Active Manual Therapy

Original Editor - Neil Tuttle Top Contributors - Neil Tuttle, Kim Jackson and Rucha Gadgil

Background[edit | edit source]

Active manual therapy suggests that the patient and clinician are active participants in the therapeutic process and are both involved in an ongoing physical as well as verbal dialogue. The concept is applicable to all hands-on interventions which can be modified in real time according to patient response including, for example, mobilization or massage, but not manipulation or electrophysical agents.  

The term Active Manual Therapy has previously been used to indicate exercises that are performed in conjunction with or following hands-on treatments[1].

Passive or Active?[edit | edit source]

Manual Therapy has traditionally been considered to be a ‘passive treatment’ which has been suggested (without evidence) to increase patient dependency[2]. The presumed passive nature of manual therapy has been challenged by the concepts of patient-centred manual therapy[3] and manual therapy as a form of tactile communication[4]. Active manual therapy includes both of these concepts of patient centeredness and interactivity.

Principles[edit | edit source]

There are various schools of Manual Therapy, each having their own type of clinical reasoning based on principles and/or rules [5] all of which can be described as types of ‘reasoning that results in action'.[6] In other words the therapist gathers information, makes decisions using clinical reasoning that may or may not involve an actual diagnosis, and acts on those decisions.

Others suggest the reasoning process by experienced clinicians extends beyond gathering of information to include intuition[7] or ‘gut’ feeling[8]. These processes, which are often presumed to be non-cognitive, are not mystical messages from the universe, but rather involve making decisions based on experience which the clinician may not be able to explain verbally. If clinical reasoning is limited to diagnostic reasoning in either form, then manual therapy can reasonably considered to be a passive modality – something that is done to a patient without their participation.

Rather than using this simple process of diagnostic reasoning, most physiotherapists use an iterative process (originally advocated by Maitland) where interventions are revised and modulated based on precise reassessments that punctuate interventions. This type of iterative process involving a series of discrete decisions is referred to as ‘reasoning in action’ or ‘reflection in action’[9].

Many experienced therapists (although often subconsciously), take this a step further by continuously adjusting their interventions in real-time as responses to changes occurring during, rather than just after, a treatment application.[10] This interactive process has been described as reasoning in interaction or reflection in interaction.[11]

Although to the author’s knowledge, the main schools of Manual Therapy do not explicitly teach this type of real-time adjustment/interaction, some allude to a similar approach. Maitland, for example advocated ‘getting inside the joint’ during treatment which was famously described by now Emeritus Professor Gwen Jull as ‘the inspired fiddle’. Although not explicitly taught, many experienced clinicians describe using a similar process. I personally observed Maitland, Kaltenborn, Evjenth, and to a lesser extent Mulligan, while treating patients, modifying and refining treatment techniques within as well as between application of techniques.

Summary[edit | edit source]

In summary, Active Manual Therapy describes an extension of the Manual Therapy paradigms[5] which move from punctuated to continuous patient-centered clinical reasoning which could be seen as a multimodal conversation. A transcription of what this type of dialogue might look like is shown.


Non-verbal content from the patient is in plain text;

Non-verbal content from the therapist is in italics;

Verbal content from the patient is in bold;

Verbal content from the therapist is in bold italics.

Conversation during manual therapy.jpg

References[edit | edit source]

  1. Rhon DI, Deyle GD. Manual therapy: always a passive treatment? J Orthop Sports Phys Ther. 2021;51(10):474-7.
  2. Cosio D, Lin E. Role of active versus passive complementary and integrative health approaches in pain management. Global Advances in Health and Medicine. 2018;7:2164956118768492.
  3. Keter D, Hutting N, Vogsland R, Cook CE. Integrating Person-Centered Concepts and Modern Manual Therapy. JOSPT Open. 2024;2(1):1-11.
  4. Tuttle, N., & Hillier, S. Developing fluency in a language of tactile communication. Frontiers in Rehabilitation Sciences, 2023. 3, 1027344
  5. 5.0 5.1 Wise CH. Orthopaedic manual physical therapy: from art to evidence: FA Davis; 2015.
  6. Wainwright SF, Shepard KF, Harman LB, Stephens J. Novice and experienced physical therapist clinicians: a comparison of how reflection is used to inform the clinical decision-making process. Physical Therapy. 2010;90(1):75-88.
  7. Ford JJ, Slater SL, Richards MC, et al. Individualised manual therapy plus guideline-based advice vs advice alone for people with clinical features of lumbar zygapophyseal joint pain: a randomised controlled trial. Physiotherapy. 2019;105(1):53-64. doi:10.1016/
  8. Langridge N, Roberts L, Pope C. The clinical reasoning processes of extended scope physiotherapists assessing patients with low back pain. Man Ther. 2015;20(6):745-750. doi:10.1016/j.math.2015.01.005
  9. Donald A. Schön, The reflective practitioner- how professionals think in action.Basic Books, 1983. Available from:
  10. Tuttle N, Hazle C. An empirical, pragmatic approach applying reflection in interaction approach to manual therapy treatments. Physiotherapy Theory and Practice. 2021;37(7):775-86.
  11. Øberg GK, Normann B, Gallagher S. Embodied-enactive clinical reasoning in physical therapy. Physiotherapy theory and practice. 2015;31(4):244-52.