Manual Therapy: Why Not “Crack AND Clang”?

When the 2021 Clinical Practice Guideline was dropped in JOSPT for management of low back pain, everyone knew what was coming (George 2021).  The publication summarized the most up to date evidence surrounding low back pain management with sections outlining efficacy of mainstay interventions like exercise, traction, dry needling, and manual therapy.  Of course, it was the modality of manual therapy that created a social media storm that would almost immediately follow the publication’s release.

What Did The Guideline Say About Manual Therapy?

We’ll keep this summary brief, but essentially this guideline gave a very strong and clear recommendation for manual therapy intervention. In fact, manual therapy (which includes thrust and non thrust joint manipulation) was the ONLY intervention that received a “should use” designation, while all other treatment options landed within “may use” or “can use”.

Feedback from the Medical Community on Manual Physical Therapy

Following the publication, it also became clear that the label “should” was too much for the manual therapy haters among us. Groups of individuals immediately began launching a counter attack saying the evidence utilized to reach the conclusion was insufficient and biased.  They argued what they always argue, that active interventions like exercise can deliver the same results while keeping the patient in control of their destiny versus relying on a “white knight” healthcare provider to work the magic for them which results in dependency.  They claim the neurophysiological benefits of manual therapy are short term and essentially leverage placebo to do anything at all.

The “exercise only” folks in the face of a comprehensive guideline in a highly reputable journal by an all-star cast of researchers stating in no uncertain terms they are wrong have chosen to yet again stand their ground.  Thus the stage is set with the manual therapy advocates on one side, the exercise zealots standing in firm opposition, and the people of ICE Physio located in the middle wondering why in the world we can’t see what we believe to be an obvious best past forward.  Let us explain.

What’s ICE’s Take on Manual Therapy?

The exercise lovers are right.  There is nothing like progressive loading and cardiorespiratory fitness development to truly change someone’s life. The goal is to make patients independent of the medical system and confident they can face most life challenges without injury and self manage when they encounter problems. With that, we also believe that manual therapy lovers are also right.  People love manual therapy.  If we had a dollar for every physical therapist that asked us why patients will pay so much out of pocket for massage, stretching, and joint manipulation – we would be set for life.  It’s simple, they’ll pay for it because they like it and believe it helps them feel better.

We’re quite certain dear reader you can identify where this plotline is heading, and you’re right, why in the world not do both?  Why can we not acknowledge that using a bit of spinal manipulation, massage, dry needling, and the like can do wonders to help someone in the short term feel good enough to try wading into some resistance training? Why not pitch those passive interventions with language that helps patients strive for autonomy and long term wins?  Comments from providers along these lines would be excellent examples: “Donna I know your back is hurting something terrible, we’ve got some ideas to take the edge off those symptoms.

The ideas aren’t long term solutions but they will help you exercise more comfortably which IS the long term win” or “Eric I wouldn’t be willing to stay active if my back hurt that bad either, but we gotta figure something out because bed rest is the one thing we know for sure moves the needle in the wrong direction.  Let’s get after this primarily with manual therapy for the first 1-2 weeks, then we’ll get you back behind the wheel and show you how to kick this thing for good with high value exercises and a few lifestyle changes”.

It doesn’t sound hard because it isn’t, we’re just too committed to defending our core beliefs to allow these two positions to merge into a best solution for our patients.  The Clinical Practice Guidelines make it clear – both manual therapy and exercise have important roles in managing low back pain, let’s leverage them together because our patients deserve it. Join The Institute of Clinical Excellence team in our three spine courses where manual therapy in all of its forms is covered ALONGSIDE individualized exercise prescription.


George, Steven Z., Julie M. Fritz, Sheri P. Silfies, Michael J. Schneider, Jason M. Beneciuk, Trevor A. Lentz, John R. Gilliam, Stephanie Hendren, and Katherine S. Norman. 2021. “Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021.” The Journal of Orthopaedic and Sports Physical Therapy 51 (11): CPG1–60.