking.54
Theoretically, there is an increased risk for injury using
KK Haussler  Vol 29, No 12 (2009)
instrument-assisted techniques or hammers to treat horses
because of the possibility of applying excessive forces by in-
experienced or lay practitioners, with little or no knowl-
edge of spinal or joint biomechanics.
Joint mobilization and manipulation can be combined
with sedation or general anesthesia, which provides in-
creased relaxation and analgesia for evaluation of subtle
joint motion restrictions or treatment of joint contractures
and spinal pain, without the influence of conscious pain or
protective muscle guarding.114 Indications for manipula-
tion under anesthesia in human beings include pain that
will not allow conscious manipulation, conditions that do
not respond to conscious spinal manipulation within 4 to
8 weeks, chronic joint or soft-tissue fibrosis, acute myofas-
cial rigidity and painful inhibition, severe joint dysfunction,
refractory contained disc herniation, and multiple recur-
rences of a condition.95 The risks of manipulation under
sedation or general anesthesia include the inability of
patients to provide verbal feedback on pain or to resist
overzealous manipulation because intrinsic guarding
mechanisms associated with voluntary muscle contraction
are absent, which can produce an increased risk of iatro-
genic injuries.95 Spinal manipulation under sedation and
anesthesia has been used in horses to address reduced joint
mobility; however, controlled studies are lacking.50,115,116
In a case series of 86 horses, 88% of horses maintained im-
proved ranges of pain-free joint motion after cervical mobi-
lization and sustained stretching at the end range of
motion while under anesthesia.115 Similar indications and
risks associated with the mobilization or manipulation
under anesthesia in human beings are expected in horses.
Although, no significant adverse effects have been reported
with cervical mobilization under general anesthesia in
horses.115 Well-designed, controlled studies are needed
to further investigate the safety and effectiveness of these
techniques in equine practice.
Manipulation combined with epidural analgesia or epi-
dural medications consists of segmental anesthesia with si-
multaneous epidural corticosteroid injection and spinal
manipulation.114 Indications for this procedure in human
beings include the following: epidural anesthesia is less
costly and is associated with fewer risks than general anes-
thesia, patients are able to cooperate during treatment, and
epidural corticosteroids reduce inflammation and reduce
fibrosis and adhesions, as compared to manipulation under
anesthesia alone. One possible indication for using this
technique in horses is severe or compensatory spinal pain
or stiffness associated with chronic limb lameness. Another
reported technique involves joint mobilization or manipu-
lation combined with intra-articular injection of either lo-
cal anesthetic or corticosteroids, which helps to reduce
pain and inflammation associated with osteoarthritis and
to more effectively restore joint mobility.114 Indications
in human beings include recalcitrant joint pain that
865
prevents mobilization or rehabilitation of the affected re-
gion. In horses, one possible indication includes cervical
facet osteoarthritis, where acute pain and inflammation
can be initially controlled with intra-articular facet injec-
tions; however, recurrent stiffness and disability are com-
mon. Intra-articular injections combined with a series of
spinal manipulations, stretching, and strengthening exer-
cises provide the opportunity to increase pain-free cervical
mobility and reduce long-term morbidly or recurrence.
Controlled clinical trails are needed to assess other possible
clinical indications and effectiveness of manipulation com-
bined with intra-articular injections in horses.
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 manipu-
lation has been shown in several studies to be effective for
reducing pain, improving flexibility, reducing muscle tone,
and improving symmetry of spinal kinematics in horses.
Because of potential misuse and safety issues, mobilization
and manipulative therapies should be provided only by spe-
cially-trained veterinarians or licensed human manual ther-
apists. Further research is needed to assess the effectiveness
of specific manual therapy recommendations or combined
treatments for management of back problems and lame-
ness issues. Additional studies are needed to objectively
monitor both short- and long-term clinical effects and im-
provements in performance. Currently, there is no vali-
dated equine model for studying the effects of manual
therapies that would allow characterization of the ana-
tomic, biomechanical, neurophysiologic, pathophysio-
logic, cellular, or biochemical changes associated with
soft tissue and joint mobilization or high-velocity thrusts.
Further understanding of the local and systemic effects of
mobilization and manipulation on pain reduction and tis-
sue healing is also needed. Additional studies are needed
to determine the duration of the clinical effects of manual
therapies and to assess if and how these modalities can en-
hance athletic performance. There is a need of controlled
trials using different forms of spinal manipulation (e.g.,
manual thrusts versus instrument-assisted thrusts versus
manipulation under anesthesia) need to be done to deter-
mine which method is most effective for treating specific
disease processes. New methods of objectively measuring
musculoskeletal dysfunction and further studies into the
pathophysiology of chronic pain syndromes are needed
to help assess the effectiveness of manual therapies on
866
reducing morbidity and improving overall performance in
equine athletes.
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