Manual Therapy as an Evidence-Based Referral for Musculoskeletal Pain

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Musculoskeletal (MSK) pain conditions are the biggest cause of disability internationally and a major societal burden.1 However, there is little guidance to assist primary care providers in implementing non-pharmacological treatments such as manual therapy in addition to, or as an alternative for, pharmacological treatment. This tool is designed to increase primary care provider confidence in implementing an evidence-based multimodal program of patient education, exercise and manual therapy for MSK pain.1–10 It will guide providers in the referral for manual therapy by a chiropractor, physiotherapist or registered massage therapist (RMT), and the evaluation of patient outcomes.

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Multimodal treatment for MSK pain

Non-pharmacological treatment for MSK pain should begin with patient education and exercise. For low back, neck and shoulder pain, current highquality clinical practice guidelines (CPGs) also recommend various manual therapies tailored to the needs and abilities of the individual patient. 2-4, 6-9

Low back pain (LBP)

Low- to high-quality evidence

Acute and chronic low back pain,with or without sciatica.

Neck pain

Low- to moderate-quality evidence

Acute and chronic:

  • neck pain-associated disorders (NAD) , grades I-III.
  • whiplash-associated disorders (WAD), grades I-III.

Shoulder pain

Low- to moderate-quality evidence

Acute and chronic:

  • non-specific shoulder pain
  • shoulder impingement syndrome
  • rotator cuff-associated disorders
  • adhesive capsulitis


Patient education

Provide patient with information about their condition and the management options available to them. Education should be customized to the individual patient. Refer to:

  • Implement clinical best practices
  • Assess manual therapy as an option


Can include formal or enhanced exercise therapy provided by a chiropractor or physiotherapist, or informal self-directed physical activity for the purpose of maintaining movement and fitness. Refer to:

  • Implement clinical best practices

Manual therapy

Chiropractors, physiotherapists and registered massage therapists are regulated professions providing manual therapy. Techniques can include joint manipulation, mobilization and soft tissue therapies. Refer to:

  • Assess manual therapy as an option
  • Evidence for manual therapy
  • Refer to appropriate clinician

Implement clinical best practices

Pain and function evaluation

Perform the same outcome evaluation measures before and after the patient has completed their course of treatment to determine effect on function and pain. Clinically meaningful improvement in function and/or pain has been defined as a 30% improvement in scores.11

The treatment is ended as soon as the agreed-upon treatment goals have been achieved, or if maximum therapeutic benefit has been reached (improvement has plateaued and is unlikely to improve further).6 If the patient’s function or pain has not improved, or has gotten worse, consider specialist referral.

Validated Measures

Updated Patient Education

Patient education is an important part of the treatment program for MSK pain and should be individualized based on patient needs.1,9,12,15 Materials should be provided in the patient’s preferred format (printed materials, videos or multimedia). Education should include information and reassurance about:

  • The nature of their symptoms
  • The low risk for serious underlying disease
  • The management plan, including prognosis and psychosocial aspects
  • The importance of resuming or continuing work or usual activities
  • The importance of the patient’s active engagement in care, including self-monitoring of symptoms, identifying causes of pain exacerbation, relaxation techniques and modification of negative self-talk. For self-management resources, see patient resources in Section F.
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Updated Exercise11

Recommend general activity and exercise therapies as appropriate. For low back, neck and shoulder exercises, see patient resources in Section F. Chiropractors and physiotherapists may provide a planned, structured and repetitive physical activity program for the purpose of conditioning any part of the body.

  • If appropriate, start low and go slow (e.g. 5 min every other day) and aim for a moderate level of intensity.
  • Encourage graded activity – add 10 min every 3-4 weeks, toward a minimal goal of 30 min of exercise 5 days a week.
  • Recommend combined home and group physical activities to help increase activity levels.
  • Pick a low impact physical activity, such as walking, Pilates, Tai Chi, yoga or aquatic therapy.
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Assess manual therapy as an option

The decision to proceed with manual therapy should be based on patient preference, functional ability and absence of absolute contraindications. Patient preference may be influenced by cost, accessibility and personal factors.

As part of the Ministry of Health’s Low Back Pain Strategy, two provincial models of care are available to eligible patients with low back pain18:

Rapid Access Clinics
Rapid Access Clinics (RAC) for low back pain are being implemented across Ontario to improve patient care and access to low back pain assessment, education and management. Referrals are available to eligible patients whose primary care provider has enrolled in the program.
For more information, go to

OHIP-funded physiotherapy clinics
Individuals with a valid Ontario health card who meet one or more of the following criteria are eligible to access OHIP-funded physiotherapy:
• 65 years and older
• 19 years and under
• After an overnight hospital stay for a condition requiring
• a recipient of the Ontario Works or the Ontario Disability
Support Program
For a directory of these clinics, go to

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Relative Contraindications

Generally, these types of conditions contraindicate the relevant anatomy and do not necessarily contraindicate therapy for other areas.6

  • Local open would or burn
  • Prolonged bleeding time/hemophilia
  • Pacemaker (contraindicated for electrotherapy)
  • Joint infection6
  • Tumour*
  • Recent/healing fracture
  • Increasing neurological deficit*

*Does not prohibit treatment, but warrants investigation via imaging or specialist referral to rule out more serious pathology. See Absolute contraindications (Red flags).

Red Flag
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Evidence for manual therapy

In the evidence table below, manual therapy is defined as treatment programs involving a variable combination of mobilization, exercise therapy and/or soft tissue therapies, with or without manipulation.
For clarification of low back and neck conditions, see Appendix A.

Evidence for Manual Therapy

Technique definitions17,21-23

Assisted Stretching

Active or passive muscle lengthening with assistance of manual therapy clinician.

Heat/cold therapy

Local application of heat or cold over protected body part.

Joint mobilization

Techniques incorporating a low velocity and small or large amplitude oscillatory movement within a joint’s
passive range of motion.


A passive, high velocity, low amplitude thrust applied to a joint beyond its physiological limit of motion but
within its anatomical limit. Includes spinal manipulative therapy (SMT).

Manual traction

A therapeutic method to relieve pain by stretching and realigning the joints.

Soft-tissue therapies

Mechanical therapy in which muscles, tendons and ligaments are passively pressed or kneaded by hand
or with mechanical devices. Includes myofascial therapy, relaxation massage, clinical therapeutic massage,
movement re-education and energy work, Active Release Therapy (ART), progressive muscle relaxation and
range of motion therapy.

Refer to appropriate clinician

Chiropractors, physiotherapists and registered massage therapists (RMT) can perform all or some of the manual therapy techniques recommended as part of a multimodal program for low back, neck and shoulder pain. However, manipulation or spinal manipulative therapy (SMT) can only be performed by chiropractors or trained physiotherapists rostered with the College of Physiotherapists to perform manipulation (rostered physiotherapists). See Appendix B for required credentials.

A qualified clinician will meet the following criteria:24,25,26

• In good standing in the appropriate provincial regulatory college.
• Willing and able to provide proof of credentials, such as degrees and proof of registration.
• Experience in treating patients with low back, neck or shoulder pain.
• Willing to work collaboratively with family physician and other health care professionals as required to provide best patient care.

For detailed patient/provider resource on selecting a clinician, see Appendix B.

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Registered Massage Therapist (RMT)
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Supporting Materials


  • [1]

    Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2019 Mar 2;bjsports-2018-099878.

  • [2]

    Low back pain and sciatica in over 16s: assessment and management [Internet]. National Institute for Health and Care Excellence; 2016. Available from:

  • [3]

    Wong JJ, Côté P, Sutton DA, Randhawa K, Yu H, Varatharajan S, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain. 2017 Feb;21(2):201–16.

  • [4]

    Côté P, Wong JJ, Sutton D, Shearer HM, Mior S, Randhawa K, et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016 Jul;25(7):2000–22.

  • [5]

    Steuri R, Sattelmayer M, Elsig S, Kolly C, Tal A, Taeymans J, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med. 2017

  • [6]

    Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, et al. Clinical Practice Guideline: Chiropractic Care for Low Back Pain. J Manipulative Physiol Ther. 2016 Jan;39(1):1–22.

  • [7]

    Busse J. The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. Cancer Pain. 2017;105.

  • [8]

    Bussières AE, Stewart G, Al-Zoubi F, Decina P, Descarreaux M, Haskett D, et al. Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative. J Manipulative Physiol Ther. 2018 May;41(4):265–93.

  • [9]

    Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, et al. Neck Pain: Revision 2017: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association.
    J Orthop Sports Phys Ther. 2017 Jul;47(7):A1–83.

  • [10]

    Hawk C, Minkalis AL, Khorsan R, Daniels CJ, Homack D, Gliedt JA, et al. Systematic Review of Nondrug, Nonsurgical Treatment of Shoulder Conditions. J Manipulative Physiol Ther. 2017 Jun;40(5):293–319.

  • [11]

    Chronic Non-Cancer Pain [Internet]. Centre for Effective Practice; 2018. Available from:

  • [12]

    Hopman K, Krahe L, Lukersmith S. Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace [Internet]. The University of New South Wales; 2013 [cited 2019 Nov 1]. Available from:

  • [13]

    Quality Standards: Care for Adults With Acute Low Back Pain [Internet]. Health Quality Ontario;2019. Available from:

  • [14]

    Clinically Organized Relevant Exam (CORE) Back Tool [Internet]. Centre for Effective Practice; 2016. Available from:

  • [15]

    Clinically Organized Relevant Exam (CORE) Neck Tool and Headache Navigator [Internet]. Centre for Effective Practice; 2016. Available from:

  • [16]

    Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Musculoskeletal Group, editor. Cochrane Database Syst Rev [Internet]. 2014 Aug 26 [cited 2019 Aug 9]; Available from:

  • [17]

    Position Statement: Manipulation [Internet]. Canadian Physiotherapy Association; 2007. Available from:

  • [18]

    Government of Ontario, Ministry of Health and Long-Term Care. Ontario’s Action Plan for Health Care – Low Back Pain Strategy [Internet]. 2016 [cited 2020 Mar 3]. Available from:

  • [19]

    de Luca KE, Fang SH, Ong J, Shin K-S, Woods S, Tuchin PJ. The Effectiveness and Safety of Manual Therapy on Pain and Disability in Older Persons With Chronic Low Back Pain: A Systematic Review. J Manipulative Physiol Ther. 2017 Sep;40(7):527–34.

  • [20]

    Bussières AE, Stewart G, Al-Zoubi F, Decina P, Descarreaux M, Hayden J, et al. The Treatment of Neck Pain–Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. J Manipulative Physiol Ther. 2016 Oct;39(8):523-564.e27.

  • [21]

    Ontario Chiropractic Association. What Is Chiropractic? [Internet]. Ontario Chiropractic Association. 2019 [cited 2019 Oct 24]. Available from:

  • [22]

    Classifying health workers: Mapping occupations to the international standard classification [Internet]. World Health Organization; 2008 [cited 2019 Nov 26]. Available from:

  • [23]

    Sherman KJ, Dixon MW, Thompson D, Cherkin DC. Development of a taxonomy to describe massage treatments for musculoskeletal pain. BMC Complement Altern Med [Internet]. 2006 Dec [cited 2020 Feb 28];6(1). Available from:

  • [24]

    Soft Tissue Therapy: Guidance for Selecting a Clinician. The Inter-professional Spine Assessment and Education Clinics (ISAEC); 2015.

  • [25]

    Exercise Therapy: Guidance for Selecting a Clinician. The Inter-professional Spine Assessment and Education Clinics (ISAEC); 2015.

  • [26]

    Manipulation: Guidance for Selecting a Clinician. The Inter-professional Spine Assessment and Education Clinics (ISAEC); 2015.

  • [27]

    Chiropractic Act, 1991, S.O. [Internet]. Sect. 21 1991. Available from:

  • [28]

    Physiotherapy Act, 1991, S.O. [Internet]. Sect. 37 1991. Available from:

  • [29]

    Massage Therapy Act, 1991, S.O. [Internet]. Sect. 27 1991. Available from:

  • [30]

    Haldeman S, Johnson CD, Chou R, Nordin M, Côté P, Hurwitz EL, et al. The Global Spine Care Initiative: classification system for spine-related concerns. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2018;27(Suppl 6):889–900.

  • [31]

    Guzman J, Hurwitz EL, Carroll LJ, Haldeman S, Côté P, Carragee EJ, et al. A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4 Suppl):S14-23.