Rethinking Manual Therapy: Why Gentle is Best

My physiotherapy approach has evolved significantly over the course of my career, and those of you who’ve followed me from previous clinics can probably attest to that.

If I’m honest, I cringe deeply when I think about how I treated people in my first few years as a physiotherapist.

The method was simple:
Find the sore spot.
Poke it.
Poke it harder.
Stretch it.
Maybe stick a needle into it.

In summary?

Poke, poke, poke and hope the muscle, trigger point, or joint eventually gave in to submission and relaxed.

At the time, it felt logical. If something hurt, it must be tight. If it was tight, it needed to be released. And surely if I just applied enough pressure with the best of intentions, I could “fix” it.

Unfortunately, instead of resulting in happy movement, my good intent was often seen for the next 3 or 4 days in the form of blue and purple patches or aching bodies. This was (and I believe somewhat unfortunately, is still) a standard treatment approach.

What I’ve learned since then is that bodies don’t respond well to forceful negotiations (much like my 4-year-old). They respond to safety, gentle facilitation, and intelligent loading patterns.

My approach has changed accordingly.

And lately, I’ve been getting a lot of questions in clinic along the lines of:

“Are you even doing anything?”

Subtle Doesn’t Mean Insignificant

One of the biggest changes for me, is that the gentler my hands seem to go, the more profound the changes seem to be.

And with this experience my thinking has had to change from a purely mechanical approach to a neurophysiological approach. Ultimately, manual therapies and hands on treatment are not primarily mechanical inputs for our bodies, they’re deeply neurophysiological.

When someone presents with pain or stiffness, it’s tempting (and I was taught) to think in purely structural terms: tight muscles, restricted joints, adhesions that need to be broken up. But modern pain science suggests that what we’re often dealing with is an output of the nervous system, not just a mechanical property of the tissues themselves.

From this perspective, forceful manual therapy can sometimes be counterproductive.

High-pressure input can increase nociceptive (painful) signalling and, depending on the context, reinforce a perception of threat. The body responds accordingly, through protective muscle activity, altered movement patterns, and sometimes post-treatment soreness that reflects sensitisation rather than resolution.

So instead… Work With the Nervous System

Gentle manual therapy takes a different approach.

The body is constantly gathering information through a wide network of sensors, updating the brain moment by moment about what’s happening. Some of these act like “danger” sensors as part of the pain system, while others are tuned to pick up touch, pressure, and movement, these are the mechanoreceptors.

In gentle manual therapy, these are the ones we’re really communicating with. Receptors like Ruffini endings and interstitial receptors are found throughout the body: in the skin, fascia, ligaments, joints, and even around the nervous system itself (dura mater etc). They tend to respond best to slow, sustained, low-level input.

When we stimulate these receptors, we’re not simply trying to mechanically lengthen or change tissue. Instead, we’re influencing the nervous system and, in turn, changing motor output through both spinal and supraspinal (brain) mechanisms. The result is often a kind of neurogenic relaxation, a softening that comes from the system itself.

At a central level, this can promote what’s known as descending inhibition. By providing novel, non-threatening sensory input, we can shift how the brain interprets signals from a given area, essentially turning down the “volume” on incoming information and changing the output.

This becomes especially important in more sensitive systems, where pain is less about local tissue damage and more about an amplified nervous system.

Clinically, this often looks like a visible shift, decreased pain on functional testing, reduced resting muscle tone, a sense of “melting,” and a slower, more relaxed breath. I have one client who checks her heart rate on her watch after sessions to tell me if I’ve done a good job. I think our current record is 48 bpm, which is lower than her resting heart rate during sleep.

When the Body Starts to Let Go

Sometimes, this process becomes more visible. And I’ve had a few clients this week where the bodies intelligence began to run the session.

When the body is safe enough, or in the right position, subtle (or not so subtle) shaking or involuntary movements can occur. These are often described as neurogenic tremors. While there’s more to understand, they are thought to reflect autonomic discharge and changing motor output as the system transitions out of a protective state.

Rather than something to suppress, these shakes can be a sign that the nervous system is reorganising, and should be welcomed.

Then there’s fascia (I’m sorry I couldn’t get through a whole blog without mentioning it). But again, if we think about it not so much as a structure we forcibly stretch or break apart, but as a highly innervated sensory tissue...some scientists refer to it as an organ.

Fascial tissue contains an insanely dense network of mechanoreceptors that we described above, making it a key contributor to interoception (the brain’s perception of the internal state of the body). Gentle fascial work (as opposed to deep myofascial release many of us are accustomed to) likely exerts its effects by altering afferent (sensory) input to the central nervous system, rather than mechanically “releasing” adhesions.

Once again, we’re not forcing change in the tissues themselves. We’re changing the conversation between the brain and the body.

And when that conversation improves, movement and a decrease in pain often follows.

Why This Tends to Last

So what does all of this actually mean for your treatment outcomes?

If these changes are being driven by the nervous system, then they’re not just temporary effects on tissue, they represent a form of learning.

The nervous system is constantly updating its internal model of the body based on incoming information. Every input, touch, movement, load, even expectation, feeds into this process. When that input is perceived as threatening, the system becomes more protective. When it is perceived as safe and predictable, it creates an opportunity for recalibration.

This is where neuroplasticity comes in.

Gentle manual therapy, especially when combined with appropriate movement and loading, helps create the conditions for the brain to revise its expectations about a previously painful or guarded area. Instead of reinforcing protection and sensitivity, we begin to establish a new pattern, one where movement is safe, variability is tolerated, and excessive muscle guarding is no longer necessary.

This is why the results often feel different.

Rather than a short-lived “release” that rebounds after a few days, people often experience a more sustained sense of ease, improved movement confidence, and less reactivity to the same aggravating factors.

It’s not that nothing ever comes back, but the system is less quick to return to a protective state.

You can think of it less like busting through an electronically locked door, and more like updating the software that controls it.

A Process, Not a Quick Fix

As much as we’d all like it sometimes, of course, this isn’t instantaneous.

Because we’re working with a learning system, repetition and consistency matter. The effects of a single session can be meaningful, but they’re usually part of a broader progression, one that includes movement, graded loading, and exposure to previously sensitive tasks.

Over time, this creates a system that is more adaptable and less reliant on protection.

One that doesn’t need constant treatment to maintain change, because the underlying drivers have been addressed.

So while the treatment itself may feel gentle, the goal is anything but small.

We’re aiming for changes that the body can understand, integrate, and most importantly hold onto for the long term.

Thanks for reading. And as always - I’d love your feedback :)

Gina Kezelman