The proportion of adults considered aging or older is anticipated to triple in the next few decades. Musculoskeletal disorders are among the most common problems affecting the aging and older adult population, with a substantial impact on function, disability, and health. With increases in prevalence, the burden of cost for management of musculoskeletal disorders also climbs sharply and is associated with utilization of imaging, medications, surgery, inpatient expenditures, and outpatient rehabilitation. It is important to note that many of the musculoskeletal disorders affecting the aging and older population are progressive in nature and most interventions, including surgery, fit more within the realm of palliative care more so than restorative. Treatment by a physical therapist can have profound impact on improving overall function, mobility, pain, and quality of life for patients with these prevalent musculoskeletal complaints.

In this issue, a group of physical therapists, educators, and clinical researchers examine the evidence of manual therapy for aging and older adults. We start with articles on the neurophysiological effects of manual therapy and its effects on aging and older adults with neurological disease. Next, evidence has been synthesized and organized by joint/region, and we present our findings on the thoracic spine, lumbar spine, knee, ankle and foot, shoulder, and elbow. Available as published ahead-of-print and in a future issue of Topics in Geriatric Rehabilitation, we present our findings on the cervical spine and hip joint ("Cervical Spine Manual Therapy for Aging and Older Adults" and "Hip Manual Therapy for Aging and Older Adults"). Our group of authors asserts that manual therapy is underutilized for aging and older adults, based on a review of contemporary literature, their clinical experience, and exploration of patient values. This may be partially due to perceived frailty, lack of expectation of response, or lack of proficiency with manual therapy techniques.

What follows is a summary of the recurring themes from all of the literature summarized across body regions:

* Few studies on the effectiveness of manual therapy are specific to older adults, but many include aging and older adults.

* There is limited high-quality evidence in favor of manual therapy, especially for aging and older adults.

* Although few studies have demonstrated the superiority of manual therapy over comparison groups, there is growing evidence that manual therapy alone, and especially when combined with therapeutic exercise, improves short- and long-term outcomes in aging and older adults.

* The most commonly reported benefits of manual therapy include improvements in pain, mobility, function, and disability. Additional and less frequently reported benefits of manual therapy include improvements in quality of life, higher levels of patient satisfaction, and positive global ratings of change.

* When applying appropriate inclusion and exclusion criteria (including ongoing clinical decision making), manual therapy caused very few adverse events and those that were reported were benign and transient in nature. Therefore, applying manual therapy techniques in the aging and older population is safe and should be utilized more often in the clinical setting.

* The heterogeneity of the manual therapy and control groups, outcome measures, and research designs prevented pooling of data from multiple studies for meta-analysis and therefore most systematic reviews are presented in narrative form.

* Ongoing high quality randomized controlled trials using consistent outcome measures are necessary to further refine the effectiveness of manual therapy and its optimal delivery parameters.

* When using multimodal interventions, the use of factorial designs will help clarify the relative contribution of manual therapy to outcomes of interest.

The articles in this special issue represent the perspective of some of the leaders in the field based on a combination of the best available evidence and their clinical experience. The decision to utilize manual therapy in an aging and older adult population should be considered on a case-by-case basis, weighing risk and benefits based on individual patient factors. The authors included in this issue ascertain that when a patient is appropriately screened, manual therapy is an underutilized and safe intervention that may improve patient-centered outcomes and potentially expedite the rehabilitation episode.

We hope this special issue on manual therapy in the aging and older adult population will provide clinicians with new information and new ideas on how to best treat their patients. We fully appreciate that for these patient presentations, we collectively as a physical therapy community must strive to improve the available scientific literature investigating the utility and safety of manual therapy for aging and older adults, while also improving consistency in care with utilization of safe evidence-based techniques.

-Kevin K. Chui, PT, DPT, PhD, GCS, OCS,

FAAOMPT

Sacred Heart University

Fairfield, Connecticut

Thomas R. Denninger, PT, DPT, OCS, FAAOMPT

Proaxis Therapy - Spine Center

Greenville, South Carolina

Cameron W. MacDonald, PT, DPT, GCS, OCS,

FAAOMPT

Beinn Sonas Physical Therapy Services, Elbert, Colorado

Regis University Manual Therapy Fellowship Program,

Denver, Colorado

Sheng-Che Yen, PT, PhD

Northeastern University

Boston, Massachusetts