CST, developed by osteopathic physician William G. Sutherland in the 1940s, is recognized by the World Health Organization as a form of complementary medicine. ^, CST is based on the theory that there is an inherent rhythmic motion of the brain, spinal cord, cerebrospinal fluid, cranial bones, and dural membranes. It aims to modulate this motion, known as the cranial rhythmic impulse, via gentle palpatory techniques (typically <5 g of pressure) applied between the cranium and sacrum. ^, CST has been theorized to release tissue restrictions and attenuate sympathetic nerve activity, which is often increased in CP patients. ^, By increasing parasympathetic activity, CST aims to enhance the body’s ability to physiologically self-regulate, encourage tissue relaxation, and reduce CP. Interestingly, a randomized control trial (RCT) on CST for fibromyalgia supports this notion, finding CST reduced pain at multiple tender points and improved heart rate variability over 20 weeks, with some benefits persisting at 1 year.

Evidence suggests CST has small to moderate short-term benefits on pain intensity and functional disability, with longer-term effects seemingly plausible as well. A 2019 systemic review of ten RCTs (n = 681) on patients with neck and back pain, migraine, headache, fibromyalgia, epicondylitis, and pelvic girdle pain found CST produced statistically significant improvements persisting up to 6 months postintervention. Condition-specific RCTs on chronic neck and chronic low back pain (cLBP), migraines, and fibromyalgia support these findings as well; however, the evidence is not robust enough to recommend CST for specific pain conditions. ^,,,,,,

No major safety concerns for CST have been reported, with only minor adverse events noted in the literature. ^,, Yet given gentle pressure may be applied to the cranium during CST, caution is warranted in patients with recent head trauma, neurosurgery, or traumatic brain injury as limited safety data is available in these populations. ^,, Overall, CST appears to have a favorable safety profile comparable to other manual therapies and may serve as appropriate adjunctive treatment for select patients with CP who have not responded to conventional therapies. It is important to note that CST is not currently included in major pain management guidelines from leading professional societies, and the quality of supporting evidence remains moderate to low due to methodological heterogeneity and small sample sizes. Thus, CST should not replace evidence-based first-line treatments. ^,

The World Federation of Chiropractic defines a chiropractic as a health professional concerned with the diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health . There is an emphasis on manual treatments such as spinal manipulative therapy (SMT), which involves mobilization (a low velocity, variable amplitude, passive movement within a patient’s range of motion) or manipulation (a high velocity, short amplitude force to a synovial joint near the end of passive of physiologic range of motion). ^, SMT is often used in combination with complementary modalities including cryotherapy, thermotherapy, massage, electrotherapy, orthotics, exercise programs, nutritional advice, lifestyle modifications, and patient education in their practice. The theory behind chiropractic interventions is complex, with five proposed mechanisms for manipulation cited in the literature. ^,

Chiropractic care using SMT has been extensively studied for the treatment of CP, particularly for cLBP. ^, A systematic review and meta-analysis of 47 RCTs (n = 9211) found SMT as effective as standard-of-care treatments (ie, physical therapy, exercise therapy, medical care) for cLBP. While a 2011 Cochrane review concluded that combined chiropractic interventions provided some short-term improvements in low back pain and disability, there was no evidence of superiority over other treatments. Similarly, the American Academy of Pain Medicine (AAPM) clinical guidelines note that SMT may lead to statistically significant—but not necessarily clinically meaningful—improvements in function, with pain outcomes comparable to those of sham or other interventions. ^,,

Chiropractic care can be a valuable alternative for patients who are not receptive to or do not engage well with physical therapy as it is generally considered safe and noninferior to physical therapy or medical care for cLBP, with low risk of adverse events. There is insufficient evidence to recommend a specific optimal dosage , but research suggests diminishing returns beyond 12 sessions. The most common minor adverse events are transient headache or local discomfort related to manual techniques. Serious adverse events, such as vertebral artery dissection are rare, with estimates ranging from 1 per 100,000 to 1 per several million manipulations. High-velocity, low-amplitude manipulations to the cervical spine are thought to be responsible for these rare instances of mechanical trauma to vascular structures. SMT is contraindicated in conditions with significant compromise to biomechanical, neurologic, or vascular integrity; for example, active spinal malignancy, severe osteoporosis, or severe or progressive neurologic deficits, though some lower-force techniques may still be considered safe in select cases. ^,,,,

Massage therapy (MT) uses a diversity of manual techniques and styles to treat chronic musculoskeletal pain. Effleurage, petrissage, friction, and tapotement are classic massage techniques frequently incorporated into manual therapy protocols for chronic musculoskeletal pain. Effleurage involves long, gliding strokes used to promote relaxation, increase superficial circulation, and prepare tissues for deeper work. Petrissage consists of kneading, rolling, and lifting of the soft tissues to mobilize muscle and fascia, enhance local circulation, and reduce muscle tension. Friction uses deep, circular, or transverse movements over local areas, often targeting adhesions or myofascial trigger points; it is intended to break down scar tissue and improve tissue extensibility. Tapotement (percussion) includes rhythmic tapping motions, thought to stimulate tissues, increase local blood flow, and facilitating healing.

While no particular technique is favored, the AAPM, American College of Physicians (ACP), and US Centers for Disease Control and Prevention (CDC) guidelines support massage as part of a multimodal treatment approach for cLBP. ^,, A 2022 NEJM review concluded massage provides small, short-term improvements in pain and function compared to controls, but the certainty of the evidence is low to very low, and these benefits tend to diminish over time. ^,

Likewise, the Veterans Health Administration (VHA) developed an evidence map of MT for pain to guide healthcare policy decisions. An updated map, published in JAMA , synthesized 41 systematic reviews from 2018 to 2023 on MT for painful health conditions in adults. It reinforced that low-certainty evidence predominates; but notably, moderate-certainty evidence was observed for two common conditions: cLBP and myofascial pain.

In summary, MT is a guideline recommended adjunct option for CP management, especially for cLBP, with small short-term benefits and a favorable safety profile. Massage is best integrated into a comprehensive, patient-centered, multimodal treatment plan.

The AT was established by Frederick Matthias Alexander in the late 1890s as a form of movement education that emphasizes changing one’s habits and awareness of movement patterns for better coordination and efficiency. This practice does not integrate any forms of exercise or movement therapy but rather focuses on self-analysis to release unnecessary forms of stress or discomfort. The technique originated as a form of management for Alexander’s recurrent laryngitis. At the time, there were no treatments that provided any significant relief for his symptoms which had limited his ability to speak in public settings. He realized that by being more consciously aware of his movements and sensory inputs while he spoke, he released tension in his body that made him more relaxed and symptom free while he spoke. Alexander also believed by being more aware of one’s posture, the spine would naturally lengthen which maximized the comfort of an individual, and when an individual forced themself to conform to an unnatural posture it would increase stress and tension.

The practice of teaching AT involves a one-to-one lesson between an instructor and patient, at which the instructor identifies points of unnecessary stress and tension that can be focused on by the student through technique stages of the following: the means-whereby (conscious awareness in action) and nonendgaining (process over product), inhibition (nondoing, noninterference), and direction (carrying out clear intention to move) . The technique can target several conditions including CP, chronic fatigue syndrome, and various disorders associated in an individual’s unique occupation.

AT is effective for reducing pain and disability associated with chronic neck and cLBP, with sustained benefits lasting at least 12 months in well-conducted RCTs. For cLBP, a large factorial RCT found that 24 individual AT lessons produced significant and clinically meaningful improvements in Roland-Morris Disability Questionnaire scores and reductions in days with pain at 1-year follow-up, compared to usual care. Notably, even just six AT lessons combined with an exercise prescription achieved nearly equivalent benefit to the full course of 24 lessons. These findings are also reinforced by systematic reviews, which conclude that the AT is supported by strong evidence for effectiveness in managing cLBP. ^, For chronic neck pain, a large RCT demonstrated that 20 1-on-1 AT lessons resulted in significant reductions in pain and disability at 12 months, as measured by a 31% improvement in Northwick Park Neck Pain Questionnaire scores and improved self-efficacy, compared to usual care. The evidence on AT for chronic neck pain is supportive but less robust than the research supporting cLBP.

While AT is considered an effective treatment option for chronic neck and cLBP, economic analyses suggest that AT is less cost-effective than exercise or acupuncture. A full course, such as the 20 to 24 lessons used in key clinical trials, may cost $1000 to 2400 per patient. Group formats may offer a more affordable option, with preliminary evidence of preserved clinical benefit. No serious harms have been reported in clinical trials, and the intervention is generally well tolerated. ^,,,,