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Manual Therapy

Original Editor - Finn Gerstell

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Introduction

Manual therapy is the use of skilled, hands-on techniques, including joint mobilisation, manipulation and soft tissue work, to assess and treat neuro-musculoskeletal conditions. Its underlying clinical rationale has undergone a fundamental shift in recent years. Historically, its effects were explained through mechanical models: correcting joint position, releasing adhesions, or restoring "normal" movement. Some local tissue and fluid-dynamic effects remain plausible, but the dominant evidence base now points to neurophysiological mechanisms and psychosocial factors as the primary drivers of clinical effects.[1][2] Understanding this shift helps clinicians move away from structural explanations towards evidence-informed clinical reasoning.

This page explores definitions, mechanisms, the major treatment frameworks, technique classification, the evidence base, safety considerations, and clinical application, including how to use manual therapy without fostering patient dependence.

Note: this page includes information and videos on manual therapy techniques. This does not replace in-person, hands-on training and clearance to perform with patients in the clinic.

Definitions

The International Federation of Manual and Musculoskeletal Physical Therapists (IFOMPT) defines orthopaedic manual physical therapy as:

"a specialised area of physiotherapy/physical therapy for the management of neuro-musculoskeletal conditions, based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeutic exercises. Orthopaedic manual physical therapy also encompasses, and is driven by, the available scientific and clinical evidence and the biopsychosocial framework of each individual patient."[3]

Similarly, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) defines it in its Description of Advanced Specialty Practice (2018) as:

"an advanced specialty area of physical therapy practice that is based on manual examination and treatment techniques integrated with exercise, patient education, and other physical therapy modalities to address pain, loss of function, and wellness. Early, consistent, and skillful manual physical therapy, combined with exercise and patient education, is central to the OMPT [orthopaedic manual physical therapy] therapist's practice. Advanced examination, communication, and decision-making skills that are built on the foundations of professional and scientific education facilitate the provision of effective and efficient care. Practitioners of OMPT provide patient management, consult with other health care providers regarding simple as well as complex neuromusculoskeletal (NMS) conditions, and provide recommendations and interventions in the area of health and wellness."[4]

These definitions reflect orthopaedic manual therapy specifically. Other specialties (such as neurological physiotherapy) have their own distinct hands-on approaches, each with specific theoretical frameworks and evidence bases.

For the purposes of this page, the Mechanisms of Manual Therapy section describes broad physiological processes that are not orthopaedic-specific, while the Manual Therapy Frameworks section details models and grading systems developed specifically within orthopaedic manual therapy.

Mechanisms of Manual Therapy

Manual therapy is conceptualised as a transient mechanical stimulus that initiates a systemic neurophysiological cascade. Bialosky et al. set out this framework in 2009 and updated it in 2018.[1][2]

Mechanical stimulus

While manual therapy produces biomechanical effects, these are transient and do not produce lasting positional or structural changes in joints or nerves. Reliability studies also show poor agreement between clinicians attempting to identify specific positional or movement "faults" by palpation, and treatment is not anatomically precise (i.e. its effects are spread across a large area). The mechanical stimulus is therefore unlikely to be the primary driver of clinical effects.[1]

Neurophysiological mechanism

Measurable post-treatment responses, such as hypoalgesia and reduced temporal summation, provide indirect evidence of underlying neurophysiological mechanisms. Bialosky et al. categorise these mechanisms across three levels: peripheral, spinal, and supraspinal.[1]

  • Peripheral mechanisms. Manual therapy may modulate local tissue inflammation following injury. Post-treatment findings include reduced blood cytokines and altered levels of circulating neurochemicals (e.g. endocannabinoids, serotonin, and substance P). On this basis, Bialosky et al. propose that manual therapy may mediate musculoskeletal pain via the peripheral nervous system.[1][2]
  • Spinal cord mechanisms. Manual therapy may act as a "counter irritant to modulate pain",[1] flooding the central nervous system with sensory input and modulating spinal excitability.
  • Supraspinal mechanisms. Manual therapy may influence higher brain centres involved in pain processing, including the periaqueductal grey (PAG), anterior cingulate cortex (ACC), rostral ventromedial medulla (RVM), and amygdala. Notably, Bialosky et al. categorise psychosocial variables (e.g. patient expectation, placebo) under supraspinal mechanisms, hypothesising that these factors may help trigger brain-mediated descending pain inhibition through endogenous opioid and dopamine pathways.[1]

Expanding on Bialosky et al.'s framework, a 2025 living review categorises reported manual therapy mechanisms across seven distinct domains: biomechanical, neurological, neuroimmune, neurovascular, neurotransmitter/neuropeptide, neuromuscular, and neuroendocrine.[5] This spread of domains indicates whole-person, systemic physiological responses rather than localised joint phenomena. Consequently, the rationale for manual therapy is better viewed through a biopsychosocial and multi-system lens rather than as a means of correcting local musculoskeletal impairment.

Manual Therapy Frameworks

The six frameworks below are the schools of thought that have most shaped orthopaedic manual therapy teaching and practice.

Framework Core approach Primary area Key techniques
Cyriax Selective tissue tension testing and differential diagnosis of soft tissue lesion[6] Spine and peripheral joints
  • Deep transverse friction
  • Traction
  • Manipulation
Lewit Dysfunctions viewed as part of an interrelated chain of pathologies[7] Spine and peripheral joints
  • Post-isometric relaxation (PIR)
  • Mobilisation and manipulation
  • Active exercise
Kaltenborn-Evjenth Convex-concave theory guiding translatory joint play assessment and treatment[8] Spine and peripheral joints
  • Transverse/functional massage
  • Muscle stretching with isometric holds
  • Joint mobilisation/manipulation
  • Neuromobilisation
Maitland Clinical reasoning and ongoing reassessment guide technique selection[6][9][10] Spine and peripheral joints
  • Oscillatory mobilisations and manipulations
McKenzie (MDT) Repeated/sustained movement testing to classify and direct treatment[11] Spine and peripheral joints
  • Direction-specific repeated movements
  • Patient self-treatment
Mulligan Active patient movement combined with passive joint correction[12] Spine and limbs (primarily peripheral)
  • NAGs
  • SNAGs
  • Mobilisation with movement (MWM)

Cyriax Techniques

Cyriax's approach centres on identifying the specific soft tissue structure at fault through selective tissue tension testing, then treating it directly, most notably through deep transverse friction massage.[6] He also described a range of traction and manipulation techniques applied to both the spine and the peripheral joints.

Deep transverse friction massage (DTFM), Cyriax's signature technique, has a modest and mixed evidence base, but remains widely used.[13][14] Reviews have reported benefit in lateral elbow tendinopathy and adhesive capsulitis, though there are a small number of available trials of variable quality.[15][16]

Please see this YouTube playlist for demonstrations of a range of Cyriax techniques.

Lewit Techniques

Lewit's approach treats musculoskeletal dysfunction as part of an interconnected chain of related problems, addressing muscle imbalance alongside joint mobilisation.[7]

The technique most associated with Lewit is post-isometric relaxation (PIR), where the muscle is placed in a stretched position, a brief low-force isometric contraction is performed against resistance, and a gentle stretch follows as the muscle relaxes. PIR sits within the wider family of muscle energy techniques (MET). PIR/MET has reasonable outcome evidence for pain and range of motion, but the classic explanation for why it works (i.e. reduced resting muscle activity (EMG) following the isometric contraction) does not consistently hold up under direct testing, even though range of motion still improves.[17]

The following video discusses the physiology behind post-isometric relaxation and muscle energy technique:

[18]

Kaltenborn-Evjenth Method

Treatment centres on restoring normal joint play (the small amount of accessory movement within a joint that is not under voluntary control) through graded traction and gliding mobilisations.[8]

The convex-concave rule is central to how mobilisation direction is selected in this framework, but much of the field now treats the rule as a teaching formula rather than a strict clinical directive. Biomechanical studies, particularly of the glenohumeral joint, have found that joints do not always move the way the rule predicts, and clinical trials testing the rule's predicted direction against the opposite direction have produced mixed results.[19][20] Kaltenborn himself revisited and clarified the rule in the current (8th) edition of his own textbook.[8] In practice, mobilisation direction should be guided by patient response and reassessment rather than applied as a fixed rule.

The following short video describes the basics behind the convex-concave rule:

[21]

Kaltenborn Traction Grading Scale

Kaltenborn Tractions can be classified as one of three grades:

Grade Description
I Neutralises joint pressure without separating joint surfaces
II Takes up the slack and separates the articulating surfaces, tightening the surrounding tissues.
III Applies a larger force that stretches the soft tissues crossing the joint.

Maitland Concept

The Maitland Concept applies rhythmic, oscillatory passive movements to joints, with technique selection driven by ongoing clinical reasoning and reassessment rather than a fixed, diagnosis-based protocol. Each treatment involves several linked decisions: the direction of mobilisation, the desired effect (pain relief or a stretch to reduce stiffness), the starting position of the patient and therapist, the method of application (position, range, amplitude, rhythm, and duration), the expected response, and how the technique might be progressed through changes in duration, frequency, and rhythm.[9] Available glide directions include anteroposterior, posteroanterior, longitudinal caudad, longitudinal cephalad, joint distraction, medial glide, and lateral glide.

Maitland Joint Mobilisation Grading Scale

There are five grades used to classify the different grading levels for Maitland mobilisations:

Grade Description
I Small-amplitude rhythmic oscillation in early range
II Large-amplitude rhythmic oscillation in mid-range
III Large-amplitude rhythmic oscillation to point of limitation
IV Small-amplitude rhythmic oscillation at end of available range
V (thrust manipulation) Small-amplitude, quick thrust at end of available range


Grades I–II are typically used to reduce pain and irritability, guided by VAS and SIN (Severity, Irritability, Nature) scores. SIN is a component of the Maitland subjective assessment, and it is used to judge how vigorously to examine and treat. Grades III–IV are used to stretch the joint capsule and surrounding passive tissue to increase range of movement. Oscillation rates of roughly 2 Hz (120 movements/minute) for 30 seconds to one minute are commonly taught.

See Maitland's Mobilisations for more information on this approach and detailed technique descriptions.

The following video describes the Maitland mobilisation grades:

[22]

McKenzie Method/Mechanical Diagnosis and Therapy (MDT)

MDT uses a patient's symptomatic response to repeated or sustained movements to classify their presentation and guide treatment. It has a strong emphasis on patient self-management rather than ongoing passive treatment.[11] MDT classification and treatment follow four main steps:[11]

  1. Assessment: history-taking (aggravating/relieving activities) followed by a movement assessment using repeated or sustained movements to determine symptomatic response.
  2. Classification: the classification step sorts patients into one of four categories
    • Derangement syndrome
    • Dysfunction syndrome
    • Postural syndrome
    • Other
  3. Treatment: repeated movements in the direction that centralises, decreases, or abolishes symptoms, sustained during return to normal activity, with concurrent patient education.
  4. Prevention: encouraging regular exercise and self-management.

Note: the "other" classification isn't just a catch-all: the McKenzie Institute has since subdivided it into 10 specific subcategories (e.g. spinal stenosis, chronic pain syndrome, mechanically inconclusive, trauma, etc), and it accounts for a substantial share of presentations in specialist settings, around 63% in one secondary/tertiary care sample.[23]

See McKenzie Method for detailed technique descriptions.

Reliability of MDT

A 2025 reliability study found almost perfect overall inter-rater agreement between MDT-trained clinicians even across these 10 subcategories. This indicates that the classification holds up well in practice, not just for the three main syndromes.[23]

Clinical Efficacy of MDT

Treatment outcomes vary by population and protocol fidelity.[23][24][25] In generic (sub)acute low back pain, there is low-certainty evidence of a slight, not clinically important, short-term pain reduction.[24] In chronic low back pain with directional preference, there is low-to-moderate certainty evidence of clinically important pain and disability reductions, when delivered by credentialed therapists.[25]

The following video, presented by the McKenzie Institute, describes the assessment and treatment philosophies behind MDT.

[26]

Mulligan Concept

The Mulligan Concept combines a therapist-applied accessory joint mobilisation with an active physiological movement at the joint.[27] It was traditionally explained as correcting a joint's "positional fault", though this specific mechanism has not been confirmed, and current explanations lean towards neurophysiological pain modulation during pain-free movement.[12]

The Mulligan Concept's core techniques are natural apophyseal glides (NAGs) and sustained natural apophyseal glides (SNAGs), both applied to the spine, and mobilisation with movement (MWM), used mainly at peripheral joints.

See [Concept|Mulligan Concept] for detailed technique descriptions.

The evidence for Mulligan techniques varies by anatomical site. Moderate-quality evidence supports MWMs for reducing pain and improving function.[28][29] [30][31] SNAGs offer potential benefits in chronic back and neck pain, though evidence certainty is low to very low, with no clear advantage in acute presentations.[27] [32]

The following video is an interview with Brian Mulligan, the creator of the Mulligan Concept.

[33]

Manual Therapy Technique Application

Manual therapy techniques can be characterised based on the following five dimensions.

  1. Speed ranges from slow and sustained (Kaltenborn's Grade I/II traction holds, or the slow stretch phase of PIR) to rapid, as in a Grade V thrust manipulation.
  2. Location within range of motion (ROM) describes where in the joint's available movement a technique is applied: early-range work tends to calm an irritable joint, while McKenzie's emphasis on repeatedly reaching end-range is a deliberate choice at the opposite end of this dimension.
  3. Force direction describes the line the applied force travels relative to the joint or tissue. For example, Cyriax's deep transverse friction is applied perpendicular to the affected tissue's fibres, while Kaltenborn's translatoric glides follow specific anteroposterior, posteroanterior, or other planes guided by the convex-concave rule.
  4. Relative movement distinguishes techniques that are purely passive, driven entirely by the therapist (e.g. classic Maitland oscillations) from those that combine the therapist's input with the patient's own active movement, as in Mulligan's MWM or McKenzie's patient-performed repeated movements.
  5. Subject position covers how the patient and the treated joint are positioned. They might be in weight-bearing or non-weight-bearing positions, sitting, lying, or standing. In Mulligan's MWM techniques, this decision depends on the irritability and nature of the condition.

Evidence Base

This section addresses manual therapy as a whole intervention. Evidence for the signature techniques of each framework is covered in the sections above.

Manual therapy is generally considered a valuable component of multimodal treatment for musculoskeletal conditions. Most systematic reviews report beneficial effects across a range of musculoskeletal conditions, although some are inconclusive and a small number report effects no better than sham or comparison treatments.[34]

Clinical practice guidelines generally recommend manual therapy as one component of a broader, active management approach, not as a stand-alone intervention. The APTA Academy of Orthopaedic Physical Therapy guidelines for neck pain and for acute and chronic low back pain recommend manual therapy in combination with exercise rather than as a stand-alone intervention.[35][36] NICE recommends that manual therapy (spinal manipulation, mobilisation, or soft tissue techniques such as massage) be considered for people with low back pain with or without sciatica, but only as part of a treatment package that also includes exercise.[37]

Clinicians should be cautious about over-interpreting in-session symptom changes (e.g. immediate improvement in a provocative movement following treatment) as predictive of long-term outcome. In-session change may reflect short-term pain modulation, but sustained improvement still depends on what the patient does between sessions.

Safety and Screening

Manual therapy is generally safe when appropriately screened and applied but is not without risk, particularly for cervical spine techniques.

International IFOMPT Cervical Framework (2020)

Before cervical spine manual therapy interventions, clinicians should screen for potential vascular pathology of the neck (e.g. cervical arterial dysfunction) through history-taking and physical examination. The examination should be adapted when risk factors are identified. Serious adverse events following cervical manipulation or mobilisation are rare, but the framework provides internationally endorsed, consensus-based guidance for clinical reasoning in this area.[38] Read the journal article here.

Red flag screening

General screening should also include standard red-flag assessment (e.g. infection, malignancy, cauda equina, fracture, cardiovascular involvement) in any person presenting with spinal or peripheral joint pain.[35][36] To learn more about clinical reasoning and red flags, see: An Introduction to Red Flags in Serious Pathology.

Blood pressure considerations

In the IFOMPT Cervical Framework, blood pressure is highlighted as an important measurement, both as a stroke risk factor and as a possible sign of arterial trauma already present. Readings are interpreted alongside other findings rather than in isolation. Patients found to be hypertensive who were unaware of it should be advised to discuss this with their primary care provider.[38]

Shared decision-making and informed consent

The IFOMPT Cervical Framework builds shared decision-making directly into its clinical reasoning process, adopting the Agency for Healthcare Research and Quality's 5-step SHARE approach. This involves:[38]

  • Seeking the patient's participation
  • Helping them explore and compare options
  • Assessing their values and preferences
  • Reaching a decision together
  • Evaluating the decision

In practice, this means risk should be discussed openly with the patient rather than managed silently by the clinician alone. This involves explaining the very low absolute risk of serious adverse events, the plausible benefits, and the alternatives, and documenting that this conversation took place.[38]

Clinical Application of Using Manual Therapy Without Creating Dependence

A key clinical risk to manage is dependence.

Framing manual therapy as something the patient needs from the clinician, rather than as a tool that supports the patient's own progress, risks fostering an external locus of control and reduced self-efficacy.

Locus of control

An internal locus of control (the belief that one's own actions influence one's health outcomes) has generally been associated with better physiotherapy outcomes in patients with chronic pain, while an external locus of control (attributing outcomes to the clinician, chance, or other external factors) has been associated with worse ones.[39] Clinicians should be explicit with patients about what a technique achieved (e.g. "you were able to move further/with less pain after this. Let's use that same movement as part of your home programme") so patients attribute improvement to their own actions rather than solely to the clinician's hands.[40]

This approach is consistent with a biopsychosocial model of care and helps mitigate the risk of manual therapy fostering unhelpful dependence, particularly in patients with an external locus of control.

Summary

Manual therapy is a structured, clinically reasoned approach to hands-on assessment and treatment, delivered within a biopsychosocial framework. Its mechanisms are better explained by neurophysiological and psychosocial pathways than by mechanical correction of joint position, so it is best understood as one component of multimodal care. Its greatest clinical value lies in supporting, rather than replacing, active, education- and exercise-based rehabilitation.

Resources (Mobilisation and Manipulation Techniques)

This video gives a good overview of the hands-on/off debate and suggestions of when to use manual therapy.

[41]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy. 2009 Oct 1;14(5):531-8.
  2. ↑ 2.0 2.1 2.2 Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the mechanisms of manual therapy: modeling an approach. Journal of Orthopaedic and Sports Physical Therapy. 2018 Jan;48(1):8-18.
  3. ↑ IFOMPT. OMPT Definition. Available from: https://www.ifompt.org/About+IFOMPT/OMPT+Definition.html (accessed 2 September 2026).
  4. ↑ American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). Orthopaedic Manual Physical Therapy: Description of Advanced Specialty Practice. 2018. Available from: https://aaompt.org/common/Uploaded%20files/DASP_October_2018.pdf (accessed 2 September 2026).
  5. ↑ Keter DL, Bialosky JE, Brochetti K, Courtney CA, Funabashi M, Karas S, Learman K, Cook CE. The mechanisms of manual therapy: a living review of systematic, narrative, and scoping reviews. PLoS One. 2025 Mar 18;20(3):e0319586.
  6. ↑ 6.0 6.1 6.2 Wise CH. Orthopaedic manual physical therapy: from art to evidence. FA Davis; 2015 Apr 10.
  7. ↑ 7.0 7.1 Lewit K. Manipulative Therapy: Musculoskeletal Medicine. Edinburgh: Churchill Livingstone/Elsevier; 2010.
  8. ↑ 8.0 8.1 8.2 Kaltenborn FM, in collaboration with Evjenth O, Kaltenborn TB, Morgan D, Vollowitz E. Manual Mobilization of the Joints, Vol. 1: The Extremities. 8th ed. Oslo: Norlis Bokhandel; Minneapolis: OPTP; 2023.
  9. ↑ 9.0 9.1 Maitland GD, Hengeveld E, Banks K. Maitland's Vertebral Manipulation: Management of Neuromusculoskeletal Disorders, Volume 1. 8th ed. Edinburgh: Churchill Livingstone/Elsevier; 2014.
  10. ↑ IMTA. Programme details. Available from: https://www.imta.ch/course-system (accessed 2 September 2026).
  11. ↑ 11.0 11.1 11.2 McKenzie RA, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd ed. Waikanae, New Zealand: Spinal Publications; 2003.
  12. ↑ 12.0 12.1 Mulligan BR. Manual Therapy: "NAGS", "SNAGS", "MWMS" etc. 6th ed. Wellington, New Zealand: Plane View Services/Orthopedic Physical Therapy Products; 2010.
  13. ↑ Pitsillides A, Stasinopoulos D. Cyriax friction massage-suggestions for improvements. Medicina (Kaunas). 2019 May 21;55(5):185.
  14. ↑ Chaves P, Simões D, Paço M, Pinho F, Duarte JA, Ribeiro F. Cyriax's deep friction massage application parameters: Evidence from a cross-sectional study with physiotherapists. Musculoskelet Sci Pract. 2017 Dec;32:92-97.
  15. ↑ Khan S, Arsh A, Khan S, Ali S. Deep transverse friction massage in the management of adhesive capsulitis: a systematic review. Pakistan Journal of Medical Sciences. 2024 Jan;40(3Part-II):526.
  16. ↑ Giannikou E, Sivrika A, Kypraios G, Karadimitri D, Dimitriadis Z, Fousekis K, Stasinopoulos D. The effectiveness of the Cyriax Method in the treatment of lateral elbow tendinopathy: A systematic review. J Bodyw Mov Ther. 2025 Oct;44:281-287.
  17. ↑ Thomas E, Cavallaro AR, Mani D, Bianco A, Palma A. The efficacy of muscle energy techniques in symptomatic and asymptomatic subjects: a systematic review. Chiropractic & manual therapies. 2019 Aug 27;27(1):35.
  18. ↑ YouTube. Muscle Energy Technique: Post Isometric Relaxation an Introduction | T3 Education - Soft Tissue Therapy. Available from: https://www.youtube.com/watch?v=Ym4_UXq7Vxo [last accessed 3 September 2026]
  19. ↑ Neumann DA. The convex-concave rules of arthrokinematics: flawed or perhaps just misinterpreted?. Journal of Orthopaedic & Sports Physical Therapy. 2012 Feb;42(2):53-5.
  20. ↑ Schomacher J. The convex–concave rule and the lever law. Manual Therapy. 2009 Oct 1;14(5):579-82.
  21. ↑ YouTube. The Convex Concave Rule in under 2 min | JP Gloria. Available from: https://www.youtube.com/watch?v=xWEQk42Spv0 [last accessed 3 September 2026]
  22. ↑ YouTube. Maitland Mobilizations Grades 1-5 | Clearly Explained | ABCs of PT. Available from: https://www.youtube.com/watch?v=yCrOXgNSXf0 [last accessed 3 September 2026]
  23. ↑ 23.0 23.1 23.2 van Helvoirt H, Tempelman H, van der Vet P, van der Vet F, van Helvoirt J, Rosedale R, Apeldoorn A. Reliability of the McKenzie Method of Mechanical Diagnosis and Therapy in the examination of spinal pain, including the OTHER classifications: Reliability of the McKenzie Method in spinal pain. Brazilian journal of physical therapy. 2025 Jan 1;29(1):101154.
  24. ↑ 24.0 24.1 Almeida MO, Garcia AN, Costa LC, van Tulder MW, Lin CW, Machado LA. The McKenzie method for (sub) acute non‐specific low back pain. Cochrane Database of Systematic Reviews. 2023(4).
  25. ↑ 25.0 25.1 Hennemann V, Ziegelmann PK, Marcolino MA, Duncan BB. The McKenzie Method delivered by credentialed therapists for chronic low back pain with directional preference: systematic review with meta-analysis. Journal of Manual & Manipulative Therapy. 2025 Mar 4;33(2):96-111.
  26. ↑ YouTube. What Physical Therapy Clinicians Need to Know About The McKenzie Method® | The McKenzie Institute, USA. Available from: https://www.youtube.com/watch?v=j2lOZBNkWZ8 [last accessed 3 September 2026]
  27. ↑ 27.0 27.1 Shager K, Murugiah M, Sze Kei T, Ranganathan H, Ahmad MA. Effects of Mulligan sustained natural apophyseal glide mobilizations on pain, mobility, and lumbar-related disability in chronic non-specific low back pain: A systematic review and meta-analysis. Medicine (Baltimore). 2026 Jun 26;105(26):e49456.
  28. ↑ ElMeligie MM, Abdeen HA, Atef H, Marques-Sule E, Karkosha RN. The effectiveness of mulligan mobilization with movement (MWM) on outcomes of patients with ankle sprain: a systematic review and meta-analysis. BMC Sports Science, Medicine and Rehabilitation. 2025 Apr 29;17(1):105.
  29. ↑ Westad K, Tjoestolvsen F, Hebron C. The effectiveness of Mulligan's mobilisation with movement (MWM) on peripheral joints in musculoskeletal (MSK) conditions: A systematic review. Musculoskelet Sci Pract. 2019 Feb;39:157-163.
  30. ↑ Hasan S, Iqbal A, Ibrahim AR, Diab RH, Iqbal ZA, Hasan T, Anwer S, Alghadir AH. Mobilization with movement enhances early rehabilitation outcomes in knee osteoarthritis: a six-week randomized controlled trial. Chiropr Man Therap. 2026 Mar 22;34(1):11.
  31. ↑ Li LL, Hu XJ, Di YH, Jiao W. Effectiveness of Maitland and Mulligan mobilization methods for adults with knee osteoarthritis: A systematic review and meta-analysis. World J Clin Cases. 2022 Jan 21;10(3):954-965.
  32. ↑ Barbosa-Silva J, Luc A, Sobral de Oliveira-Souza AI, Martins de Abreu R, Cipriano J, de Schaetzen M, et al. The effectiveness of Mulligan's techniques in non-specific neck pain: a systematic review and meta-analysis. Physiother Res Int. 2025 Jul;30(3):e70045.
  33. ↑ YouTube. Brian Mulligan Interview | Remedy Physio. Available from: https://www.youtube.com/watch?v=GWkpcWnb1KI [last accessed 3 September 2026]
  34. ↑ Kerry R, Young KJ, Evans DW, Lee E, Georgopoulos V, Meakins A, et al. A modern way to teach and practice manual therapy. Chiropr Man Therap. 2024 May 21;32(1):17.
  35. ↑ 35.0 35.1 Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK, Altman RD, Beattie P, Boeglin E. Neck pain: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jul;47(7):A1-83.
  36. ↑ 36.0 36.1 George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA, Gilliam JR, Hendren S, Norman KS, Beattie PF, Bishop MD. Interventions for the management of acute and chronic low back pain: revision 2021: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2021 Nov;51(11):CPG1-60.
  37. ↑ National Institute for Health and Care Excellence (NICE), Low back pain and sciatica in over 16s: assessment and management: NICE Guideline [NG59]. Reviewed 2026. Available from: https://www.nice.org.uk/guidance/ng59 [Accessed 8 September 2026].
  38. ↑ 38.0 38.1 38.2 38.3 Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, Kerry R. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to musculoskeletal intervention: international IFOMPT cervical framework. Journal of Orthopaedic & Sports Physical Therapy. 2023 Jan;53(1):7-22.
  39. ↑ Álvarez-Rodríguez J, Leirós-Rodríguez R, Morera-Balaguer J, Marqués-Sánchez P, Rodríguez-Nogueira Ó. The influence of the locus of control construct on the efficacy of physiotherapy treatments in patients with chronic pain: a systematic review. Journal of Personalized Medicine. 2022 Feb 7;12(2):232.
  40. ↑ Rainey, N. Manual Therapy Considerations in Clinical Practice. Physioplus. 2023.
  41. ↑ The Canadian Physio Student MANUAL THERAPY IN PHYSIOTHERAPY PRACTICE WITH JESSE AWENUS Available from: https://www.youtube.com/watch?v=g36vqjx5N-Q&app=desktop (last accessed 21.9.2019)
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