“Manual therapy is an effective, evidence-based practice that provides long-term treatment benefits.”

Manual therapy (MT) offers significant short-term benefits in reducing pain and disability in individuals with chronic nonspecific low back pain (CNLBP). Like most interventions for CNLBP, the effects of MT tend to diminish over time. Nevertheless, MT may serve as a valuable treatment option for short-term pain relief and functional improvement.

This systematic review suggests that manual therapy may be associated with short-term improvements. Variability in techniques, professional settings, and study designs precludes firm conclusions regarding long-term effectiveness or superiority of specific approaches.

Compelling evidence demonstrates that MT is not superior to sham MT in musculoskeletal pain (Lavazza et al. 2021; Molina‐Álvarez et al. 2022) but that MT reduces pain intensity in the short term through neurophysiological and non‐specific contextual effects (Bialosky et al. 2009). MT, a non‐pharmacological intervention frequently used by physiotherapists in patients with musculoskeletal pain, appears to work primarily through non‐specific effects—an explanation that has also been proposed by MT proponents.

The most common limitation declared, in almost half of our sample, related to sample size (47.5%) followed by limitations related to study length and follow-up (33.3%) and inadequate controls (32.5%). Our results indicate that at least two different limitations are consistently acknowledged in MT trial reports, the most common being those related to sample size, study length, follow-up, and inadequate controls.

Adding manual therapy to a resistance and stretching exercise program improved long-term shoulder disability, satisfaction, and perceived benefit in patients with subacromial pain.

We identified 11 recommendations for MSK pain care: ... use manual therapy only as an adjunct to other treatments; offer high-quality non-surgical care prior to surgery and try to keep patients at work.

Short-term results (at 7 weeks) have shown that MT speeded recovery compared with GP care and, to a lesser extent, also compared with PT. In the long-term, GP treatment and PT caught up with MT, and differences between the three treatment groups decreased and lost statistical significance at the 13-week and 52-week follow-up.

Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period. The effects were reflected on all outcome measures, both on short and long-term follow-up.

The findings indicate that both exercise therapy and manual therapy provide modest but statistically significant improvements in pain and function compared with minimal or usual care. Exercise therapy demonstrated more consistent long-term benefits for disability and functional outcomes, while manual therapy was primarily associated with short-term pain relief. Overall, the evidence supports exercise therapy as the foundation of management for chronic non-specific low back pain, with manual therapy serving as a useful adjunct for short-term symptom relief.

This evidence-based guideline provides updated recommendations for physical therapist management of hip osteoarthritis, supporting improved clinical decision-making and patient outcomes. The 2025 revision includes new research and refined guidance on: Manual therapy techniques to improve mobility and reduce pain.

For CLBP, there is very-low-quality evidence showing that SMT is not superior to sham interventions such as detuned short-wave diathermy, sham SMT, and detuned ultrasound for pain relief at 1-month, 3-month or 6-month follow-ups. However, Rubinstein et al. found high-quality evidence that SMT is equally beneficial in patients with CLBP in the short-term as other interventions.

For low back, neck and shoulder pain, current high-quality clinical practice guidelines (CPGs) also recommend various manual therapies tailored to the needs and abilities of the individual patient. This tool is designed to increase primary care provider confidence in implementing an evidence-based multimodal program of patient education, exercise and manual therapy for MSK pain.

Overall, there was limited high quality evidence for the effectiveness of manual therapy. The UK evidence report concluded that spinal manipulation/mobilisation was effective in adults for: acute, sub-acute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilisation was effective for several extremity joint conditions; and thoracic manipulation/mobilisation was effective for acute/sub-acute neck pain.

Manual therapy is effective for ankle ROM and self-perceived function (CAIT), although effectiveness remained below the MCID values and certainty of evidence was low. Meta-analysis of ROM, FAAM and CAIT included four, four and five studies, respectively, of which ROM and CAIT were significantly effective compared to comparison groups.

Despite disparate recommendations from Clinical Practice Guidelines (CPG), manual therapy (MT) is as effective as other available treatments and may be offered to patients with low back pain (LBP), especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique.

While manual therapy provides immediate relief, its effects are often short-lived unless combined with other interventions like exercise therapy. Manual therapy doesn't always address the root causes of pain, such as muscle weakness, poor posture, or imbalances, which can lead to recurrence of the condition over time.

Manual therapies are very difficult to properly investigate. Study limitations include inadequate sham treatments, inconsistent/variable treatment styles, techniques and approaches, inability to blind patients and providers and other factors which are difficult to control. The consensus from recent studies, reviews, and metanalyses is that more research is needed, because manual therapies can provide improvement of pain and function in many patients.