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I have spent most of my career reading, writing, and thinking about manual therapy, and it still manages to be polarizing in certain circles. What amazes me is how much energy gets spent fighting the same fight, because honestly not much has changed.
The myths are still alive and well, and the research keeps pointing in the same direction it has for years. Manual therapy can help in the short term, and when you test it in a tightly controlled trial it comes out no better than most other things we do.
Meanwhile, in clinic, people want it, I am happy to provide it, and for many it offers meaningful relief that lets them move more. A few papers landed this year, so it felt like a good moment to think about the gap between the debate and the day to day.
Here is the headline from the past year of manual therapy research.
Not much changed. And I mean that as a good thing.
A 2025 systematic review with meta-analysis in the European Journal of Pain by González-Gómez and colleagues put manual therapy head to head against exercise for chronic low back pain across six trials and 743 people, and neither pulled clearly ahead. Both helped, to a broadly similar degree.
A 2025 umbrella review pooling twenty-one reviews and around thirty-five thousand participants found manual therapy delivers short-term relief for pain, a standardized mean difference near minus 0.43 (small to moderate effect) strongest when paired with exercise, with the long-term picture staying uncertain.
And a 2025 network meta-analysis in the Journal of Orthopaedic and Sports Physical Therapy asked whether how we deliver spinal manipulation changes the result? Target, thrust, measure. The answer, in line with a 2023 review in the same journal on hitting a specific vertebral level, was no.
None of this is new. Most of us never believed or stopped believing we were putting bones back into place, breaking up adhesions or realigning the body a long time ago, even if that myth still runs wild through the rest of healthcare, social media, and our patients' heads. So the new evidence is not overturning our model.
I had the chance to hear Joel Bialosky speak to the advances in manual therapy in 2025, and he said as much. Not much has changed in the model of his thinking or in the research he has conducted, and this is a man who has spent a career studying the mechanisms. Manual therapy is a short-term symptom modifier that works through the nervous system and the context around it.
What is worth sitting with is not the mechanism, but the tone we should take about it. Some seem to keep waiting for research that either rescues manual therapy or finally kills it, and instead we get another year of data saying the same measured thing. It helps some people, to varying degrees, and a lot of them want it and like it.
That is allowed to be enough in my view.
Short-term relief is not a consolation prize.
Let me repeat this...
Short-term relief is not a consolation prize.
In my view anyways.
Somewhere along the way, "it only helps in the short term" hardened into an insult, and I think that is a mistake. A window of less pain is often the exact thing that lets a frightened, guarded person move, trust you, and start the active work that carries the long-term load. Manual therapy buys that window, safely, for a good chunk of people.
If I was in a ton of pain, and knew there was something that was quick and low risk that might get me some relief, even for a short period of time, I would take it. What if it was you or a family member, what would you want for them?
Okay, I want to hold two things at once here, because this is where I think some people tend to overcorrect. Yes, the effects are transient and non-specific, and no, that does not make manual therapy useless. The relief is real and measurable. Dismissing it as pure theatre is its own kind of overclaiming, just pointed the other way.
While I am at it, one of the loudest arguments against manual therapy deserves a harder look. We often hear that it strips away self-efficacy and breeds dependence on the therapist. But I have not actually come across research that demonstrates this to date in 2026. I hear about it in clinical circles, and I have no doubt it happens in some rooms with some clinicians, so I am not claiming it does not exist. I am saying I do not know of the study, and it is worth being honest that a good chunk of our anti-manual-therapy conviction rests on a mechanism we mostly assume rather than one we have measured.
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My position has not really moved in years: I use it, on almost everyone, and never as the main event. It sits a bit further down on my list behind specific reassurance, education, treatment planning and exercise. But I don't forget how using our hands can calm things down to give people a well deserved break from their suffering and advance loading.
We can turn a scary movement into a lived demonstration that hurt did not equal harm and pain can be changed. Meeting a patient where their expectations already are so they stay in the room long enough to hear the rest is important too. When it does those things, it is helping. When it is just something I do to every patient because my hands are trained and the visit has a gap, I should ask myself what it is actually for.
I think it also helps to run the simple risk calculation. Manual therapy is low risk, it takes very little time to apply, and in the right person it carries real potential upside. We have all met the rapid responder, the patient whose neck or back settles dramatically inside a session and who never looks back. You cannot always pick them in advance, but the cost of finding out is small. Low risk, low time, some genuine potential benefit. In that setup, trying it and watching how this particular person responds is a perfectly reasonable clinical move, as long as you stay honest about what you are doing and are ready to move on if it does not deliver. Is this safer and potentially more effective than say a patient taking a pile of Tylenol, Advil, muscle relaxants or gabapentin...I tend to think yes.
The part that has aged well, and that this year's research reinforces, is that the value of manual therapy is not in the specificity. If the exact tissue or level does not matter and the exact technique does not matter, then the skill was never in finding the perfect spot. It is in the therapeutic alliance, the thorough assessment, the planning, the timing, the confidence of the contact, and above all the words wrapped around it.
Manual therapy paired with a fragilizing story is a net negative no matter how good your hands are. The same technique paired with "we are settling this down so we can get you moving, and the fact that we can change it at all tells us a lot" becomes a door into everything that actually helps.
So use it, and use it transparently. Tell people it is short-term on purpose. Fold their preferences into the decision. And plan your own exit from the start, because the goal is to prove to the patient that they do not need you or your hands to be okay.
That is the whole game, and it has not changed.
Next time you use a hands-on technique and someone feels better, turn it into a prediction error instead of a treatment.
Before you start, pick a movement they expect to hurt and ask them to rate it. Do your technique. Then retest that exact movement while the relief is fresh and let them feel the gap between what they predicted and what happened.
Say something like, "You thought that would be a six, it was a two, so your system can change. Let us use that."
Then move straight into an active task. You are borrowing the short-term relief to teach a long-term belief, and handing the credit to them.
The pieces I drew on this edition, in one line each:
- González-Gómez et al., European Journal of Pain, 2025: head to head, manual therapy and exercise came out about even for chronic low back pain.
- Manual therapy umbrella review, 2025: pooling twenty-one reviews, manual therapy gives real short-term pain relief, strongest alongside exercise, with long-term effects still uncertain.
- Spinal manipulation application procedures, network meta-analysis, JOSPT, 2025: how you deliver the manipulation, target, thrust, and region, did not change the outcome.
- Targeting a specific vertebral level, JOSPT, 2023: hitting a precise segment was no better than a general approach.
- Spinal Manipulation: Time to Rethink How We Deliver and Teach It, JOSPT blog, 2025: a readable companion piece arguing we should teach manipulation as a contextual tool, not a precision one.
- Shhhh, I use manual therapy, parts 1 and 2: my own two-part piece on keeping manual therapy inside a modern, active practice, which still holds up against this year's data.
Joel Bialosky put it better than I ever have:
"attributing successful spinal manipulative therapy outcomes solely to the identification and correction of biomechanical faults makes as much sense as crediting a beard for winning a hockey playoff series."
The relief is real for many people.
The story we tell about why it happened is where we either help or harm.
Get the story right and a two-minute technique becomes an argument for the patient's own resilience.
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Touch is one of the oldest things we do to each other. A firm handshake, a hand on the shoulder, the way a team pats each other on the back before a big game. It lowers the volume on threat, and that is not a trick, it is biology.
So I have made my peace with using my hands, as long as I stay honest about what they are for. Not to fix, not to correct, not to make anyone dependent on me. Just to open a short, safe window where a person hurts a little less and is willing to move, and then to spend that window building something they can carry out the door without me.
This year's research did not tell us to put the tools down. It told us we can stop apologizing for picking them up, as long as we use them well.
