Gepubliceerd op: 02 Apr 2025
Manual Therapy and Contextual Factors: The Complex Interaction Between Technique, Patient, and Environment
Manual therapy (MT) remains a cornerstone in treating musculoskeletal disorders within primary care in the Netherlands. While clinical practice guidelines support MT for conditions like neck and back pain, systematic reviews consistently show only modest treatment effects. These limited outcomes have sparked renewed interest in understanding the underlying mechanisms—how and why MT works—with a growing focus on contextual factors (CFs). This blog explores recent research by Bialosky, Keter, and Cook, offering insights that deepen our understanding of MT and provide practical tools for healthcare professionals pursuing continuing professional development (CPD).
From Technique to Context: The Bialosky Model
Bialosky et al. (2018) proposed an influential model highlighting that MT's effectiveness stems not just from biomechanical action but also from neurophysiological pathways, particularly central pain modulation. These effects are shaped by psychological and social inputs, such as patient expectations, previous experiences, and the therapeutic relationship. This model challenges the traditional belief that stronger or more precise techniques yield better results. Instead, it emphasizes a biopsychosocial approach, where brain processes, emotional states, and environmental cues play crucial roles in the patient’s experience of pain (Bialosky et al., 2018).
The Impact of Contextual Factors: Insights from Keter et al.
Keter et al. (2025) build on this foundation by categorizing CFs into patient-, provider-, environmental-, and system-level influences. These can function as mediators (how a treatment works) or moderators (for whom it works). Their review shows that variables like anxiety, catastrophizing, sleep deprivation, and even room lighting can affect treatment outcomes. They recommend researchers either control or systematically record CFs in study designs. For clinical practice, this means CFs should not be dismissed as noise, but seen as key components in tailoring treatment to individual needs.
New Research: Shared vs. Specific Mechanisms in Neck Pain
Cook et al. (2024) introduced a novel study protocol exploring whether MT and resistance exercise achieve their results via different mechanisms (specific) or common pathways (shared). Their randomized trial with chronic neck pain patients compares outcomes between these interventions while assessing both types of mechanisms. They hypothesize that while MT and exercise may improve similar clinical outcomes, the pathways differ: MT enhances range of motion, while exercise builds endurance. Crucially, shared factors such as therapeutic alliance and self-efficacy may be more predictive of recovery than the technique itself. This suggests the “how” and “why” of treatment matter more than “what” is done (Cook et al., 2024).
Clinical Implications for Dutch CPD Participants
For Dutch clinicians, including physiotherapists and manual therapists, these findings signal a shift: from a technique-dominated view to one embracing patient-centered care. Communication skills, managing expectations, and optimizing the treatment environment become as vital as technical prowess. CPD programs should therefore emphasize “soft skills” alongside manual techniques, highlighting their measurable impact on patient outcomes.
Toward Precision Manual Therapy
The integration of these insights leads to the concept of “Precision Manual Therapy”—a model that aligns treatment with a patient’s unique biopsychosocial profile. This approach requires clinicians to measure and interpret CFs such as expectations, pain beliefs, and emotional states. Tools like PROMIS and OSPRO-YF can aid this process. When combined with strong therapeutic rapport and evidence-based interventions, MT evolves into a modern, scientifically grounded, and highly individualized care model.
Unraveling the Mechanisms of Manual Therapy (Bialosky et al., 2018)
Context is Complex (Keter et al., 2025)
SS-MECH Trial Protocol (Cook et al., 2024)