Manual Therapy Mechanisms in Musculoskeletal Pain Management

Manual therapy encompasses a range of hands‐on interventions, including joint mobilisation, high‐velocity low‐amplitude thrusts and soft‐tissue techniques, employed to alleviate musculoskeletal pain. Historically attributed to biomechanical effects on joint alignment and tissue extensibility, contemporary research emphasises neurophysiological processes. Mechanical stimuli are thought to activate peripheral mechanoreceptors, leading to modulation of dorsal horn excitability and engagement of descending inhibitory pathways. These effects can manifest locally at the site of application, regionally within the same spinal or articular segment and, in some cases, systemically through central pain‐modulatory networks. Factors such as dosage, force magnitude and segmental targeting influence the magnitude and distribution of hypoalgesic responses. Emerging evidence also highlights the role of patient expectation and contextual factors in shaping clinical outcomes. Advancements in imaging and quantitative sensory testing have begun to elucidate changes in pressure pain thresholds, thermal pain sensitivity and temporal summation following manual interventions. Understanding the interplay between biomechanical loading, neurophysiological modulation and psychosocial influences is essential for optimising treatment protocols and integrating manual therapy within multimodal pain management strategies.

Research from Nature Portfolio

One systematic review compared spinal manipulation applied to clinically prescribed versus non-prescribed segments and found no superior pain relief with “targeted” versus “non-targeted” application, challenging the premise of strict joint specificity. A randomised trial further investigated manipulation delivered to the stiffest segment versus the segment with lowest pain threshold; while patient‐reported pain and stiffness did not differ significantly, pressure pain threshold increased markedly when treatment was directed according to pain sensitivity. Together these studies support a primary neurophysiological mechanism, in which reflexive and segment‐dependent pathways modulate nociceptive processing rather than precise biomechanical correction alone.

Manual Therapy Mechanisms in Musculoskeletal Pain Management publication trend

The graph below shows the total number of articles in manual therapy mechanisms in musculoskeletal pain management across all publications each year (not limited to Nature Index journals).

Technical terms

Hypoalgesia: A reduction in pain sensitivity following an intervention.

Pressure pain threshold (PPT): The minimum force that elicits pain when applied to tissue.

Temporal summation: Progressive increase in pain perception during repetitive noxious stimulation.

Conditioned pain modulation (CPM): The capacity of one painful stimulus to inhibit another, reflecting endogenous analgesic systems.

High‐velocity low‐amplitude (HVLA) manipulation: A rapid, controlled thrust applied to a joint to induce movement and neurophysiological effects.

References

1. The Immediate Hypoalgesic Effect of Low and High Force Thoracic Mobilizations in Asymptomatic Subjects as Measured by Pain Pressure Thresholds (PPT). Diagnostics (2023).
2. The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review. Scientific Reports (2021).
3. Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study. BMC Musculoskeletal Disorders (2006).
4. The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders (2008).
5. The regional effect of spinal manipulation on the pressure pain threshold in asymptomatic subjects: a systematic literature review. Chiropractic & Manual Therapies (2018).
6. Manipulation-induced hypoalgesia in musculoskeletal pain populations: a systematic critical review and meta-analysis. Chiropractic & Manual Therapies (2019).
7. The effect on clinical outcomes when targeting spinal manipulation at stiffness or pain sensitivity: a randomized trial. Scientific Reports (2020).
8. Efficacy of Manual Therapy on Facilitatory Nociception and Endogenous Pain Modulation in Older Adults with Knee Osteoarthritis: A Case Series. Applied Sciences (2021).