Manual physiotherapy and orthopaedic manual therapy (Maitland, McKenzie)

1. Introduction

Version followed: the Maitland Concept as presented in Maitland's Vertebral Manipulation, 8th edition (Hengeveld and Banks, eds, 2013), with Maitland's mobilisation grades as given in his Peripheral Manipulation (1977); McKenzie Mechanical Diagnosis and Therapy (MDT) as currently described by the McKenzie Institute International; and the IFOMPT International Framework for Examination of the Cervical Region (Rushton et al., 2020) for neck-treatment safety. Kaltenborn-Evjenth (Nordic) manual therapy and Brian Mulligan's mobilisation with movement belong to the same professional family but are not described procedurally here [uncertain: not verified].

What it is. Orthopaedic manual therapy (OMT) is defined by its international federation as "a specialization within Physical Therapy" for conservative management of pain and other symptoms of neuro-musculo-articular dysfunction in the spine and limbs [source: IFOMPT History 2011]. It is a hands-on and exercise-based physiotherapy specialism, not a psychotherapy. For the psychotherapist it is a referral and collaboration method: the assessment, mobilisation, manipulation and exercise described below are delivered by physiotherapists (and, for MDT, other trained clinicians), never by the psychotherapist.

• Maitland Concept (Geoffrey Maitland, Australia): the therapist examines movement in detail, applies passive movement (mobilisation or manipulation) chosen through clinical reasoning, and continuously re-assesses to judge the effect. The current textbook stresses keeping the patient "at centre", shared decision-making and continuous communication [source: Hengeveld & Banks 2013, publisher page].
• McKenzie MDT (Robin McKenzie, New Zealand): described by its institute as a biopsychosocial system of assessment and care centred on patient empowerment and self-management. The patient performs repeated movements and sustained positions; the symptom and range response classifies the problem and guides a self-treatment programme [source: McKenzie Institute UK, "The McKenzie Method"].

How change is thought to happen (as the developers describe it). In the Maitland Concept, carefully graded passive movement is used to influence pain and stiffness, and the effect is judged by re-testing movements and symptoms before and after each technique [source: Hengeveld & Banks 2013, publisher page; WSCC/UWS Maitland grades protocol]. In MDT, movement in a patient's "directional preference" is said to produce rapid change, including "centralisation" (pain retreating from the limb towards the spine), which the institute links with better outcomes; the patient learns to produce this effect themselves and to prevent recurrence [source: McKenzie Institute UK]. Both are mechanical models; neither claims to treat psychological problems.

Who delivers it and how it is regulated.

• UK: "Physiotherapist" and "physical therapist" are titles protected by law; anyone using them must be on the Health and Care Professions Council (HCPC) Register [source: HCPC, The professions].
• International: IFOMT was founded in Montreal in June 1974, after the first international OMT examinations in Gran Canaria in 1973. Kaltenborn, Maitland, Grieve and Paris are recognised as founders, and McKenzie sat on the founding committee. In 1978 it became the first official subgroup of the World Confederation for Physical Therapy [source: IFOMPT History 2011]. The federation now publishes as IFOMPT [source: IFOMPT Cervical Framework 2020].
• McKenzie MDT: courses (Parts A to D, then a Credentialling Examination conferring "CredMDT") are open to qualified physiotherapists, chiropractors, osteopaths and GPs; a Diploma in MDT is required for faculty [source: McKenzie Institute NZ, Education FAQ]. An MDT credential is a postgraduate qualification, not a licence; the clinician's own registration (e.g. HCPC, GOsC, GCC, GMC) governs conduct.
• USA (state physical therapy licensure; APTA as professional body), Australia (Physiotherapy Board of Australia via AHPRA), Canada and Europe: [uncertain: not verified]. Check the relevant national register before referring.

Evidence status (brief). NICE NG59 (low back pain and sciatica) advises clinicians to "consider manual therapy" (manipulation, mobilisation or soft-tissue techniques) "only as part of a treatment package including exercise" [source: NICE NG59, rec 1.2.7]. A 2018 meta-analysis found MDT no better than other rehabilitation for acute low back pain; for chronic low back pain it reduced disability more than exercise alone but did not differ from manual therapy plus exercise [source: Lam et al. 2018, via PEDro]. Wider reviews of manipulation for neck pain and of Maitland mobilisation specifically: [uncertain: not verified].

2. Framework

This is a physiotherapy pathway, not a psychotherapy protocol. The phases below describe what a client will meet, so the psychotherapist can prepare, refer and collaborate. [source: as tagged per phase]

Session count and format. One-to-one physiotherapy sessions; the cited sources give no standard number of sessions [uncertain: not verified]. MDT aims to reduce dependence on the clinician by teaching self-treatment [source: McKenzie Institute UK]. Psychotherapy runs in parallel as a separate service with separate sessions [synthesis].

3. Guiding principles

Principles of the methods (as published), then of the psychotherapist's stance.

• Patient at the centre, shared decisions. The client is a partner in choosing treatment; the psychotherapist reinforces this rather than "prescribing" physiotherapy [source: Hengeveld & Banks 2013, publisher page; IFOMPT Cervical Framework 2020].
• Assess, treat, re-assess. Every technique is judged by re-testing; the client can expect the physiotherapist to ask repeatedly what changed [source: Hengeveld & Banks 2013, publisher page].
• Clinical reasoning over protocol. IFOMPT calls its framework "informative and not prescriptive"; decisions balance probabilities and, when in doubt, the clinician considers not intervening [source: IFOMPT Cervical Framework 2020].
• First do no harm. Screening comes before any hands-on treatment, especially for the neck [source: IFOMPT Cervical Framework 2020].
• Express, revisable consent. Consent is obtained before treatment, renewed when treatment changes, recorded, and can be withdrawn at any time [source: IFOMPT Cervical Framework 2020].
• Self-treatment before hands-on (MDT). Patient-generated movement comes first; clinician force is added only if needed [source: McKenzie Institute UK].
• Prevention over short-term relief (MDT). Teaching the client to manage recurrences is part of treatment [source: McKenzie Institute UK].
• Communication and the therapeutic relationship are treated as core skills, with a dedicated chapter in the Maitland text [source: Hengeveld & Banks 2013, contents].
• Manual therapy as part of a package. Not a stand-alone treatment for back pain; combined with exercise [source: NICE NG59].
• Psychotherapist stays in role. Most mainstream psychotherapy codes cited contain no explicit touch clause but all prohibit sexual contact and require working within competence and referring when appropriate (e.g. UKCP item 23: "Offer only the forms of therapy in which you have had adequate training"). So the psychotherapist refers for hands-on work and does not perform it [source: touch-code sources listed under Web sources; synthesis].
• Body-psychotherapy codes regulate touch directly. USABP requires informed consent before touch, the right to refuse or end it at any time, and states genital or sexual touch is "always inappropriate"; EABP asks therapists to consider and discuss with the client any parallel service from another professional [source: USABP Code; EABP 2020]. Practical meaning: name the parallel physiotherapy openly and agree how the two will connect.
• Never sexual touch; intimate areas only via regulated clinicians. Pelvic-region physiotherapy is a separate regulated specialism; refer and do not discuss technique detail beyond what helps consent [synthesis].
• Mechanical frame, psychological meaning. The method is mechanical; pain beliefs, fear of movement and trauma responses are the psychotherapist's territory, worked with collaboratively [synthesis].

4. Intervention inventory

Part A covers the procedures physiotherapists deliver, described as published so you can explain them to clients and recognise when something is off. They are not instructions: forces, grades, amplitudes, repetitions and dosages are the physiotherapist's clinical decisions and are deliberately not prescribed here. Part B covers the psychotherapist's own interventions, which are [synthesis] unless tagged otherwise.

Part A. Delivered by physiotherapists (and, for MDT, other credentialled clinicians)

A1. History, red-flag screening and risk stratification

• Purpose / when: Start of every episode. Rules out serious pathology and decides whether manual therapy is appropriate. For back pain NICE suggests risk stratification (e.g. the STarT Back tool) at first contact to match the intensity of support to the risk of a poor outcome [source: NICE NG59, recs 1.1.2–1.1.3]. MDT clinicians screen for red flags and refer unsuitable presentations to a specialist [source: McKenzie Institute UK].
• What happens: Questions about onset, behaviour of symptoms, general health and medication, then questionnaire-type measures. The tool items are not reproduced here.
• Psychotherapist's steps: (1) Tell the client to expect detailed health questions. (2) Encourage full disclosure of trauma history only as far as the client wishes; physical history (falls, accidents, assaults affecting the body) is clinically relevant. (3) With consent, share your own concerns, such as high distress or fear of movement, which bear on risk stratification [synthesis].
• Example language (illustrative): "The physio will ask a lot about your health first. That's to check it's safe to treat, not because they doubt you."
• Watch for: Clients minimising symptoms to "get on with it". Shame about weight, medication or substance use blocking disclosure. Anxiety spikes when asked about bladder, bowel or sexual function, which are standard back-pain screening topics [synthesis].

A2. Cervical vascular screening before neck treatment (IFOMPT 2020)

• Purpose / when: Before any orthopaedic manual therapy to the neck (mobilisation, manipulation or exercise), to find the rare client with vascular pathology [source: IFOMPT Cervical Framework 2020].
• What happens (as the framework describes it): The history covers risk factors (recent trauma including minor trauma, vascular anomaly, smoking, migraine, high cholesterol, hypertension, recent infection, oral contraceptive use, family history of stroke) and symptoms. Headache and neck pain are the most common presenting features; others include visual disturbance, limb or facial paraesthesia, dizziness, swallowing or speech difficulty, unsteadiness, drooping eyelid, facial palsy, nausea, and confusion or loss of consciousness. Acute pain described as "unlike any other" raises suspicion. The examination includes blood pressure, neurological and cranial-nerve testing and carotid examination. The framework does not recommend provocative positional testing. Where suspicion is supported, the clinician should "refer for immediate medical investigation". The absence of risk factors does not rule out risk [source: IFOMPT Cervical Framework 2020].
• Risk as characterised: Serious adverse events are rare. Estimated vertebral artery dissection rates associated with OMT are about 0.4 to 5 per 100,000, against 0.75 to 2.9 per 100,000 in the general population. Most reported harm has followed cervical manipulation. The framework's working hypothesis is that treatment may aggravate a pre-existing dissection rather than cause it alone [source: IFOMPT Cervical Framework 2020].
• Psychotherapist's steps: If a client with neck pain and a new or unusual headache, dizziness, visual, speech or swallowing change, or facial or limb numbness mentions planned neck manipulation, advise them to report those symptoms to the treating clinician before treatment. For acute neurological symptoms, advise emergency care now [synthesis, based on the framework's symptom list].
• Example language (illustrative): "Before anyone treats your neck, please tell them about that new headache and the dizziness. They'll want to know."
• Watch for: Health-anxious clients may fixate on the dissection risk. Give the framework's "rare" framing and route questions to the physiotherapist rather than amplifying fear [synthesis].

A3. Maitland examination, assessment and re-assessment

• Purpose / when: The core of the Maitland Concept. Observation, listening, palpation and movement testing establish physical dysfunction, and repeated re-assessment judges the effect of each treatment [source: Hengeveld & Banks 2013, publisher page]. The textbook includes movement diagram theory and recording conventions (appendix) and a chapter on clinical reasoning (Mark Jones) [source: Hengeveld & Banks 2013, contents].
• What happens: The physiotherapist identifies specific movements or signs that reproduce the problem, treats, then re-tests the same signs and asks what changed. The client is asked to report symptoms during and after technique [source: Hengeveld & Banks 2013, publisher page; detail of terms such as "comparable sign" or "brick wall" thinking: uncertain: not verified].
• Psychotherapist's steps: Prepare clients who freeze, dissociate or comply under authority. They need to know they will be asked "what changed?" and that "I don't know" or "it's worse" are useful answers. Rehearse giving a precise symptom report [synthesis].
• Example language (illustrative): "They'll keep checking what changed. There's no right answer. 'Worse' is as useful to them as 'better'."
• Watch for: Clients reporting improvement to please the clinician. Inability to locate or describe sensations, which is common after trauma and may need interoceptive work in therapy [synthesis].

A4. Passive mobilisation (Maitland grades I to IV)

• Purpose / when: Graded passive oscillatory movement chosen through clinical reasoning for pain or stiffness [source: Hengeveld & Banks 2013, publisher page].
• What it is (grades as published): Maitland's grades classify the amplitude and position in range of passive rhythmic oscillations. Grade I: small amplitude at the beginning of range. Grade II: large amplitude within range, below tissue resistance. Grade III: large amplitude up to the limit of available motion and into resistance. Grade IV: small amplitude at the limit of motion. [source: WSCC/UWS Maitland grades protocol, citing Maitland 1977]. A secondary teaching source links lower grades with pain and irritability and higher grades with stiffness [source: WikiMSK, Joint Mobilisation]. Choice and dosage belong to the physiotherapist and are not given here.
• Psychotherapist's steps: Explain to clients that mobilisation is usually rhythmic and gentle, is graded, and can be stopped at any moment [synthesis]. Agree a stop word or hand signal the client will tell the physiotherapist about [synthesis].
• Example language (illustrative): "It's a gentle rocking movement of a joint. You can ask them to stop or go gentler at any point."
• Watch for: Rhythmic passive handling can evoke strong body memories or relaxation-induced anxiety in trauma survivors. Treat these as present-moment reactions to explore, not as evidence of past events [synthesis].

A5. Manipulation (Maitland grade V, high-velocity thrust)

• Purpose / when: A small-amplitude, high-velocity thrust at the limit of motion, which the protocol states "should be construed as joint manipulation". Grades I to IV may be used as a pre-test, as preparation, or as a substitute where manipulation is contraindicated [source: WSCC/UWS Maitland grades protocol]. For the neck, IFOMPT advises low force, mid-range rotational techniques and avoiding end range where possible, with monitoring of facial expression, tone and responsiveness during and after treatment and before each new session [source: IFOMPT Cervical Framework 2020].
• What happens: Discussed and consented separately. A change of treatment needs a new consent process [source: IFOMPT Cervical Framework 2020].
• Psychotherapist's steps: For clients with trauma involving restraint, the neck or sudden force, explore whether they want manipulation at all, and support them to ask for alternatives (MDT puts patient-generated movement first) [source: McKenzie Institute UK; synthesis].
• Example language (illustrative): "You're allowed to say you'd prefer a gentler option. Physios use mobilisation in place of manipulation too."
• Watch for: Startle, freezing or a panic response after a thrust. Post-treatment neurological symptoms, which are an emergency (see B7) [synthesis; IFOMPT 2020 symptom list].

A6. MDT repeated-movement and sustained-position assessment

• Purpose / when: The MDT examination. The patient performs movements and positions and reports their effect, establishing how symptoms and range respond [source: McKenzie Institute UK].
• What happens: The clinician asks how symptoms limit the patient, then guides movement testing and monitors symptom location and intensity and range. Centralisation, where distal pain moves proximally, is recorded. The institute states rapid changes occur in 50–70% of spinal cases depending on duration, and that centralisers tend to do better [source: McKenzie Institute UK]. Sequences and repetition counts are not reproduced here.
• Psychotherapist's steps: Explain that some movements may briefly change symptoms and that location matters as well as intensity. Encourage the client to report changes rather than stopping silently [synthesis].
• Example language (illustrative): "They'll be interested in where you feel it, not just how much. If it moves towards your back, tell them."
• Watch for: Catastrophic readings of any increase in pain. Avoidance of the test movements, which you can name and explore (see B4) [synthesis].

A7. MDT classification

• Purpose / when: After assessment. Patients are classified as Derangement, Dysfunction, Postural or Other (with subgroups); the institute describes 16 mutually exclusive classifications with operational criteria [source: McKenzie Institute UK]. Criteria per subgroup: [uncertain: not verified].
• What happens: Management follows the classification. Derangement: exercise in the directional preference. Dysfunction: graded tissue loading. Chronic pain: an individualised, graded, paced plan to rebuild confidence in movement [source: McKenzie Institute UK].
• Psychotherapist's steps: Ask the client what their classification means to them. Correct alarming misreadings of mechanical labels, for example "derangement" heard as "I'm deranged" or "damaged", by asking the physiotherapist to explain it [synthesis].
• Example language (illustrative): "What did you take 'derangement' to mean? It's a mechanical label, so let's check with your physio what they meant."
• Watch for: Labels turning into identity or proof of fragility [synthesis].

A8. MDT self-treatment in the directional preference and force progression

• Purpose / when: The patient learns movements and positions that improve their symptoms. Patient-generated forces come first, and clinician procedures such as mobilisation are added only when these are insufficient [source: McKenzie Institute UK].
• What happens: A home programme set by the clinician, with education about symptom behaviour and posture [source: McKenzie Institute UK]. The programme content is the clinician's and is not given here.
• Psychotherapist's steps: Support adherence (see B5). Never alter or add to the programme. Pass questions back to the clinician [synthesis].
• Example language (illustrative): "What did your physio give you to do, and what gets in the way of doing it?"
• Watch for: Over-doing it in a "no pain, no gain" pattern, or under-doing it from fear. Both go back to the clinician [synthesis].

A9. MDT prevention and recurrence management

• Purpose / when: Toward discharge. The institute stresses preventing recurrence over short-term relief, since spinal pain tends to recur, often more severely, and patients are taught their role in managing it [source: McKenzie Institute UK].
• Psychotherapist's steps: Build a relapse plan that links the physiotherapist's self-management steps with your emotional relapse-prevention work, for example noticing stress-related guarding [synthesis].
• Example language (illustrative): "If the pain comes back, what's your physio's plan, and what's our plan for the worry that comes with it?"
• Watch for: Recurrence being read as total failure [synthesis].

A10. Shared decision-making and informed consent for manual therapy

• Purpose / when: Before treatment and whenever it changes. IFOMPT draws on the AHRQ SHARE steps: invite participation, explore options with benefits and harms, assess values, decide together, evaluate. It recommends express (verbal or written) consent for initial treatment, records disclosure and consent, notes patients can withdraw at any time, and advises against a standardised consent form [source: IFOMPT Cervical Framework 2020].
• Psychotherapist's steps: Rehearse consent conversations with clients who struggle to say no. Help them list questions, for example about what will be touched, positioning, clothing, chaperones and alternatives [synthesis]. UK physiotherapy chaperone and clothing guidance (e.g. CSP or HCPC conduct standards): [uncertain: not verified]; the client can ask the service.
• Example language (illustrative): "Let's practise: 'Before you start, can you tell me where you'll put your hands, and can I have someone with me?'"
• Watch for: Consent given in a fawn or freeze state, where the client says yes but their body says no [synthesis].

Part B. The psychotherapist's interventions

The items in Part B are [synthesis] built around the published methods above, except where a source is tagged. The psychotherapist talks, prepares, collaborates and refers, and does not touch.

B1. Deciding when to suggest a physiotherapy assessment

• Purpose / when: The client reports musculoskeletal pain (back, neck, joints) that limits activity, is unassessed, or is being managed only by rest and avoidance. Manual therapy is one option within an exercise-based package for back pain [source: NICE NG59, rec 1.2.7].
• Steps: (1) Ask whether the pain has been assessed by a GP or physiotherapist. (2) Screen for urgent features and advise same-day medical care for them. These include new neurological symptoms, bladder or bowel change, saddle numbness, fever, unexplained weight loss, a history of cancer, significant trauma, or the neck symptoms listed in A2 [synthesis; neck list from IFOMPT 2020; other red flags: uncertain: not verified against a guideline]. (3) Otherwise suggest a registered physiotherapist (in the UK, check the HCPC Register) [source: HCPC, The professions]. (4) If the client wants an MDT approach, they can ask for a credentialled clinician (CredMDT) [source: McKenzie Institute NZ, Education FAQ].
• Example language (illustrative): "Your back sounds like it's been running your life for months. Would you be open to a physiotherapy assessment alongside our work?"
• Watch for: Referral heard as "it's all physical, so you're dismissing my feelings", or as "it's all in my head". Present the two services as complementary.

B2. Referral and ongoing collaboration

• Purpose / when: Once the client is under a physiotherapist. EABP asks body psychotherapists to consider and discuss with the client the implications of parallel services from another professional [source: EABP 2020, 6.b]. Mainstream codes require referral within competence and cooperation with other professionals [source: UKCP items 14, 24; APA 3.09; HCPC SOP 4.4].
• Steps: (1) Get written consent to share specific information and agree what will not be shared. (2) In a brief letter, give relevant psychological factors, such as fear of movement, trauma-related responses to touch, or panic, plus the client's preferences (chaperone, stop signal, gender of clinician) [synthesis]. (3) Ask the physiotherapist what they want reinforced, such as the self-management messages from A8 and A9. (4) Agree who the client contacts about which problems.
• Example language (illustrative): "Would it help if I wrote to your physio about how hard it is to say 'stop'? You decide what goes in."
• Watch for: Splitting ("the physio understands me, you don't", or the reverse). Mixed messages about activity; resolve them by contacting the clinician, not by giving your own exercise advice.

B3. Exploring pain beliefs and the meaning of mechanical labels

• Purpose / when: The client holds threat-laden beliefs about their body, such as "my spine is crumbling", "a disc slipped out" or "if it hurts I'm doing damage". Diagnostic terms from imaging or classification (A7) can reinforce these.
• Steps: (1) Elicit the client's picture of what is wrong and where it came from (a clinician, a scan report, family, the internet). (2) Explore the feelings and behaviours it drives. (3) Separate the questions you can answer (meaning, fear, prediction) from the clinical questions only the physiotherapist can answer (structure, safety of a movement). (4) Help the client write questions to take back to the physiotherapist.
• Example language (illustrative): "What do you picture happening inside your back when it hurts? Where did that picture come from?"
• Watch for: Reassurance-seeking loops (do not offer medical reassurance yourself). Beliefs eased by the physiotherapist's explanation are a sign it is working.

B4. Working with fear-avoidance, alongside the physiotherapy plan

• Purpose / when: The client avoids movements, activities or the self-treatment programme for fear of pain or harm. The MDT chronic-pain plan aims to rebuild confidence in movement [source: McKenzie Institute UK]. NICE NG59 (2016) recommended considering cognitive-behavioural psychological therapy only within a package including exercise (1.2.13), and a combined physical and psychological programme where psychosocial obstacles are significant (1.2.14) [source: NICE NG59]. A July 2026 update is reported to have deleted 1.2.13 and 1.2.14 because they were partly based on later-retracted evidence [source: Guideline Central, Aug 2026; uncertain: check the current NICE text].
• Steps: (1) Map the avoided activities and the predicted catastrophe for each. (2) Ask the client to get the physiotherapist's view on which activities are safe to approach and in what order. The physiotherapist sets the physical grading. (3) In therapy, work on the emotional side: predictions before and after, tolerating uncertainty and discomfort, self-compassion. (4) Review what happened against what was predicted.
• Example language (illustrative): "Your physio says bending to the dishwasher is OK to practise. What does your mind predict will happen? Let's write it down and check afterwards."
• Watch for: Never set exercise targets, intensities or repetitions yourself. Progress is shown by wider activity, more accurate predictions and less checking.

B5. Supporting self-treatment and adherence

• Purpose / when: MDT relies on the patient doing their programme (A8), and NICE expects tailored self-management information throughout [source: McKenzie Institute UK; NICE NG59, rec 1.2.1].
• Steps: (1) Ask what the programme is and how it is going, in the client's own words. (2) Explore barriers: time, shame, perfectionism, fear, low mood, chaotic routine. (3) Use problem-solving or motivational interviewing to link the programme to the client's values. (4) Send technical questions back to the clinician.
• Example language (illustrative): "On the days you skip the exercises, what's happening just before?"
• Watch for: All-or-nothing patterns. Using the exercises to self-punish. Over-checking symptoms.

B6. Preparing clients with trauma histories for hands-on assessment and treatment

• Purpose / when: Before a first physiotherapy appointment, for clients with sexual, physical or medical trauma, or with dissociation or fear of being touched. Body-psychotherapy codes set the touch standards most relevant here: informed consent before touch, consent monitored over time, the right to refuse or end touch at any time, and genital or sexual touch always inappropriate [source: USABP Code, section VIII]. Manual-therapy consent is express, renewed when treatment changes, and withdrawable [source: IFOMPT Cervical Framework 2020].
• Steps: (1) Explain the likely sequence: talking, then looking at movement, then possibly hands-on (A1 to A5). (2) Identify triggers such as lying face down, a clinician standing behind, clothing adjustment, the neck being held, closed doors, or the clinician's gender. (3) Draft requests together: a chaperone or companion, explanations before each contact, a stop signal, staying partly clothed or bringing shorts or a vest, starting with self-movement (MDT puts this first) [source for MDT order: McKenzie Institute UK]. (4) Practise grounding the client can use on the plinth. (5) Plan a debrief session afterwards.
• Example language (illustrative): "You can say, 'I have a history that makes touch hard. Please tell me before you put your hands anywhere, and I'll say if I need to stop.'"
• Watch for: Over-preparation can heighten anticipatory anxiety, so keep it proportionate. Pelvic-region physiotherapy is a separate regulated specialism; discuss it only in general terms, and the client raises details with that clinician.

B7. Recognising adverse effects and passing them on

• Purpose / when: At every session during a course of manual therapy. Mild short-lived soreness after treatment is commonly reported [uncertain: not verified]. Serious events are rare, but after neck treatment new neurological signs need urgent action. The IFOMPT framework advises contacting emergency services or a physician as appropriate [source: IFOMPT Cervical Framework 2020].
• Steps: (1) Ask briefly how the last physiotherapy session went and how the body felt in the following days. (2) For symptoms listed in A2 (severe new headache, dizziness, visual, speech or swallowing change, facial or limb numbness, unsteadiness, confusion), advise emergency services now. Do not wait for the next physiotherapy appointment. (3) For non-urgent but worrying changes, encourage the client to contact the physiotherapist or GP the same day. (4) Record what you advised.
• Example language (illustrative): "Since your neck was treated, have you had any new headache, dizziness, problems seeing or speaking, or numbness? If yes, we need to get you checked today."
• Watch for: Clients who blame themselves for a flare-up and stop going. Help them report it so the clinician can adjust.

B8. Integrating body experiences from treatment into psychotherapy

• Purpose / when: The client reports emotional reactions during or after physiotherapy, such as tears, anger, sudden calm, dissociation or memories.
• Steps: (1) Invite a description of what happened, in the body and emotionally. (2) Stay with present-moment meaning and what the reaction tells the client about safety, control and trust. (3) Do not treat body reactions as proof of specific past events. Memory research cautions that suggestion can shape memories, so avoid leading questions [synthesis; memory-research sources: uncertain: not verified]. (4) Agree whether anything should be passed to the physiotherapist, such as a need to pace hands-on work.
• Example language (illustrative): "You said you felt suddenly tearful when they worked on your shoulder. What was that like, and what do you make of it now?"
• Watch for: Any clinician, including a manual therapist, telling the client that tissues "hold" specific memories or emotions. These are claims outside the published Maitland and MDT methods described here. Discuss them with the client cautiously.

B9. Recognising boundary violations and supporting a complaint

• Purpose / when: The client describes treatment that felt sexual, unexplained intimate-area contact, pressure to undress beyond what was explained, refusal to stop, comments about their body, or contact outside the clinic.
• Steps: (1) Listen, believe and name that sexual touch is never part of treatment [codes: USABP; sexual-contact prohibitions in all codes listed under Web sources]. (2) Attend to safety and safeguarding duties. (3) Explain the options: complaining to the service, and in the UK raising a concern with the HCPC, which keeps the register and acts on misuse of protected titles [source: HCPC, The professions; HCPC concerns procedure: uncertain: not verified]. Where a crime may have occurred, the police. For MDT-credentialled clinicians who are not physiotherapists, the complaint goes to their own regulator (e.g. GOsC, GCC, GMC). (4) Support the client through the process without directing it.
• Example language (illustrative): "What you describe isn't part of any physiotherapy treatment. You have options, and we can go through them at your pace."
• Watch for: Self-blame and minimising ("maybe it was a technique"). If unsure whether a touch was clinical, the client can ask the service for an explanation of what was done and why.

B10. Holding your own role: no hands-on work

• Purpose / when: Always. Mainstream psychotherapy and psychology codes say nothing explicit about touch, but all prohibit sexual contact and require practising within competence and training [source: BACP 2018 paras 13, 34; UKCP items 4, 23–24; BPS 2009 2.3; APA 2.01, 10.05; AAMFT 3.10]. Mobilisation and manipulation are physiotherapy specialist procedures [source: IFOMPT History 2011].
• Steps: Do not demonstrate, test or "check" movements, and do not copy techniques you have heard about. Body-psychotherapists whose code permits touch still work within their own training and do not provide manual therapy [synthesis].
• Example language (illustrative): "That's one for your physio to look at. I'd rather not guess. What I can help with is the worry about it."
• Watch for: Pressure from the client to "just show me the stretch".

5. Handling problems

The cited sources do not address the psychotherapist's side of these problems. Everything below is [synthesis] unless tagged.

• Client won't go to physiotherapy ("they'll just crack my neck", "it'll make it worse"). Explore the specific fear. Explain that MDT starts with the client's own movement and adds clinician force only if needed, and that consent can be withdrawn at any time [source: McKenzie Institute UK; IFOMPT Cervical Framework 2020]. Offer to rehearse the first appointment (B6). Respect a considered refusal.
• Stuck: no physical change and growing hopelessness. Separate the two questions. Whether the physical plan should change is for the physiotherapist, and the client can ask for a review or second opinion. How the client copes with uncertainty and loss is your work. Watch for depression and screen for risk.
• Non-adherence to the self-treatment programme. Use B5. Check whether the programme was understood. Shame often hides confusion, so encourage the client to ask the clinician to re-teach it rather than giving your own version.
• Overwhelm or dissociation on the treatment couch. Debrief (B8). Agree a stop signal and pacing requests for the clinician (B6). With consent, write to the physiotherapist (B2). Consider grounding and window-of-tolerance work before resuming hands-on sessions.
• Flare-up after treatment. Normalise contacting the physiotherapist. Screen for the urgent symptoms in A2 and B7, and if present, emergency care. Work on catastrophic interpretations without giving medical reassurance yourself.
• Conflicting advice (physio says move, GP or family say rest). Do not adjudicate. Help the client bring the conflict to the clinicians and ask for one agreed message. NICE frames manual therapy within an exercise-based package [source: NICE NG59, rec 1.2.7].
• Dependence on hands-on treatment ("only the physio's hands fix it"). MDT explicitly aims for self-management and prevention [source: McKenzie Institute UK]. Explore what the passive treatment means relationally, for example care, being held or being fixed, and support the move to self-treatment.
• Rupture with the physiotherapist (felt dismissed, hurt or rushed). Help the client tell it apart from a boundary violation (B9). If it is a rupture, rehearse raising it, or support a change of clinician.
• Rupture with you ("you're sending me away", "you think it's physical"). Name the complementary roles. Repair openly, and keep the referral as an offer, not a condition.
• Client asks you to assess, massage, or "just check" their neck or back. Decline and refer (B10).
• Client reports unusual claims from a practitioner (e.g. that a body region stores a specific trauma memory, or a promise to cure non-musculoskeletal disease). These sit outside the published Maitland and MDT methods described here. Discuss them cautiously and encourage the client to check the practitioner's registration. Advertising-standards rulings on manual-therapy claims: [uncertain: not verified].
• Health anxiety amplified by safety information (e.g. dissection risk). Give the proportionate framing (rare; screening exists) [source: IFOMPT Cervical Framework 2020] and work on reassurance-seeking (B3).
• Guidance changes. NICE recommendations on psychological and combined programmes for low back pain are reported to have been withdrawn in July 2026 [source: Guideline Central, Aug 2026; uncertain: check current NICE NG59]. Psychological support for pain-related distress remains a matter of individual clinical formulation and local pathways.

Sources

Web sources

• McKenzie Institute International (UK branch): The McKenzie Method
• McKenzie Institute New Zealand: Education Frequently Asked Questions
• Rushton A, Carlesso LC, Flynn T, Hing WA, Kerry R, Rubinstein SM, Vogel S. International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention. IFOMPT, 2020
• IFOMPT History (definitive 2011)
• Elsevier Health: Maitland's Vertebral Manipulation, 8th Edition (Hengeveld E, Banks K, eds; Churchill Livingstone, 2013), publisher page with contents
• WSCC Clinics / University of Western States: Grades of Mobilization (Maitland's), protocol adopted 1998
• WikiMSK: Joint Mobilisation
• NICE NG59 Low back pain and sciatica in over 16s: Recommendations
• Guideline Central: NICE low back pain and sciatica guideline spotlight (Aug 2026)
• PEDro record: Lam OT et al. (2018) Effectiveness of the McKenzie method of mechanical diagnosis and therapy for treating low back pain: literature review with meta-analysis. J Orthop Sports Phys Ther 48(6):476–490
• HCPC: The professions (protected titles)

Books cited

• Maitland GD (1977). Peripheral Manipulation. Boston: Butterworths (as cited in the WSCC/UWS protocol).
• Hengeveld E, Banks K (eds) (2013). Maitland's Vertebral Manipulation: Management of Neuromusculoskeletal Disorders, Volume 1, 8th ed. Churchill Livingstone/Elsevier.

Web sources (professional codes on touch, sexual contact, competence and referral)

• BACP Ethical Framework for the Counselling Professions (2018)
• BACP Ethical Framework for the Counselling Professions (2026)
• UKCP Code of Ethics and Professional Practice (2019)
• BPS Code of Ethics and Conduct (2009), Keele-hosted copy
• HCPC Standards of Proficiency: Practitioner Psychologists (2023)
• APA, Ethical Principles of Psychologists and Code of Conduct (2002, amended 2010 and 2016)
• AAMFT Code of Ethics (2015)
• USABP Code of Ethics
• EABP Ethics Guidelines (2020)

Not verified [uncertain]: Kaltenborn-Evjenth and Mulligan methods; Maitland terminology beyond the grades and the textbook description; MDT subgroup criteria; national physiotherapy regulation outside the UK; physiotherapy chaperone and consent guidance (CSP/HCPC conduct standards); HCPC concerns procedure; independent reviews of cervical manipulation and Maitland mobilisation; advertising-standards rulings; memory-research sources.