What Manual Therapy Actually Does: The Modern Science Behind the Technique

If you've ever visited a physical therapist and experienced joint mobilization, soft tissue massage, or spinal manipulation, you’ve likely benefited from manual therapy. But what’s actually happening when a therapist lays hands on you? Are we moving joints into alignment? Breaking down scar tissue? Releasing fascia?

At Rise Rehab and Sport Performance, we integrate manual therapy as part of a broader movement-based strategy. But we also believe in transparency — helping you understand not just what we do, but why it works.

Thanks to a growing body of modern research—most notably a 2025 publication by D.L. Keter and colleagues titled “The Mechanisms of Manual Therapy: A Living Review of Systematic, Narrative, and Scoping Reviews”—we now have a much more nuanced understanding of what manual therapy is really doing to the human body. Spoiler: it’s probably not what many of us were taught back in the 1990s.

Gone are the days of confidently claiming that we “realign joints” or “break up scar tissue” with our hands. What’s emerging instead is a complex picture of multisystem effects—neurological, vascular, hormonal, and perceptual—that challenge older biomechanical narratives. This updated perspective doesn’t diminish the value of manual therapy; rather, it reframes it in a more scientifically grounded, patient-centered way.

In this post, we’ll explore the key mechanisms behind manual therapy — what it does (and doesn’t) do — and how we at Rise use this knowledge to create meaningful, long-lasting change for our patients.

What Is Manual Therapy?

Manual therapy refers to a collection of hands-on techniques aimed at improving movement, reducing pain, and restoring function. These may include:

• Joint mobilizations and manipulations

• Myofascial release and soft tissue mobilization

• Trigger point therapy

• Muscle energy techniques (METs)

• Neural mobilizations

Historically, these were explained through biomechanical models: therapists were taught they were “realigning” the spine, “lengthening” fascia, or “breaking adhesions.” But modern science tells a more nuanced — and more powerful — story.

The Shift from Structural to Neurophysiological Models

One of the biggest takeaways from Dr. Keter’s review is the understanding that manual therapy works primarily through neurophysiological — not purely biomechanical — mechanisms.

Let’s break that down.

1. Manual Therapy Doesn’t “Fix” Structure

Despite what we may have heard in the past, research shows manual therapy doesn’t significantly alter joint position or “release” fascia in the mechanical sense.

For example:

• Spinal manipulation does not permanently reposition vertebrae.

• Myofascial release does not physically “melt” fascial adhesions.

These structural metaphors can be misleading — and they don’t hold up under scientific scrutiny. The forces applied during manual therapy are often too small to cause actual deformation of tissue, especially deeper structures like fascia or intervertebral discs.

Instead, the effects of manual therapy are better understood through changes in the nervous system and how the brain processes sensory input.

The Real Mechanisms: A Multi-System Response

According to Dr. Keter’s review, manual therapy creates a multimodal physiological response — involving mechanical, neurophysiological, endocrine, and psychological effects.

Let’s look at each of these mechanisms in detail.

1. Mechanical Stimulus

Yes — manual therapy does create a mechanical input. When a therapist mobilizes a joint or applies soft tissue pressure, that’s a mechanical load on skin, muscle, fascia, and even the nervous system (in the case of neurodynamic techniques).

But this is just the starting point — the real impact comes from how the body interprets that input.

2. Peripheral Nervous System Response

That mechanical input stimulates mechanoreceptors and proprioceptors in the skin, muscles, and joints. These receptors send signals to the spinal cord and brain, initiating a cascade of responses.

This can lead to:

• Reduced activity in nociceptive (pain) pathways

• Temporary improvements in muscle tone and flexibility

• Changes in stretch tolerance and protective guarding

It’s not that we’ve “fixed” the tissue — we’ve changed how the nervous system is interpreting the area.

3. Central Nervous System Modulation

Manual therapy also affects the central nervous system (CNS) — especially the brain’s pain modulation centers.

Studies show that manual therapy:

• Activates the periaqueductal gray (PAG) — a brain region involved in pain inhibition

• Modulates activity in the anterior cingulate cortex, insula, and prefrontal cortex

• Releases endogenous opioids, cannabinoids, and serotonin

• Alters body schema and movement perception

In plain terms: manual therapy can “recalibrate” how the brain perceives threat, pain, and movement — often leading to decreased pain, improved range of motion, and better motor control.

4. Autonomic Nervous System Response

Manual therapy can also affect the autonomic nervous system — particularly shifting patients from a sympathetic (fight-or-flight) state to a parasympathetic (rest-and-digest) mode.

This explains why some patients feel calm, relaxed, or even sleepy after treatment. Heart rate variability studies show increased parasympathetic tone following hands-on therapy.

This is especially important for patients in persistent pain, where chronic sympathetic dominance can heighten sensitivity and muscle tone.

5. Placebo and Expectation Effects

We can’t ignore the role of context, communication, and expectation.

Manual therapy — delivered with confidence, clinical reasoning, and therapeutic intent — creates a powerful contextual effect. This can:

• Lower anxiety

• Improve trust and therapeutic alliance

• Increase patient belief in recovery

• Activate endogenous pain modulation pathways

As Dr. Keter notes, these aren’t “just placebo” — they’re real, measurable, and biologically grounded responses.

6. Psychological and Cognitive Shifts

Manual therapy also affects the way patients think and feel about their body.

A well-timed manual technique can:

• Disconfirm fear-based beliefs (e.g., “my spine is out of place”)

• Enhance movement confidence (“I can bend again without pain”)

• Serve as a “gateway” to active therapy and exercise

This is especially helpful in patients with kinesiophobia, catastrophizing, or poor interoception.

So… Should We Still Use Manual Therapy?

Absolutely — but with the right intent, explanation, and integration.

At Rise, we don’t use manual therapy as a “standalone fix” or passive modality.

Instead, we use it strategically:

• To reduce sensitivity and improve movement tolerance

• To enhance the effect of exercise

• To build trust and therapeutic momentum

• To facilitate body awareness and motor relearning

We also educate our patients on what’s actually happening — to remove fear and replace it with clarity.

Manual Therapy in Practice at Rise

Let’s walk through how we use manual therapy as part of a complete plan of care.

1. Initial Assessment and Hypothesis-Driven Application

We start with a full functional assessment: movement screening, orthopedic testing, palpation, and patient history.

From there, we form hypotheses:

• Is there protective guarding limiting movement?

• Is there neural sensitivity?

• Is a patient stuck in a sympathetic state?

• Is pain affecting motor control?

Manual therapy is then applied intentionally — not generically.

2. Reassessment and Immediate Feedback

We always follow manual therapy with reassessment. For example:

• Did cervical joint mobilization improve rotation or reduce headache intensity?

• Did thoracic manipulation change shoulder elevation?

• Did glute release increase hip mobility?

This not only helps us measure impact — it shows patients that change is possible.

3. Integration with Movement and Exercise

Manual therapy is followed by targeted exercise to:

• Reinforce new range of motion

• Retrain motor control

• Promote movement variability

• Build resilience through load

For example:

• After ankle joint mobilization → deep squat variations

• After lumbar manipulation → core control drills

• After scapular release → serratus and lower trap activation

The goal is to transition patients from passive input to active self-regulation.

4. Education and Self-Mobilization

We believe in empowering patients. If a manual technique helps, we’ll teach:

• Self-mobilization (e.g., peanut rollers, banded joint mobilizations)

• Nerve glides and neurodynamic drills

• Breath work and vagal tone enhancement

• Movement awareness strategies (e.g., Feldenkrais-inspired exercises)

Manual therapy should never create dependency — it should create momentum.

When Manual Therapy Might Not Be Indicated

Despite its value, manual therapy isn’t appropriate for every case.

At Rise, we avoid or modify manual therapy when:

• There’s acute inflammation or tissue healing where compression would delay recovery

• A patient has high levels of fear, anxiety, or medical trauma history (unless touch is clearly beneficial)

• Passive treatments risk reinforcing a belief that the body is “broken” or needs to be “fixed externally”

• The technique might provoke a flare-up or worsen central sensitization

Clinical reasoning and patient context always come first.

Final Thoughts: Manual Therapy Isn’t Magic — But It’s Powerful

At Rise Rehab and Sport Performance, we use this science to shape how we treat. Manual therapy is a tool — not a cure. But when applied thoughtfully, it becomes a catalyst for better movement, reduced pain, and renewed confidence.

If you’re dealing with pain or movement limitations and wondering whether manual therapy might help, we’d love to talk. Our team of physical therapists blends the best of hands-on care, movement science, and patient education to help you move stronger, live better, and perform at your best.

Curious if manual therapy is right for your condition? Book a free 1-on-1 consult with a RISE physical therapist — no pressure, no obligation. Just real answers from people who care.