A critical review of the role of manual therapy in the treatment of individuals

Key points

1. 01Manual therapy is not clearly superior to sham interventions for either acute or chronic low back pain, but is comparable to other recommended treatments.
2. 02The specific technique, vertebral segment selected, or force parameters do not appear to drive outcomes - effects are not technique-specific.
3. 0330-40% of the treatment effect in conservative musculoskeletal interventions is attributable to contextual effects such as patient expectations, therapeutic alliance, and prior beliefs.
4. 04Early referral to guideline-adherent physiotherapy is associated with reduced opioid use, less advanced imaging, and lower healthcare costs.
5. 05Outdated biomedical explanations about spinal realignment persist among clinicians and patients and should be replaced with evidence-based neurophysiological communication.

How it was conducted

Design

Narrative critical review adhering to the Scale for the Assessment of Narrative Review Articles (SANRA)

Scope

Effectiveness of manual therapy, clinical practice guideline recommendations, mechanisms of action, and clinical implications for low back pain

Sources examined

Prior systematic reviews, Cochrane reviews, RCTs, retrospective analyses, cross-sectional studies, and 20 international clinical practice guidelines

Population focus

Adults with acute low back pain (< 6-12 weeks) and chronic low back pain (> 12 weeks)

Manual therapy definition

Generic term encompassing thrust and non-thrust joint mobilizations (manipulation and mobilization)

What they found

• One review found SMT was associated with a pain benefit of -9.95 mm on a 0-100 NRS for acute LBP at six weeks, comparable to NSAIDs (-8.39 mm on 0-100 NRS), but Hancock et al. found neither SMT nor NSAIDs significantly reduced days until recovery compared with sham/placebo within 12 weeks.
• Placebo interventions were more effective than no intervention by approximately 8 points on a 0-100 mm pain scale in the short term, with effects no longer evident in the medium term (Strijkers et al.).
• For chronic LBP, Rubinstein et al. found high-quality evidence that SMT is equally beneficial as other interventions in the short term, and moderate-quality evidence that SMT was as effective as other recommended interventions or sham SMT at 1- and 12-month follow-ups.
• Menke et al. calculated that 96% and 66% of observed improvement in acute and chronic LBP respectively was unrelated to the specific treatment received (56 trials, 1974-2010).
• Saueressig et al. found 30-40% of treatment effect attributable to contextual effects in conservative musculoskeletal interventions; a separate systematic review estimated 39% of treatment effect attributed to contextual effects.
• In 31 of 33 comparisons, there was no significant difference in pain, disability, or perceived stiffness whether SMT was applied to a specifically selected or randomly assigned vertebral segment (Nim et al., 10 studies).
• Early physiotherapy in a RCT of 220 participants with acute LBP yielded a between-group difference of -3.2 on the Oswestry Disability Index (0-100 scale) at three months, which did not reach the minimal clinically important difference, and no difference was observed at one year.
• Small to moderate pain reductions in chronic LBP seen with multidisciplinary biopsychosocial rehabilitation (1.5-2.0 points, NRS 1-10) and exercise therapy (-1.5 points, NRS 1-10).
• Neurophysiological effects of a single spinal mobilization session on pain intensity lasted five minutes or less in most studies, with one exception showing hypoalgesia for 24 hours.
• Guideline adherence among physiotherapists treating musculoskeletal pain showed no significant improvement over three decades: 40% in 1990 versus 35% in 2017.

Limitations

• Narrative review methodology does not follow a strict systematic process, limiting reproducibility and introducing potential selection bias in included studies.
• The review draws on heterogeneous populations and study designs, making direct comparisons of effect sizes difficult.
• Most RCT evidence comes from highly specialized centers with strictly controlled populations, limiting generalizability to real-world clinical settings.
• Classification and risk-stratification tools for identifying patients likely to benefit from manual therapy have shown limited and often non-reproducible results.

Why it matters

For patients

Patients with low back pain can be reassured that manual therapy is a reasonable and safe option when offered alongside exercise and education, but should not expect it to 'realign' the spine - the benefit comes through multiple pathways including the therapeutic relationship and expectations.

For clinicians

Clinicians should offer manual therapy as part of a multimodal biopsychosocial treatment package rather than a stand-alone technique, communicate its mechanisms accurately using neurophysiological rather than biomechanical explanations, and prioritize early guideline-adherent care to reduce downstream healthcare costs.

For readers

This review highlights that the debate over which manual therapy technique to use may be less important than the quality of the clinical encounter, communication style, and alignment with current guidelines - factors that collectively shape treatment outcomes.