| How We Treat
Manual Therapy
Bang your elbow and you rub it. Everything here is that reflex — refined by anatomy and aimed on purpose.
Pain gating, descending inhibition, affective touch and PNF: how hands-on treatment actually works, what it definitely isn’t doing, and where it earns its place.
Overview
Why Rubbing It Better Actually Works
Bang your elbow and you rub it. You’ve done this since you were four, and you never needed a theory.
In 1965 two researchers gave it one, and in doing so wrote the first line of everything on this page. Manual therapy is that childhood reflex — refined by anatomy, aimed deliberately, and dosed on purpose.
It’s also the treatment most surrounded by nonsense. So, plainly: nothing is being put back in. Nothing was out. The click isn’t the point, and the click isn’t the cure.
What manual therapy actually does is more interesting than the folklore, better supported by evidence, and — this matters — more honest about its own limits.
The Mechanism
Four Levels, All at Once
The modern explanation is simpler than the old one: pressure or movement applied to your body sets off a chain of events in your nervous system. The hands pull the trigger. Your nervous system does the work. Tap through each level.
"But doesn’t it release endorphins?"
Almost everyone asks this, and the answer is a bit more interesting than yes or no.
Yes, endorphins go up. After neck manipulation, endorphin levels in the blood rose slightly five minutes later — while the people who got a fake treatment, or nothing at all, drifted the other way.17 After massage, they rose by about 16%, peaking at five minutes and settling back over the next hour.18
But they don’t seem to be the thing easing your pain. Researchers switched the endorphin system off and treated anyway — and the pain relief was exactly the same. Switch off serotonin instead, and it disappeared completely.5
So two things are happening at once, and they’re doing different jobs. One system turns your pain down. The endorphins are more likely why people say they feel well afterwards — warm, calm, lighter — rather than just less sore.
Worth knowing: the endorphin studies are small and old, and a blood test can’t tell you what’s happening inside the spinal cord. The switching-off experiments are stronger evidence, but were done in animals. This is our best current read, not the last word.
The mechanical event is the doorway. The nervous system is the building.
Myth or Fact
What Manual Therapy Is Not Doing
Being clear about this is part of the treatment — because the explanations people carry away shape what they believe about their own fragility. Tap each.
Nothing was out. The forces involved aren’t sufficient to reposition a joint, and manipulation doesn’t produce demonstrable changes in alignment.
This matters, because believing your spine slips out of place makes you treat it as fragile — and fragility beliefs predict worse outcomes.
The click is a gas bubble forming in the joint fluid. It isn’t required for the technique to work, its presence doesn’t predict a better outcome, and its absence doesn’t mean anything failed.
Studies comparing manipulation aimed at a specific segment with deliberately non-targeted manipulation repeatedly find similar effects.
If the mechanism were purely mechanical and local, that could not possibly be true — which is one of the strongest arguments that the effect is neurological.
The forces needed to meaningfully deform dense connective tissue are far beyond what hands can generate.
What changes is muscle tone, tolerance and sensitivity — all via the nervous system. Which is a far more robust thing to be than a plumbing repair.
There are no “toxins” being flushed. And the widely-repeated claim that massage lowers cortisol rests on much weaker ground than its popularity suggests — a careful re-analysis of the literature found the evidence didn’t hold up.8
The C-tactile afferent system, by contrast, is solid neuroscience. We’d rather tell you the real mechanism.
There is human evidence that massage and affectionate touch can raise circulating oxytocin. But the studies are small and the effect sizes vary considerably.
We’d rather flag it as interesting than sell it as fact.
Stretching
PNF — and the Stretch That Isn’t a Stretch
Proprioceptive neuromuscular facilitation came out of work in the 1940s and remains one of the quickest ways to gain range.
The technique is simple. We take the limb to its available end range, you push against resistance for several seconds, then relax — and the limb moves further. Often immediately, and often startlingly.
A reflex that switches the muscle off
The textbook version was that pushing against resistance builds tension in the tendon, sensors there notice it, and they reflexively tell the muscle to let go — so it lengthens.
Neat, tidy, and taught for decades. The evidence doesn’t really back it up.
Your nervous system changes its mind
When researchers measured the muscle, the switching-off simply wasn’t there — and the timings didn’t add up either.
What seems to happen instead is that you become willing to go further. Your nervous system revises its judgement about how much length is safe at this joint, today, with someone else supporting the limb.13 The muscle didn’t get longer. Your body stopped objecting.
Occupy the range or lose it
If the gain is a change of mind rather than a change of length, it’s reversible — and it will reverse unless you give your nervous system a reason to keep it.
Which is exactly why we’ll ask you to use the new range under load, immediately, rather than admire it. Tolerance that isn’t occupied is tolerance that gets handed back.
The Evidence
How Well Does It Work?
The consistent finding across every body region
Back, neck, shoulder, knee, headache — wherever you look, the reviews say much the same thing:
Hands-on treatment produces real but modest improvements in pain and movement. On its own, those improvements don’t last long. Combined with exercise, they do.
Hands-on plus exercise reliably beats hands-on alone. It doesn’t reliably beat exercise alone. That’s the honest shape of it.
NICE reached the same conclusion and wrote it into guidance. NG59 recommends considering manual therapy for low back pain and sciatica only as part of a package that includes exercise — not as a standalone treatment.12
That isn’t a slight. It’s an accurate description of where the benefit lies — and it gives manual therapy its clearest job in a physiotherapy clinic.
Opening a window
If pain or stiffness is preventing you from loading a tissue properly, then reducing that pain and stiffness for the next twenty minutes — or the next three days — is not a trivial achievement.
It’s the difference between a rehabilitation programme that happens and one that doesn’t. The hands buy time. The exercise spends it.
What We Do
The Techniques, and What Each Is For
Joint mobilisation
Graded, rhythmic movement at a joint. Used to reduce pain and increase tolerated range — the grade and speed chosen for how irritable the joint currently is.
Manipulation
A single, small, fast thrust. Occasionally noisy. Used sparingly and specifically, never as a routine, and never without telling you first.
Soft tissue work
Sustained pressure and gliding through muscle and its coverings — both to reduce tone and to make movement tolerable enough to practise.
PNF and muscle energy
Your own contraction used to unlock range, then immediately loaded so you keep it.
Neural mobilisation
Graded movement of a nerve relative to the tissues around it, where a nerve has become mechanically sensitive.
Unhurried, deliberate touch
Not filler. The C-tactile system is a real analgesic pathway, and how fast someone works is part of the treatment.
Safety
Including the Question You Might Not Ask
Manual therapy is a low-risk treatment. By a considerable margin the most common side effect is transient soreness — an ache for a day or two afterwards, reported by a substantial minority of people, which settles without consequence. We’ll always warn you in advance rather than let you discover it.
Neck manipulation and stroke — the honest position
This is the question people most often want to ask and often don’t, so here it is.
A tear in one of the arteries in the neck is a very rare event. And yes — studies have found that people who’ve had one are more likely to have seen someone for neck treatment beforehand.
What’s genuinely unresolved is whether the treatment caused it. Here’s the problem: a tear like this starts with neck pain and headache. Those are exactly the symptoms that make someone book an appointment in the first place. So the treatment may be a sign that something was already going wrong, rather than the thing that caused it. Tellingly, the same increased likelihood shows up for having seen a GP.9
We take this seriously without dismissing it or dramatising it: we screen for it, we don’t use fast cervical technique routinely, we’ll tell you when we’re considering it and why — and you can decline it and still get everything else.
When to Seek Help
⚠ Tell us, or seek medical advice, if you notice
- Dizziness, visual disturbance, difficulty speaking or swallowing, or unsteadiness — particularly after neck treatment
- A sudden, severe headache unlike any you’ve had before
- New or worsening numbness, pins and needles, or weakness in an arm or leg
- Numbness around the saddle area or loss of bladder or bowel control — this is an emergency
- Soreness after treatment that is severe, or that lasts more than three days
- Pain that wakes you every night, unexplained weight loss, or feeling generally unwell
Common Questions
Frequently Asked Questions
Does it need to hurt to work?
No. There’s no evidence that harder is better, and the affective touch pathway responds to gentle, slow contact rather than deep pressure.
Some techniques are firm and some discomfort is normal, but if you’re bracing against it, we’re working against ourselves — the nervous system doesn’t turn its guard down while you’re gripping the couch.
Does it release endorphins?
Yes — but probably not for the reason you’d think.
Endorphins do go up after both massage and manipulation, peaking about five minutes in.17,18 The surprise is that when researchers switched the endorphin system off, the pain relief happened anyway. Switch off serotonin instead and it vanished.5
So something else is easing your pain. The endorphins are more likely why you feel good afterwards — calm, warm, lighter — rather than just less sore. Both are real. They’re doing different jobs.
How long will the effect last?
Used alone, honestly: hours to a few days. That’s what the evidence shows and we won’t pretend otherwise.
Which is exactly why we use it to open a window rather than as the treatment itself. What makes the change stick is what you do in that window.
Why do I feel sore afterwards?
Transient post-treatment soreness is the most common side effect — a normal tissue response, similar to the day-after ache from unfamiliar exercise. It typically settles within 24–48 hours.
If it’s severe, or lasting beyond three days, tell us. We’ll adjust the dose.
Do I need to keep coming for maintenance?
Almost certainly not, and be sceptical of anyone who says you do — including us.
Open-ended hands-on appointments with no plan for what you do in between is the pattern to watch for. Manual therapy earns its place in a plan that has a goal, a measure and an end.
Is manipulation safe on my neck?
For most people, yes — and we screen carefully. But we don’t use it routinely, we’ll always explain first, and declining it costs you nothing: mobilisation, soft tissue work and exercise are all available and effective.
See the honest position on arterial dissection above.
Can I have manual therapy while pregnant, or on blood thinners?
Usually yes, with technique modified accordingly — position, force and grade all adjusted. Blood thinners mean we avoid firm soft tissue work that could cause bruising.
Tell us about medications, recent surgery, osteoporosis, inflammatory arthritis and any recent trauma at your assessment.
Where we won’t oversell it
Used alone, manual therapy’s effects are modest and they fade. It doesn’t correct posture, realign a pelvis, break down scar tissue by force, or fix a tendon.
It earns its place here the same way everything else does: by making the loading possible — in a plan with a goal, an outcome measure and an end.
Where We Work
Manual therapy in North Norfolk
Tidal Physiotherapy is based in Wells-next-the-Sea, and manual therapy is available both at the clinic and on home visits across North Norfolk — including Fakenham, Holt, Burnham Market, Walsingham and Blakeney.
Appointments are with Brandon Dobson MSc, MCSP, HCPC registered. You do not need a GP referral, and we will tell you honestly at your assessment whether manual therapy is the right tool for your problem — or whether something else on this list is.
Not Sure If This Is Right for You?
Nothing on this page is a plan until it’s pointed at your goal. An assessment is where we work out which of these tools — if any — belongs in yours. If you have a scan report you don’t understand, bring it with you.
Book Your AssessmentOther Treatment Modalities:
References
- Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy, 2009;14(5):531–538.
- Bialosky JE, Beneciuk JM, Bishop MD, et al. Unraveling the mechanisms of manual therapy: modeling an approach. Journal of Orthopaedic & Sports Physical Therapy, 2018;48(1):8–18.
- Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965;150(3699):971–979.
- Bishop MD, Beneciuk JM, George SZ. Immediate reduction in temporal sensory summation after thoracic spinal manipulation. The Spine Journal, 2011;11(5):440–446.
- Skyba DA, Radhakrishnan R, Rohlwing JJ, Wright A, Sluka KA. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain, 2003;106(1–2):159–168.
- Löken LS, Wessberg J, Morrison I, McGlone F, Olausson H. Coding of pleasant touch by unmyelinated afferents in humans. Nature Neuroscience, 2009;12(5):547–548.
- McGlone F, Wessberg J, Olausson H. Discriminative and affective touch: sensing and feeling. Neuron, 2014;82(4):737–755.
- Moyer CA, Seefeldt L, Mann ES, Jackley LM. Does massage therapy reduce cortisol? A comprehensive quantitative review. Journal of Bodywork and Movement Therapies, 2011;15(1):3–14.
- Chaibi A, Russell MB. A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual therapy. Journal of Headache and Pain, 2015;16:99; and Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care. Spine, 2008;33(4S):S176–S183.
- Hidalgo B, Hall T, Bossert J, et al. The efficacy of manual therapy and exercise for treating non-specific neck pain: a systematic review. Journal of Back and Musculoskeletal Rehabilitation, 2017;30(6):1149–1169.
- Rubinstein SM, de Zoete A, van Middelkoop M, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis. BMJ, 2019;364:l689.
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59, 2016 (updated 2020).
- Hindle KB, Whitcomb TJ, Briggs WO, Hong J. Proprioceptive neuromuscular facilitation (PNF): its mechanisms and effects on range of motion and muscular function. Journal of Human Kinetics, 2012;31:105–113.
- Testa M, Rossettini G. Enhance placebo, avoid nocebo: how contextual factors affect physiotherapy outcomes. Manual Therapy, 2016;24:65–74.
- Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist–patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical Therapy, 2010;90(8):1099–1110.
- Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical Therapy, 2013;93(4):470–478.
- Vernon HT, Dhami MS, Howley TP, Annett R. Spinal manipulation and beta-endorphin: a controlled study of the effect of a spinal manipulation on plasma beta-endorphin levels in normal males. Journal of Manipulative and Physiological Therapeutics, 1986;9(2):115–123.
- Kaada B, Torsteinbø O. Increase of plasma beta-endorphins in connective tissue massage. General Pharmacology, 1989;20(4):487–489. doi:10.1016/0306-3623(89)90200-0.