Manual Therapy in Physiotherapy: Want, Need, and What’s Supported

Manual therapy can help some people feel better in the short term. It is not a requirement for recovery, and it is rarely the thing that creates lasting change. It’s a want, not a need.

This might challenge what you’ve heard, so I’ll explain my stance on this area.

What do we mean by manual therapy?

Manual therapy is a broad label for hands‑on treatments where a therapist uses their hands and sometimes tools to apply physical techniques aimed at reducing pain or temporarily improving movement. This includes things like mobilisation, manipulation, massage, acupuncture, cupping, or scraping techniques.

There are plenty of confident claims about what these treatments do. I have more questions than answers about most of them.

Why I started questioning manual therapy

Like many physiotherapists, I was initially fascinated by hands‑on techniques. At university and early in practice, I wanted to learn everything: manipulation, mobilisation, soft‑tissue work, acupuncture, cupping, the lot.

The promise was that if I developed skilled enough hands, I could feel what was “wrong”, correct it, reduce pain, restore movement, and fix the problem.

Looking back, that story relied on two big assumptions:

• That human bodies behave like predictable machines

• That the profession already has clear answers for pain and injury

  
  

Neither assumption holds up very well.

How precise can we be when feeling structures?

One of the first cracks appeared when I noticed how confidently we’re taught to detect tiny differences by hand:

• This joint moves less than the one next to it

• This vertebra is stiffer on one side

• This muscle feels tighter than it should

Before physiotherapy, I worked as a carpenter and studied sport and exercise science, fields where measurement error is openly acknowledged and controlled for.

So a simple question kept bothering me:

If five clinicians assess the same spine, are they really detecting the same thing or comparing what they feel to their own internal reference?

Research suggests agreement between clinicians is often poor. That doesn’t mean clinicians are unskilled. It means the human hand is a blunt measurement tool, and our expectations and biases can quietly influence what we think we feel.

Once you accept that, many confident mechanical explanations become harder to defend.

What manual therapy is commonly claimed to do

Manual therapy is often explained using mechanical language:

• Joints are “out of place”

• Muscles are “tight” or “switched off”

• Fascia is “stuck”

• Hands‑on techniques “release”, “realign”, or “correct” these problems

These explanations are appealing because they’re simple. If pain is mechanical, a mechanical fix makes sense.

If the main effects we observe are short-term symptom changes without clear physiological mechanisms, why are we still making precise mechanical claims at all?

What does the evidence actually show?

When manual therapy is tested, pain can improve in the short term, usually with small to moderate effects. When it’s compared directly with exercise, outcomes are broadly similar. Adding manual therapy to a well‑designed exercise programme rarely produces meaningful extra benefit.

The same pattern shows up with movement. Manual therapy can create modest, short‑term improvements in range of motion, often immediately after treatment. But these changes usually fade over hours or days unless they’re followed by ongoing movement and loading.

Crucially, these improvements happen without clear evidence of lasting structural change. Similar effects are seen with exercise, stretching, and even sham treatments.

So the obvious question becomes:

If rehab is about creating lasting change, can that really come from passive, hands‑on treatment alone?

What manual therapy does not appear to do

If manual therapy truly repositioned joints, lengthened tissues, or corrected alignment in a lasting way, we would expect to see this on scans, biomechanical testing, or long‑term follow‑up.

When researchers look for these changes, they generally don’t find them. Any mechanical effects appear small, short‑lived, or absent altogether.

That doesn’t mean people aren’t experiencing real improvement.

It means the explanation likely lies somewhere else.

So why does it still help some people?

This to me is the most interesting question.

Current models suggest manual therapy works largely by influencing pain perception rather than tissue structure. Things like expectation, reassurance, touch, context, and belief all matter.

If someone expects relief, pain can genuinely reduce. The brain has its own pain‑dampening systems, and hands‑on treatment can help switch those on.

These effects are real. They’re just often misunderstood.

When we drop the structural claims it doesn’t lose the effect, it’s more of an honest representation.

Context matters - and it cuts both ways

Human touch can be reassuring. Feeling listened to and cared for can improve confidence and engagement with rehab.

But the context of manual therapy can have a negative impact.

If someone is told they need hands‑on treatment to stay aligned, released, or pain‑free, the locus of control quietly shifts away from them and towards the clinician.

The story becomes:

“Something has gone out again and I need fixing.”

That belief encourages dependence and fragility. Ironically, if manual therapy truly corrected structure, ongoing maintenance wouldn’t be required.

The real problem with overhyping manual therapy

The issue isn’t that manual therapy does nothing.

It’s that:

• Effects are oversold

• Mechanisms are misrepresented

• Structural explanations increase fear

• Passive care is prioritised over building capacity

When people are told they need hands‑on treatment to improve, confidence in movement often drops.

That’s the opposite of rehabilitation.

Is there still a place for manual therapy?

Possibly.

Short‑term symptom relief can help some people re‑engage with movement, especially when pain or fear is high. In that sense, manual therapy can act as a bridge but not a solution.

The key issue isn’t whether it’s used. It’s how it’s explained, and how much importance it’s given compared to building strength, confidence, and capacity.

How I use manual therapy

If I use manual therapy, honesty matters.

I frame it like this:

• “This may help calm symptoms in the short term.”

• “The real change comes from what you do afterwards.”

• “This isn’t fixing structure, it’s creating an opportunity to load and move more confidently.”

That framing preserves autonomy rather than taking it away.

Final thoughts

The most useful questions aren’t whether manual therapy helps some people.

They’re:

• Why does it help?

• For how long?

• And what happens next?

Physiotherapy works best when we’re honest about what we know, open about what we don’t, and willing to update our explanations as evidence evolves.

Manual therapy can be useful.

But it’s a want - not a need.

And the real power in rehab isn’t in a therapist’s hands, it’s in yours.