Dora Jackson RMT

Why does manual therapy work? An increasing amount of evidence points to systemic rather than local effects. Why does it matter? We need to keep it real so as not to perpetuate myth and reliably replicate results.

Why does manual therapy work?

It’s a question most of us have been asked — by patients, by students, sometimes by ourselves mid-treatment.

A 2025 living review in PLOS ONE (Keter et al.) pulled together 62 systematic, narrative, and scoping reviews to map the current evidence.

Manual therapy doesn’t act on one system. It produces measurable responses across the following:

- Neurological
- Neurovascular
- Neurotransmitter,
- Neuroimmune
- Neuromuscular
- Neuroendocrine
- Biomechanical

The strongest, most consistent signals are central, not local: increased pressure pain thresholds at sites distant from treatment and enhanced descending pain modulation.

The biomechanical “joint-out-of-place” model? It's not supported by the evidence. The treatments purporting to do this may help, but for the reasons above, not because the joint has been popped back in.

What this means in practice: our hands are interacting with the central nervous system at least as much as the tissue beneath them and the language we use with patients should reflect that.

The full one-page clinical summary is below 👇

📖 Source: Keter et al. (2025), PLOS ONE. doi:10.1371/journal.pone.0319586

Pain is complex but there are a few simple concepts at it’s core that everyone should know and understand.

Pain does not always mean damage.
Threat increases pain and safety reduces it.
Pain is always real.