Integrated manual therapies: IASP taskforce viewpoint

Key points

1. 01Effect sizes for manual therapy range from small to large for pain and function in tension headache, cervicogenic headache, fibromyalgia, low back pain, neck pain, knee pain, and hip pain.
2. 02Mechanisms include both specific biological effects (reduced inflammation, fibrosis, altered biochemical markers) and contextual effects (expectation, therapeutic alliance, patient-clinician communication).
3. 03Minor or moderate adverse events occur in approximately 41% of cases; major adverse events are estimated at 0.13%.
4. 04Modern integrated manual therapy is well-suited to a person-centred, shared decision-making model of care.
5. 05The site of spinal manipulation does not appear to correlate with clinical outcomes, challenging older biomechanical models.

How it was conducted

Design

Narrative clinical update based on expert evidence synthesis, commissioned by the IASP Global Year for Integrative Pain Care task force

Scope

Mechanisms and clinical effectiveness of manual therapies for pain, including animal models, human studies, and condition-specific effectiveness data

Evidence appraisal

Key and recent articles brought by multidisciplinary experts, appraised for quality and relevance, synthesised iteratively and peer-reviewed by other IASP task force members

Conditions covered

Chronic tension headache, cervicogenic headache, fibromyalgia, acute and persistent low back pain, pregnancy-related low back pain, neck pain, knee osteoarthritis, hip osteoarthritis

Comparators

No treatment, active interventions, sham or placebo controls; some three-arm trial data

What they found

• Chronic tension headache: moderate effect size on pain (short and long term) and function (short term), low to moderate evidence.
• Cervicogenic headache: large effect on pain intensity, moderate-to-large effect on frequency (short term); small-to-moderate effect on function (short and long term), low to moderate evidence.
• Fibromyalgia: small to moderate effect on pain (long term) and function (intermediate term), low evidence.
• Acute low back pain: moderate effect on pain and function, low to moderate evidence.
• Persistent low back pain: small effect on pain for short term (massage) and intermediate term (manipulation); small effect on function for both terms, low to moderate evidence.
• Pregnancy-related low back pain: moderate pain effect during pregnancy, small postpartum; moderate function effect during pregnancy, small postpartum, low to moderate evidence.
• Persistent neck pain: small-to-moderate effect on pain (short term), moderate effect on function (short term), low to moderate evidence.
• Knee osteoarthritis: moderate effect on pain (short and intermediate term), small effect on function (short term), low to moderate evidence.
• Hip osteoarthritis: small effect on pain (short term) and function (short and intermediate term), low to moderate evidence.
• A systematic review comparing manipulation applied to candidate vs. non-candidate sites found no significant differences in clinical outcomes between groups.
• Spinal manipulation influenced biochemical markers including cortisol and interleukins immediately after application, but substance-P, neurotensin, oxytocin, orexin-A, testosterone, and epinephrine/norepinephrine were not influenced.
• A meta-analysis found massage therapy effective for musculoskeletal pain mostly when compared to no treatment, and weakly effective compared to other interventions.

Limitations

• This is a narrative review rather than a systematic review, and some literature may have been missed.
• Evidence quality is mostly low to moderate across conditions, limiting the strength of conclusions.
• Design heterogeneity across manual therapy trials makes it difficult to directly compare techniques or isolate mechanisms.
• Findings from animal models are difficult to translate directly to human care settings due to differences in social, cognitive, and contextual factors.

Why it matters

For patients

Manual therapy is a relatively safe option for common pain conditions such as low back pain, neck pain, and headache, with modest to moderate benefits, and is most effective when delivered within a person-centred, shared decision-making approach.

For clinicians

Evidence supports manual therapy as part of an integrative care plan for musculoskeletal conditions, but clinicians should incorporate communication, therapeutic alliance, and psychologically informed practice rather than relying on technique-specific or biomechanical rationales alone.

For readers

This IASP task force update synthesises the current state of the field, highlighting that manual therapy mechanisms are multifactorial and that the profession is evolving toward broader integrative and person-centred models of care.