Manual Therapy and Pain Management

What Is Manual Therapy?

Manual therapy is an evidence-based assessment and treatment approach applied by the physiotherapist’s hands, addressing pain and movement restrictions. It encompasses methods such as joint mobilisation, joint manipulation, soft tissue techniques and neural mobilisation.

When Is It Applied?

Manual therapy is particularly effective for mechanically based musculoskeletal complaints. The conditions for which it is commonly applied in my practice include:

• Low back pain: Mechanical low back pain, lumbar disc problems including disc herniation, facet joint–related pain, sacroiliac joint dysfunction
• Neck and upper back pain: Cervical disc problems including disc herniation, neck stiffness, posture-related upper back pain
• Shoulder complaints: Frozen shoulder, impingement syndrome, rotator cuff–related problems
• Other joint pain: Mechanical complaints involving the knee, hip, ankle, elbow (including tennis/golfer’s elbow — epicondylitis) and wrist
• Headaches and temporomandibular joint complaints: Cervicogenic headache, tension-type headache, pain and movement restrictions related to the temporomandibular joint (TMJ)
• Nerve entrapment–related complaints: Neural mobilisation approaches for conditions such as carpal tunnel syndrome
• Foot-related complaints: Plantar fasciitis (heel spur), Achilles tendon–related complaints
• Office worker–related musculoskeletal issues: Neck, shoulder, upper back and lower back complaints associated with prolonged desk-based work

The choice of techniques is made following each patient’s assessment; treatment is not a standard protocol but is shaped to suit the individual.

What Does a Session Look Like?

A manual therapy session typically begins with a review of the patient’s current symptoms. Manual techniques planned according to the assessment findings are then applied. In the second half of the session, we work through exercises tailored to the patient’s needs to gain as much benefit as possible from the work done that day. Where appropriate, exercises to be performed between sessions are provided as a home programme. In certain cases, complementary applications such as compression therapy, percussive massage or instrument-assisted soft tissue mobilisation (IASTM) are also incorporated into the session plan.

Treatment Process and Session Frequency

The duration of treatment varies depending on each patient’s condition and clinical presentation; a realistic estimated range is provided after the initial assessment. In most cases, symptoms begin to ease gradually from the first session. A noticeable improvement is generally observed within 3–5 sessions, and a 10-session course of treatment is often sufficient for many patients. Orthopaedic rehabilitation cases naturally tend to take longer. Sessions are typically scheduled twice per week, with adjustments made according to the clinical picture.

When Is Manual Therapy Not Suitable?

Because manual therapy covers a broad range of techniques, it can usually be adapted to most patients in different ways. However, in some clinical situations — particularly for manipulation techniques — these methods are not applied, or are deemed unsuitable following assessment. The main conditions identified in the scientific literature as absolute contraindications to manipulation include:

• Conditions that weaken the bone (tumour, metastasis, infection, fracture, severe osteoporosis)
• Progressive neurological deficit, spinal cord or significant nerve root compression
• Active rheumatological conditions (such as a rheumatoid arthritis or ankylosing spondylitis flare-up)
• Vertebrobasilar insufficiency or suspected vascular pathology in the cervical region

For this reason, every patient’s first session begins with a thorough assessment. When clinical findings indicate a red flag, the patient is referred to an appropriate medical practitioner. Even in cases where manual therapy is not suitable, a way forward involving soft tissue work, patient education and an appropriate exercise programme can often be found.

Once symptoms have decreased substantially towards the end of treatment, continuing the process with therapeutic exercise or clinical pilates is generally recommended to support the durability of the gains achieved and reduce the likelihood of symptom recurrence.

Note: For postoperative, post-traumatic or longer-term chronic cases, please refer to the orthopaedic rehabilitation page.