A critical review of the role of manual therapy in the treatment of individuals with low back pain

ABSTRACT

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients’ expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients’ beliefs, addressing illness behaviors, and seeking to understand each patient’s journey.

Background

In 2020, the Global Burden of Disease study estimated that there were over half a billion cases of low back pain (LBP) worldwide, expected to reach over 800 million by 2050 [1]. Despite the escalating healthcare costs, associated with a rise in spinal fusion surgeries, facet joint injections, opioid prescriptions, and increasingly advanced diagnostic imaging studies [2–4] the burden of LBP remains substantial [5]. Considering the harms caused by the opioid epidemic [6–8] and the limited efficacy of other pharmacological treatment options [9], current clinical practice guidelines (CPG) focus on non-pharmacological interventions [10]. Despite an abundance of clinical research comprising over sixty years and 15,000 patients, high-quality evidence on analgesic medicines for patients with acute LBP to guide clinicians remains scarce [11]. Medication is considered a second line treatment, emphasizing the need for effective non-pharmacological interventions to reduce the disability in patients with LBP [12].

In addition to exercise, education, and advice for self-management, manual therapy (MT) may be valuable for these patients [13]. Although there is no uniformly used definition of MT in research or clinical practice [14], it is usually defined as a passive or mechanical [15] intervention manually applied to patients in the form of manipulation, mobilization, or massage [16]. At times, MT is perceived as also incorporating therapeutic exercises within a biopsychosocial framework [17]. In this review, we define MT as a generic term encompassing thrust- and non-thrust joint mobilizations [18,19].

Many CPG recommend that MT ‘may be offered’ as an intervention in patients with acute (ALBP) or chronic LBP (CLBP), either as a stand-alone intervention or adjunct to exercise therapy [20–25]. However, the recommendations for spinal manipulative therapy (SMT) are inconsistent compared to the strongly recommended exercise and education, where the majority of the variation is explained by the acuity of LBP (see Table 1). From the 20 CPG illustrated in Table 1, one strongly recommends (‘should use’) thrust- and non-thrust joint mobilization in patients with ALBP and CLBP [26], five do not mention SMT, and two recommend against SMT (one in patients with acute, one in patients with CLBP) [27,28]. Wiles et al. conducted a modified Delphi process to establish what constitutes appropriate care for LBP by appraising recommendations from CPG. They suggested that a short course of MT may be offered as an adjunct intervention to patients with ALBP who do not improve with self-managed care within 2–4 weeks, but did not mention MT for CLBP [29].

Table 1.

Overview of clinical practice guidelines recommendations for manual therapy, education, and exercise in patients with low back pain.

Clinical Practice Guideline (CPG)	Manual therapy Thrust-, and non-thrust joint-mobilization	Education Diagnosis, self-management, goal setting, reassurance	Exercise Combined with education and cognitive therapeutic elements
Academy of Orthopedic Physical Therapy, APTA CPG (2021)[26]	Strongly recommended (‘should use’)	May be offered in ALBP	May be offered in ALBP
		Strongly recommended in CLBP	Strongly recommended in CLBP
African CPG for acute LBP (2015)[28]	Recommended against	Not mentioned	Strongly recommended
American College of Physicians CPG (2017)[30]	Strongly recommended	Strongly recommended	Not mentioned in ALBP
			Strongly recommended in chronic LBP
Australian Clinical Care Standard (2022)[31]	Not mentioned	Strongly recommended	Strongly recommended
Austrian CPG (2018) [21]	May be offered	Strongly recommended	Strongly recommended
Belgian CPG (2017)[32]	May be offered*	Strongly recommended	Strongly recommended
Brazilian CPG for chronicLBP (2012)[33]	Not mentioned	Not mentioned	Strongly recommended
Canadian CPG (2015)[34]	May be offered, for patients who do not improve with ALBP	Strongly recommended	Not mentioned in ALBP
	Not mentioned in CLBP		Strongly recommended in chronic LBP
Denmark CPG for acute LBP (2018)[35]	May be offered*	Weakly recommended	Weakly recommended
Finland CPG (2011)[36]	Not mentioned	Strongly recommended	Not mentioned in ALBP
			Strongly recommended in chronic LBP
German CPG (2017) [37]	May be offered	Strongly recommended	Strongly recommended
Malaysia CPG (2012)[27]	May be offered*	Strongly recommended	Not mentioned in ALBP
			Strongly recommended in chronic LBP
Mexico CPG (2011)[38]	Not mentioned	Not mentioned	Not mentioned in ALBP
			Strongly recommended in CLBP
Netherlands CPG (2010)[27]	Recommended in ALBP	Strongly recommended	Strongly recommended
	Recommended against in CLBP
NICE UK CPG Update (2020)[22]	May be offered*	Strongly recommended	Strongly recommended
NASS USA CPG (2020)[24]	May be offered	Strongly recommended	Strongly recommended
Philippine CPG (2017)[27]	May be offered	Strongly recommended	May be offered in ALBP
			Strongly recommended in chronic LBP
Spain CPG (2012)[27]	Not mentioned	Strongly recommended	Not mentioned in ALBP
			Strongly recommended in chronic LBP
VA/DoD USA CPG (2022)[39]	Not recommended in ALBP	Strongly recommended	Strongly recommended
	Weakly recommended in CLBP
WHO CPG for chronic LBP (2023)[40]	May be offered*	May be offered	May be offered

Note *manual therapy is recommended in combination with exercise therapy and education (or as part of a multimodal program).

**specifically spinal manipulative therapy.

ALBP, acute Low Back Pain; CLBP, chronic Low Back Pain; CPG, Clinical Practice Guideline; ACP, American College of Physicians; NASS, North American Spine Society; NICE, National Institute for Health and Care Excellence; APTA, American Physical Therapy Association; VA/DoD, Department of Veterans Affairs/Department of Defense; WHO, World Health Organization.

Overview adapted from Oliveira 2018, while the Austrian CPG, North American Spine Society CPG, Physical Therapy (APTA) guideline, the CPG from the Department of Defense from 2022, the Australian Clinical Care Standard, and the WHO guideline for non-surgical management for chronic LBP in adults from 2023 were added to this table.

If there is no distinction made between acute and chronic LBP, the recommendation applies to LBP of any duration.

In general, CPG recommendations show consistent alignment for various interventions in this patient population, but inconsistencies remain, particularly for MT, and some other aspects of care despite analyzing the same scientific literature [10,41]. For instance, there is little consensus on what psychosocial factors [42], or ‘red flags’ [43], that patients should be screened for and whether opioids should be prescribed for CLBP [41].

For patients with LBP, accurate communication of the mechanisms of pain alleviation by MT is important [44]. Physiotherapists with predominantly biomedical orientations often recommend delayed return to work and restricted physical activity for patients with LBP [45]. Alarmingly, these outdated structure-oriented beliefs persist and prevail among both clinicians [46–48] and patients [49]. Although MT is safer than opioids for patients with LBP, this alone is insufficient [50,51]. The outdated biomedical and structure-oriented approach to MT can still be detrimental to patients, and merely surpassing the harm threshold set by opioids is a minimal standard [52].

Thus, this narrative review aimed to critically summarize the available evidence underlying the disparate recommendations of the LBP guidelines for MT. Furthermore, we explored the evidence on the mechanisms of action of MT for patients with LBP. We propose several steps on how an accurate understanding and communication of these mechanisms, which may directly or indirectly shape treatment outcomes, can be integrated into a person-centered approach.

This review adhered to the guidelines of the Scale for the Assessment of Narrative Review Articles [53]. We searched the existing literature by examining prior reviews, editorials, RCTs, retrospective analyses, and cross-sectional studies. Although our approach may not adhere to a strict systematic process, we ensured a thorough exploration and critical appraisal of the available research. Detailed methodological considerations can be found in the supplementary files.

Prognosis for low back pain

Cumulative evidence suggests that 60–70 % of ALBP (<6–12 weeks) resolves within six weeks without treatment and 90 % within one year, whereas 40–70 % of CLBP (>12 weeks) resolves per year without treatment. This can be considered the natural history of the disease, regardless of what intervention actually occurs [54,55]. Contrary to the assumption of spontaneous recovery in most cases of LBP, evidence on the clinical course of LBP in primary care suggests that, after one year of onset, 65% of patients with ALBP report persistent pain [56]. Systematically reviewing eight studies, Lemeunier et al. found that among those with initial LBP, a significant proportion (38% to 88%) still experienced pain in follow-up assessments [57]. In the latest systematic review of acute, subacute, and CLBP, the authors observed a favorable course with substantial pain and disability reduction in the initial six weeks for ALBP. However, recovery slowed thereafter. For subacute and CLBP, improvements in pain and disability were minor and less favorable over time. Thus, confirming that despite a favorable initial prognosis, many patients continue to experience persisting pain and disability [58].

Numerous methodological challenges complicate the exploration and comprehension of the persistence, recovery, and recurrence rate of LBP. This includes difficulties in distinguishing fluctuating pain from recurrences. Existing studies lack robust data on the recurrence rate of LBP in affected individuals. Da Silva et al. propose a 1-year recurrence rate of 33% as the most reliable estimate [60]. In addition, there is considerable variation in the methods employed to measure recovery from LBP. Kamper et al. identified 66 distinct recovery measurement approaches, with only seven used in more than one study [61]. Considering this, research indicates that many individuals with LBP experience persistent or recurrent symptoms, but cease seeking medical care. In a prospective cohort study by Croft et al., including patients who consulted their GP about LBP at least once within a 12-month period 90% did not return for medical attention, yet only 25% had fully recovered after one year [62]. A timely assessment within the first three months after an episode of LBP to identify patients with slow recovery who would benefit from additional treatment is recommended [56–59]. Subsequently [63], effective, and low-risk treatments for affected individuals are needed.

Evidence for manual therapy in treating low back pain

The United Kingdom evidence report on MT for musculoskeletal and non-musculoskeletal conditions analyzed 178 relevant studies and found inconclusive evidence regarding whether MT for LBP was more effective than other treatments, placebo, or no treatment [64]. A Cochrane review identified 20 trials investigating SMT with few studies on spinal non-thrust joint mobilization techniques. Overall, the authors found low- to very-low-quality evidence that SMT had comparable pain reduction or improved function in ALBP compared with sham interventions, sham SMT, or when added to other interventions [65]. Other systematic reviews confirmed these results. Lavazza et al. analyzed 24 trials comparing SMT with sham SMT; in 19 the sham intervention involved hand contact in the area of pain by the treating clinician, while in 5, patients received manipulations in non-pain spinal regions. Although most studies have shown statistically significant results in favor of SMT, the small effects are of questionable clinical relevance. In three studies comparing SMT with no intervention, two found no difference in pain intensity, whereas one study found that patients in the no-intervention group performed significantly better [66]. Similarly, Alvarez-Molina et al. could not demonstrate the superiority of MT over sham interventions [67]. However, comparable findings have been obtained for a variety of primary care treatments [68] and pharmacological options [69–71] alongside usual care.

For ALBP, Hancock et al. compared spinal versus sham manipulations and diclofenac versus placebo, in addition to usual care (advice to stay active and paracetamol prescription). Neither intervention significantly reduced the days until recovery compared with the placebo/sham treatment within the twelve-week follow-up period [72]. Only one review concluded that SMT for ALBP was associated with a significant benefit in in terms of pain and function at six weeks follow-up. The size of the benefit for the patients receiving SMT was −9.95 mm (0–100 numeric rating scale, (NRS)), comparable to the effect of non-steroidal-anti-rheumatic drugs (NSAIDs) for ALBP (−8.39 mm 0–100 NRS) [73]. However, as Hancock et al. showed that neither SMT nor NSAIDs significantly altered the course of recovery in patients with ALBP [72]. While the observed benefit was −9.95 mm on 0–100 NRS [73], Strijkers et al. found that in general, placebo interventions in general were more effective than no interventions by approximately 8 points on a 0–100 mm pain scale. In the medium term, these effects were no longer evident [74]. Thus, the observed benefit after SMT could also reflect the natural history of LBP, contextual effects, and shared mechanisms. Systematic reviews have indicated a similar improvement in pain intensity over time in both RCTs and observational studies involving patients with LBP seeking medical advice, irrespective of the study design and the type of intervention received, thereby supporting this argument [68,75].

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 [76]. The authors recently confirmed most of their previously drawn conclusions and found moderate-quality evidence that SMT was as effective as other recommended interventions or sham SMT in patients with CLBP at 1- and 12-month follow ups [77]. Patients with CLBP typically experience stable pain trajectories with limited improvement over time, as suggested by prognostic studies [58]. Small to moderate pain reductions in this population, seen in interventions like multidisciplinary biopsychosocial rehabilitation (1.5–2.0 points, NRS 1–10) [78] or exercise therapy (−1.5 points, 1–10 NRS) [79], reinforce this pattern.

All these results were from randomized controlled trials (RCTs) primarily conducted in highly specialized centers in strictly controlled populations. However, these trials cannot inform us about the real-world effectiveness of MT, where populations and degrees of specialization vary significantly [81]. While efficacy trials are necessary to examine potential interventions in evidence-based medicine, the next step would be to examine the intervention’s effectiveness, followed by cost-efficiency analyses where MT could be compared to other available interventions of similar effectiveness [82,83].

Cost-effectiveness and early contact with physiotherapy in patients with low back pain

MT is seldom administered in isolation; but is typically integrated into a comprehensive treatment package including exercise and education. Promising data suggest that early exposure or referral to guideline-adherent physiotherapy for patients with ALBP may enhance outcomes and is cost effective. Frogner et al. showed that patients who initially or subsequently consulted a physiotherapist for LBP had an 89% reduced likelihood of being prescribed opioids and a 28% lower probability of undergoing advanced diagnostic imaging [84]. A retrospective review of claims data confirmed and extended these findings; patients who began LBP treatment with a physical therapist or chiropractor, instead of a primary care practitioner experienced reduced risks of undergoing imaging, spinal injections, surgery, and lower costs [85]. These results were confirmed in another analysis of insurance claims data from 2015 to 2018, which included nearly 30,000 patients [86].

Nevertheless, while early referral to physiotherapy or initial presentation to physiotherapists may offer benefits for patients with LBP, this is not a one-size-fits-all solution. The most supportive data are retrospective analyses, often lacking clinical information and subject to uncontrolled differences between patients who chose different providers, making it challenging to match cohorts. These limitations are underscored by less encouraging prospective data.

Fritz et al. conducted a RCT involving 220 participants with ALBP, assigning them to receive either early PT (four sessions of SMT and exercise) or usual care alongside education that emphasized a favorable prognosis. Early physiotherapy yielded a modest improvement after three months, with a between-group difference of −3.2 on the Oswestry-Disability-Index (0–100 scale). However, this did not reach the minimal clinically important difference threshold, and no difference was observed after one year, nor any improvements in secondary outcomes at any follow-up [87]. However, the observed small clinical benefit of early physiotherapy was shown to be cost-effective compared with usual care after one year [88].

Early referral to physiotherapy aligned with CPG recommendations can be valuable. Childs et al. found that early referral to guideline-adherent physiotherapy (within 14 days of the initial visit) was associated with a reduced likelihood of advanced imaging, spinal injections, lumbar spine surgery, opioid use, and a 60% decrease in total LBP-related costs. Only 16% of patients were referred to physical therapy within 90 days of their initial consultation, and only 24% of those who utilized PT received guideline-adherent treatment [89]. Similarly, Zadro et al. demonstrated that adherence to guidelines among physiotherapists treating musculoskeletal pain remains concerning, with no significant improvement over the past three decades (40% in 1990, 35% in 2017) [90]. Non-adherence to CPG for patients presenting with ALBP in primary care not only escalates healthcare costs and utilization, as evidenced by Hanney et al. [91], but is also associated with a higher likelihood of experiencing ongoing LBP six months after the initial presentation [92].

In summary, early referral or initial contact with a physiotherapist can lead to reduced healthcare costs and lower risks associated with advanced early imaging, spinal injections, or spinal surgery for some patients. However, these benefits might be overestimated in retrospective analyses, as the prospective data is less convincing. Nevertheless, patients with ALBP should receive care adherent to CPG when consulting physiotherapists, especially considering its association with decreased healthcare costs and improved treatment outcomes. Building upon the discussed data on the efficacy and cost-effectiveness of MT, the subsequent discussion will delve into the mechanisms of action of MT and its implications for clinical practice.

Lack of evidence for the specificity of different MT techniques

The finding that MT is not superior to sham or placebo interventions may be unexpected. This is noteworthy as practitioners of MT often grapple with the challenges of mastering and applying these techniques [93]. Their intricate assessments aim to precisely identify and treat the specific spinal segments responsible for the pain [94]. Therefore, systematic reviews or individual RCTs examining mobilizations and manipulation together are sometimes criticized for a lack of specificity. Proponents of this argument claim that different results might emerge if manipulation and mobilization techniques were investigated separately or if patients were assessed differently [95].

Several RCTs have shown no significant difference between manipulation and mobilization in reducing pain or disability in patients with LBP [96–98]. In a systematic review on SMT in patients with CLBP, Rubinstein et al. conducted a sensitivity analysis. Their findings indicated that neither mobilization nor manipulation had an effect on the overall pooled effect after one or six months [77]. Therefore, there is lacking evidence regarding the superiority of manipulation over mobilization techniques.

Comparisons among various MT concepts, including Maitland, Kaltenborn, and Mulligan techniques, consistently produced similar results across a diverse range of interventions, populations, countries, and pain sites [99–102]. Overall, the current evidence suggests that the intended target and force parameters of the mechanical stimulus administered by the practitioner are not significant mediating factors for patient outcomes [103].

Recently, the importance of selecting the right vertebral segment for performing has been challenged [104]. Nim et al. found ten studies comparing SMT, on the ‘right’ vertebral levels to non-selected (randomly or prescriptively assigned another vertebral region, segment, or side) SMT in patients with neck and LBP. In 31/33 comparisons, there was no significant difference in pain, disability, or perceived stiffness if patients received SMT in a specifically selected or randomly assigned vertebral segment [104]. In that review studies examining mobilization techniques were excluded. Another systematic review, encompassing studies that examined mobilization techniques in cases of acute, subacute and CLBP showed that targeting a specific vertebral level did not result in improved pain intensity or disability when compared to a non-targeted approach [105]. Consequently, these reviews suggest that the effects of both manipulation and mobilization techniques do not manifest through specific pathways within the vertebral segments, supporting an earlier review that found no improvement in RCTs of MT for patients with LBP when clinicians were able to select the vertebral treatment segment and specific technique [106].

Similarly, studies have demonstrated the poor reliability of manual segmental motion testing in patients with LBP [107–110]. Assessments to ‘identify’ supposed aberrant segmental motion or dysfunctions were invalid when compared to the segmental motion of vertebral segments on magnetic resonance imaging (MRI) [103]. Thus, if a manual assessment is invalid and has poor reliability, the treating clinician may not correctly identify the responsible segment. Sørensen et al. recommended that educational institutions update the academic curriculum and textbooks to reflect the best available evidence [105]. However, clinicians must acknowledge the caveats and limitations of the validity and reliability of palpation and physical examinations and patients seeking medical care for LBP generally expect a comprehensive physical assessment [111]. CPG recommend a thorough physical examination, encompassing assessments of mobility, strength, position, proprioception, and neurological function [112]. Moreover, clinicians assess the spine’s sensitivity during the manual examination, and tactile inputs can strengthen therapeutic relationships, fostering (epistemic) trust. Tailoring the treatment strategy [114] to individual patients based on tests lacking validity and reliability is an area that requires improvement.

Evidence-based mechanisms of manual therapy

The current understanding of the mechanism of action of MT is insufficient. Recent evidence refutes the specific biomechanical mechanisms [104]. Several articles challenge these biomechanically outdated and scientifically invalidated concepts, urging clinicians to update their understanding of the mechanisms of MT [52,103,115,116]. However, the biomedical model, with limited applicability in chronic pain populations, prevails among physiotherapists, physicians, and the public [117]. Many patients expect MT treatment and believe in its effectiveness; however, they often assume that manipulative techniques realign the spine and rectify vertebral positioning [118]. Considering the persistence of these misconceptions regarding the mechanisms of action of MT, a deeper dive into mechanisms research is indicated.

Bialosky et al. proposed a model that postulates that mechanical stimuli from MT lead to neurophysiological adaptations within the peripheral and central nervous system which ultimately resulting in pain reduction [103]. Functional MRI studies suggest that MT may alter the cortical interactions of nociceptive processing, dampening subsequent stimuli [103]. However, the pain-reducing effect of MT is not mediated by correcting dysfunctions, aberrant movement, or manipulation of specific facet joints [119].

However, the neurophysiological effects of a single session of spinal mobilizations on pain intensity lasted for five minutes or less in most studies, except one in which hypoalgesia was present for 24 h [120]. Clinicians should cautiously interpret immediate physiological reactions to MT interventions [119], given that these may also occur after ineffective treatment and rarely result in improved clinical outcomes in the short- and the long-term [121].

While non-refutable short-term biomechanical effects are exerted by the manual application of these techniques, they are not specific to biomechanical direction, impulse, or assumed dysfunction. SMT may influence pain processing through many neurophysiological and complex mechanisms that are not restricted to arthrokinematics at one or two spinal levels [52,122]. Different interventions (e.g. MT, strengthening exercises, and cognitive functional therapy) have specific mechanisms through which they influence patient outcomes; however, they also share mechanisms of action mediating treatment success [123,124]. Self-efficacy, expectancy of treatment benefits, and the quality of the therapeutic relationship have been identified as possible shared mechanisms for treatment success [125]. Other factors mediating treatment effects may encompass patients expectations’, prior experiences, beliefs, and convictions, epistemic trust, and nonspecific contextual effects [123].

The neurobiological pathways of contextual effects in physiotherapy and their potential to enhance or diminish treatment effects have been previously described [126,127]. Indeed, a substantial proportion of the treatment effect can be attributed to contextual factors. Menke et al. summarized the results of 56 trials published between 1974 and 2010 on MT, physiotherapy, and exercise for patients with LBP [80]. They calculated that 96% and 66% of the observed improvement in ALBP and CLBP, respectively, was unrelated to the treatment patients received. Recently, Saueressig et al. systematically summarized three-armed RCTs (intervention group, placebo control group, no intervention group) to estimate the proportion of the treatment effect attributable to contextual effects in conservative interventions for musculoskeletal pain [128]. They found that 30–40% of the treatment effect is attributable to contextual effects, aligning with another recent systematic review covering both physical and psychological interventions, which estimated that 39% of the treatment effect is attributed to contextual effects [129].

MT is often described and conceptualized [130] more as a process than as an intervention [132]. MT should be practiced within a person-centered, biopsychosocial approach while also incorporating patients beliefs [133], addressing illness behaviors [134], and seeking to understand each patient’s journey [135]. These elements are essential to cognitive functional therapy, which conveyed sustained benefits compared to usual care at one-year follow-up in patients with CLBP in the RESTORE trial [136]. While proficiency in precise manual examination and treatment techniques is important for clinicians, understanding the mechanisms of action of MT in patients with LBP, as discussed above, should encourage a shift away from primarily focusing on identifying and treating subtle abnormalities. Instead, it should foster an ability to perceive the person, considering their unique needs, concerns, and goals. This, in turn, is important to patients [137,138].

Challenges ahead and open questions

The early identification of patients who do not improve and require specific interventions to prevent them from developing chronic and highly disabling LBP is of paramount importance; however, current classification approaches have demonstrated limited success [139]. Current CPG recommend that clinicians may use risk stratification tools like the StarT Back Screening tool in patients with CLBP [26]. The first trial results of the STarT Back Screening tool, intended to identify subgroups of patients with LBP with a higher risk for poor prognosis to inform a tailored treatment approach [140], were not reproducible, and several other trials found no benefit to providing stratified care for LBP or other musculoskeletal pain sites compared with usual care [141–143]. Given that a significant number of patients continue to experience persistent pain one year after their initial episode of LBP, some authors recommend reassessing patients within the first three months of an ALBP episode to identify those who would benefit from additional treatments [56,58]. Further research, robust data and diagnostic algorithms are warranted to guide clinicians in this regard.

Instead of attributing the effectiveness of therapy to a specific technique, pain phenotyping associates the patient’s pain phenotype with the observed outcomes. It aims to categorize patients into distinct groups based on their response to treatment, pain outcomes, and individual characteristics. Tailoring MT to an amenable pain phenotype may improve clinical outcomes, as suggested by Damian et al. [144]; however further research into mechanisms of action for MT, tailoring it to pain phenotypes, and for risk stratification in patients with LBP is necessary.

How we communicate with patients and the words we use can have an lasting impact on patients with musculoskeletal pain [145,146]. Currently, it appears prudent to proactively mitigate nocebo effects through the adoption of a patient-centered and mindful communication approach [131] and enhancing supportive contextual effects that aid in the recovery process [127]. Despite ongoing advances in this field, further scientific inquiry is needed to explore how healthcare practitioners can effectively harness and maximize contextual effects, and to determine how such approaches can be integrated into clinical practice. We are optimistic about the potential benefits of a person-centered approach in physiotherapy. Nevertheless, further research is necessary to validate and explore the person-centered approach described in this review and by others [138,147–149].

Conclusion and clinical implications

We conducted a comprehensive narrative review of the available evidence regarding the effectiveness of MT, incorporating recommendations from CPG for patients with LBP. Furthermore, we delved into evidence regarding the specificity of MT, its mechanisms of action, and how this knowledge could be translated into clinical practice. This should assist clinicians in adopting a broader perspective when assessing the individual before them.

While many patients with ALBP experience notable improvement within the initial six weeks of onset, a significant portion reports persistent pain after one year or encounters recurring episodes. This underscores the imperative to identify patients at risk of slow recovery who stand to benefit from additional treatments. Despite disparate recommendations from CPG for or against MT in patients with LBP, this review concludes that MT is not obligatory, but may be offered to patients with LBP within a biopsychosocial framework incorporating a person-centered approach (see Figure 1) [150]. Clinicians administering MT, should engage in accurate evidence-based discussions regarding the mechanisms of action, including a modern neurophysiological explanation [103], that replaces outdated and potentially harmful explanations [46]. Overly simplistic biomedical explanations regarding the mechanisms of action of MT reducing pain and improving function are refuted by an abundance of data, but these beliefs continue to persist.

Figure 1.

Manual therapy within a person-centered approach that considers biopsychosocial factors. These factors interact directly and indirectly with each other as part of a complex system, shaping the emerging unique pain experience of the person with low back pain. The manual mechanical stimulus applied during therapy can impact multiple domains (e.g. therapeutic alliance, trust, expectations) and is only one part of the clinical encounter. Therefore, manual therapy can be thought of as a process influencing a complex system rather than an intervention.

To improve patient outcomes, aspects other than manual mechanical stimuli also require scientific and clinical attention. Improved diagnostic screening for specific pathologies that cause pain [151], enhanced patient-centered communication [137], integrated shared decision-making [152], addressing of fear-avoidance behaviors [153], and optimal knowledge and utilization of contextual effects may be useful. Several suggestions and proposed action steps for clinicians and educators on how to address these concerns are presented in Table 2.

Table 2.

Action steps for clinicians and educators.

Action steps moving forward	Explanation and recommendation for clinicians and educators
Embrace complexity and reject reductionism	Background
	Although research has indicated that many of our concepts in physiotherapy fall short of addressing the extensive challenges posed by LBP to both individuals and society, overly simplistic biomedical models persist. Numerous concepts that have been debunked or can be deemed outdated continue to persist in both undergraduate and postgraduate educational curricula and in clinical practice[122]. The concerns raised in this review are not groundbreaking or novel. In 1999, Max Zusman wrote: ‘As the evidence clearly demonstrates, patients pay an undeservedly high price in return for structure-oriented diagnoses and treatment of their back pain.’ [46] It is imperative to accurately represent and effectively communicate the principles behind the application of manual therapy and its mechanisms for reducing pain intensity.
	Clinical implication – Recommendation for clinicians
	We argue that simply positioning manual therapy as a ‘safer’ and ‘less harmful alternative’ to opioids for patients with LBP is insufficient. Research has shown that how we communicate and what we communicate directly and indirectly influences treatment outcomes, patients’ preferences, and their ability to self-manage their condition. We strongly encourage clinicians and educators to embrace the complexity of LBP and the array of treatment approaches available, while discarding outdated and reductionistic ideas that no longer hold ground[154].
Ensure consistent high-quality care for LBP	Background
	CPG aim to and minimize unnecessary variation in the diagnostic and treatment processes when patients seek medical care for LBP. Most CPG for LBP recommend that some form of manual therapy (thrust- or non-thrust joint-mobilization) can be offered alongside exercise and education for nonspecific LBP [22,25,41], while some CPG are more (‘should use’) [26] or less (‘should not use’)[28] confident in their recommendations.
	Clinical implication – Recommendation for clinicians
	In line with recommendations from clinical practice guidelines, clinicians should, if they use manual therapy, incorporate it into a comprehensive, person-centered treatment approach, alongside exercise and education.
Practice communication	Background
	Patients value a person-centered communication style[]. Research has demonstrated that this communication can foster a stronger therapeutic alliance[113,137]. In education and clinical practice, therapists often focus on mastering palpation and complex therapeutic techniques.
	Clinical implication – Recommendation for clinicians
	We suggest prioritizing, practicing, and teaching effective, empathetic and mindful (e.g. diagnostic labeling, attention paid to potentially harmful language) communication in undergraduate and post-graduate education for the benefit of both clinicians and patients[155] .
Adopt a person-centered approach	Background
	Collaboratively working with individuals suffering from back pain, the aim is to guide them toward a life with improved movement, reduced anxiety, less pain, and an enhanced quality of life. While there is no instant remedy for chronic LBP, physiotherapists are well-placed to support patients on their journey to recovery[138].
	Clinical implication – Recommendation for clinicians
	We urge clinicians to adopt a person-centered approach by improving our own clinical reasoning and how we communicate during the clinical encounter. Streamlining our treatment techniques by removing unnecessary complexity allows us to direct our attention more effectively toward the individual in pain, avoiding confusion.

LBP, low back pain; CPG, clinical practice guidelines.

Research is the foundation of modern medical practices. As Jules Rothstein [156] stated, ‘Research is only useful if we use it and too often, we do not.’ Physiotherapists work within a biopsychosocial framework and strive to base treatments and clinical reasoning on the best available evidence, placing patients first. Our profession will move forward only if we use and integrate available research and update our understanding of our interventions. While one may debate when MT should be used in patients with LBP, its mechanisms of action should be acknowledged and scientific debates and contemporary clinical practice should reflect this.

Biographies

Dr. Jean-Pascal Grenier, MSc, is a Medical Doctor currently in residency for internal medicine at the University clinic in Innsbruck (Austria), aiming to specialize in rheumatology. He has a background as a chartered physiotherapist and has worked with patients with musculoskeletal disorders for several years. Additionally he holds a Master’s Degree in Musculoskeletal Physiotherapy and is OMPT certified (IFOMPT). Dr. Grenier served as part of the medical staff for the Austrian Basketball Men’s team during qualifaction rounds for two years. He is also an adjunct lecturer at the University for Applied Health Sciences (FH) Tyrol for Physiotherapy, where he teaches and supervises bachelor theses for undergraduate students. His research interests include musculoskeletal disorders, rheumatology and physiotherapy. His recent work has delved into physiotherapy utilization in patients with knee osteoarthritis, as well as physical activity and low back pain.

Maria Rothmund, MSc, is a Research Associate at the Medical University of Innsbruck and a PhD Candidate at the Leopold-Franzens-University of Innsbruck (Austria). Her primary research interests are patient-reported outcomes, health-related quality of life, and psychometrics. In her role as a Clinical Psychologist in Training at the University Clinic in Innsbruck, she works with patients in the field of psychosomatics and eating disorders.

Funding Statement

This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sectors.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Author contributions

Draft of manuscript JPG and MR, editing and revision of manuscript JPG and MR, visualization JPG, conceptualization or design JPG, final approval JPG and MR. JPG revised the manuscript, MR proofread and approved the final version.

Ethics statement

As this was a narrative review, ethical approval was not required.