Manipulative physiotherapy is the term used to describe the field of physiotherapy practice which relates to disorders of the musculoskeletal system. Physiotherapists who practise in this area, are skilled in the assessment, diagnosis and physiotherapy management of musculoskeletal conditions.

The physiotherapy profession recognises the importance of evidence based practice and actively encourages practitioners to consider the scientific evidence when developing management programs. So what is the evidence for manipulative physiotherapy practice?

Manipulative physiotherapy works

Manipulative physiotherapists are highly trained in assessing musculoskeletal disorders. The clinical reasoning processes employed by manipulative physiotherapists enables them to reach a diagnosis consistent with the findings of the clinical examination.

Research has shown that manipulative physiotherapists are highly skilled in their examination such that they are able to form a diagnosis similar to or better than those determined by sophisticated imaging processes. For example, studies have shown that manipulative physiotherapists are skilled in the diagnosis of symptomatic facet joints (Philips and Twomey 1996), symptomatic intervertebral discs (Donelson et al 1997) and lumbar instability (Avery 1997).

Benefits of manipulative physiotherapy

Manipulative physiotherapists have advanced skills in the assessment, diagnosis and management of musculoskeletal conditions. These skills assist the medical practitioner with accurate, cost effective diagnosis and appropriate evidence based management. Manipulative physiotherapists in Australia have world leading expertise in the effective management of pain and other disorders related to the musculoskeletal system.

Evidence on the effectiveness of physical treatments as practiced by manipulative physiotherapists is constantly being reviewed. The Manipulative Physiotherapists Association of Australia (MPAA) has recently reviewed the literature on low back pain, based on level I evidence (systematic reviews) and level II evidence (randomised controlled trials).

Spinal manipulative therapy (SMT – including both passive mobilisation and manipulation), McKenzie therapy and promoting early activity is effective in the short-term management of low back pain (ACHPR 1994, van Tulder et al 1997). General exercise programs designed and supervised by physiotherapists result in reduced disability, reduced absenteeism and faster return to work rate compared to control groups (Frost et al 1995, Gundewall et al 1993, Kellett et al 1991, Mitchell et al 1990, Moffett et al 1999).

Physiotherapists are also pioneering investigations of the proposed mechanisms contributing to chronic and recurrent low back pain by evaluating the effects of specific exercise programs. Evidence to support their efficacy is mounting (O’Sullivan et al 1997). There is strong evidence that SMT is more effective in the management of chronic low back pain than bed rest, analgesics, and massage, with six out of eight trials supporting this evidence (van Tulder et al). More importantly, the combination of SMT and exercise has increasing support in the management of low back pain (Ottenbacher and Difabio 1994, Scheer et al 1995).


1) Agency for Heath Care Policy and Research (ACHPR) (1994): Acute low back problems in adults. Clinical Practice Guideline no 14. US department of Health and Human Services, Public Health Services. December, Rockville MD USA.

2) Avery (1997): The reliability of manual physiotherapy palpation techniques in the diagnosis of bilateral pars defects in subjects with chronic low back pin. MPAA proceedings, 10th Biennial Conference Melbourne November.

3) Donelson, Aprill, Medcalf and Grant (1997): A prospective study of centralisation of lumbar and referred pain: A predictor of symptomatic discs and annular competence. Spine 22 (10) 115-122.

4) Frost, Moffett, Moser and Fairbank (1995): Randomised controlled trial for evaluation of fitness program for patients with chronic low back pain. British Medical Journal 310 (21): 151-154.

5) Gundewall, Liljeqvist and Hansson (1993): Primary prevention of back symptoms and absence from work. Spine 18(5) 587-594.

6) Kellett, Kellett and Nordholm (1991): Effects of an exercise program on sick leave due to back pain. Physical Therapy 71 (4) 283-293.

7) Moffet, Torgerson, Bell-Syer, Jackson, Llewlyn-Phillips, Farrin and Barber (1999): Randomised controlled trial of exercise for low back pain: clinical outcomes, costs and preferences. British Medical Journal 319: 279-283.

8 ) Mitchell and Carmen (1990): Results of a multicentre trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries. Spine 15(6):514- 519.

9) O’Sullivan, Twomey and Allison (1997): Evaluation of specific stabilising exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 22: 2959-2967.

10) Ottenbacher and Difabio (1994): Efficacy of Spinal Manipulation/Mobilisation Therapy. A meta-analysis. Spine 10 (9) 833-837.

11) Scheer , Radack and O’Brien (1995): randomized controlled trials in industrial low back pain relating to return to work. Part 1. Acute Interventions. Arch Phys Med. Rehab, Vol. 76, 966-973.

12) Phillips and Twomey (1996): A comparison of manual diagnosis established by a uni-level lumbar spinal block procedure. Manual Therapy 2, 82-87.

13) van Tulder, Koes and Bouter (1997): Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomised controlled trials of the most common interventions. Spine 22 (18) 2128-2156.