What Should a Modern Evidence-Based Myotherapist Actually Believe?

Sorting Through a Century of Explanations

Manual therapy carries a long history of explanatory models, many developed long before modern pain science and tissue biology existed to test them. A modern, evidence-based practitioner is left with a genuinely useful task: working out which of these traditional explanations have held up to scrutiny, which need updating, and which should be set aside altogether.

What Should Be Abandoned

Several once-popular explanations have not survived contact with the evidence: the idea that massage mechanically "flushes" lactic acid or toxins from tissue; that manual pressure can permanently and mechanically "release" fascia in a literal structural sense; that cracking a joint "puts it back into place"; and that the degree of post-treatment soreness reliably indicates treatment quality. These explanations are now better understood as folk descriptions of genuine clinical outcomes, attached to mechanisms that do not hold up under direct testing (Chaudhry et al., 2008).

What Requires Modification

Other explanations were broadly on the right track but needed significant refinement. "Muscle tone" and "looseness" are real, clinically meaningful changes, but are now better understood as predominantly neurologically mediated — reduced protective guarding and altered motor control — rather than genuine mechanical lengthening of tissue. Similarly, "increased blood flow" as a universal mechanism needs the important caveat that this effect is clearly demonstrated at the skin but considerably less certain at the deep intramuscular level (Mori et al., 2004).

What Remains Plausible but Unproven

A further group of ideas sit in a genuinely uncertain middle ground: the precise contribution of mechanotransduction-driven cellular signalling to long-term treatment outcomes, and the exact balance between local tissue effects and broader central nervous system changes, remain active and legitimate areas of ongoing research rather than settled questions in either direction.

What Has Genuinely Survived Scrutiny

Meanwhile, several core mechanisms have held up well under direct testing: the gate control mechanism of pain modulation, the existence and clinical relevance of conditioned pain modulation, the measurable influence of expectation and context on treatment outcomes, and the comprehensive, multi-system model of manual therapy's mechanisms proposed by Bialosky and colleagues (Bialosky et al., 2009) all remain well supported by current evidence.

What a Modern Practitioner Is Left Believing

Put together, a defensible modern position holds that manual therapy produces genuine, clinically meaningful change — primarily through neurophysiological and psychologically mediated mechanisms, built on a real but more modest foundation of local biological tissue effects — and that honest, updated communication about these mechanisms serves clients better than either uncritically repeating outdated folk explanations or dismissively discounting manual therapy's value altogether.