What Most Therapists get Wrong About Manual Therapy

Mobilisation of the spine

Now, I’m not, by default, against the use of manual therapy (MT). However, MT is almost always done with the wrong patient narrative (“fixing” the body), the wrong mindset (operator, not interactor), and for the wrong reason (practitioner-centered and not patient-centered), and typically only supported by an outdated model (biomechanical), dubious clinical anecdotes and traditionalist beliefs.

Sadly, manual therapist experts are often seen doing showmanship patient demonstrations, all within a “fixer” mindset (also coined Healer Syndrome, read more here), and still use the outdated ‘operator’ treatment model. This operator mindset implies that the patient is viewed as a passive recipient in the therapeutic encounter. The therapists do not consider themselves an “interactor” (Jacobs et al. 2011) who is interacting with another human being.

When MT is used in the above way, it’s not supported by the current manual therapy models and pain research or what we presently know about how the body works. 

Current models of manual therapy (Bialosky et al. 2009 and Bialosky et al. 2017) seem to be aligned with pain research in general and particularly with neuroscience. The models accept that we, as therapists, actually can’t have any direct physical impact on somebody else’s tissues. As noted by Diane Jacobs in her article on manual therapy models, read it here.

We now know that the supposed effect of manual therapy is not, as previously assumed, only interfered by bottom-up-mediated factors but to a large part, also by top-down-mediated factors like a person’s expectations.

“Traditionally, manual therapy interventions are thought to be dependent upon bottom-up-mediated factors like stimulus intensity, but in recent years greater attention has been drawn to top-down-mediated factors like the patient’s expectations” Puentedura et al. 2016

The prerequisite for the use of manual therapy is that it is used in alignment with current research. It’s not about “fixing” anything (we can’t); the person in front of us is viewed as an autonomous being who has their own expectations and belief systems. It is about interacting with another human being who has an active role in the therapeutic encounter. 

Our use of any intervention should always lead to increases in empowerment while preserving bodily integrity and autonomy. Our choice of intervention, including manual therapy, should be based on the person’s representation, goals, and needs, all within a patient-centered framework. 

To have another human being leave believing that they have been “fixed” by us is not only wrong, but it’s also a travesty of humanity.


Thanks to Diane Jacobs and Brendan Mouatt for the inspiration to write this short article.



Jacobs DF, Silvernail JL. Therapist as operator or interactor? Moving beyond the technique. J Man Manip Ther. 2011 May;19(2):120-1. 

Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018 Jan;48(1):8-18. Epub 2017 Oct 15.

Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):531-8. 

Puentedura EJ, Flynn T. Combining manual therapy with pain neuroscience education in the treatment of chronic low back pain: A narrative review of the literature. Physiother Theory Pract. 2016 Jul;32(5):408-14.