Skip to main content

Can you be a manual therapist without using your hands?



To align with current best practices, manual therapists have refined their treatment options to include exercise and pain education for people with chronic musculoskeletal pain. In this commentary, we suggest that manual therapists should also add telehealth to their toolbox. Thus, we aim to discuss the use of telehealth by manual therapists caring for patients with musculoskeletal disorders.

Main body

Telehealth can be delivered to the patient in different modes, such as real-time clinical contact or asynchronously. Platforms vary from websites and smartphone apps to virtual reality systems. Telehealth may be an effective approach, especially for improving pain and function in people with musculoskeletal pain, and it has the potential to reduce the individual and socioeconomic burden of musculoskeletal conditions. However, the certainty of evidence reported in systematic reviews is often low. Factors such as convenience, flexibility, undivided attention from the clinician, user-friendly platforms, goal setting, and use of evidence-based information are all enablers for telehealth use and improving patients’ knowledge, self-efficacy, and self-management. Barriers to widening the use of telehealth in musculoskeletal care include the reliability of technology, data privacy issues, difficult to build therapeutic alliance, one-size-fits-all approaches, digital health literacy, and payment models.


We suggest that practitioners of manual medicine make telehealth part of their clinical toolbox where it makes sense and where there is evidence that it is beneficial for people who seek their care.


Telehealth can be defined as the use of electronic information and telecommunications technologies to support long-distance clinical health care [1]. Telehealth is not a new approach; it has been around for half a century. One of the first reports of the use of telehealth, from the 1970s, used black and white television systems and telephone consultations to deliver care to remote, medically underserved areas [2, 3]. The integration between audio and video was only possible via satellite, microwave, or cable. It required the bandwidth of a thousand telephones, which was very expensive and unfeasible at that time. Today, advances in technology and telecommunication have enabled an exponential increase in telehealth initiatives. These advances include videoconferencing, store-and-forward information, patient monitoring (wearables, devices, self-report), streaming, and communication, and can assist with diagnosis, treatment, or prevention of a condition.

Telehealth has the potential to reach every population in the world. In high-income countries, more than two-thirds of the population has internet access. Low- and middle-income countries report much lower rates, but access is increasing substantially [4], and soon disadvantaged populations may have better access to the internet than to in-person quality health services [5]. Despite its great potential, telehealth is still in its infancy and faces many implementation barriers, especially from clinicians [6]. Manual therapists such as chiropractors define themselves by the physical clinical encounter with a patient and primarily rely on hands-on approaches. Over the years, however, most have added other strategies such as exercise and pain education to their toolbox, evolving to more complete and guideline-based care offered to their patients [7]. We suggest it is time they also add telehealth to that toolbox. This commentary discusses the use of telehealth by manual therapists.

How telehealth has been used in musculoskeletal practice

Telehealth can be delivered to the patient in different modes, and interventions are often multimodal. One characteristic is whether the telehealth intervention includes a clinician with whom the patient can communicate. Clinician contact can be in real time, where the patient directly sees and talks with the clinician, or it can be asynchronous, where the communication is direct with the patient, but responses may be delayed and delivered via email, voice messages, or via images, videos, or other messages. Interventions not involving clinicians directly can be characterized by the platform, i.e., website, app, virtual reality, or audio/podcasts. The level of interaction through the platform can also vary as content and tools can be static, active, or interactive, and the level of personalization and use of methodology to tailor or personalize can vary.

Effectiveness of telehealth for musculoskeletal care

Previous studies have tested many different telehealth approaches. Most telehealth modalities benefit people with musculoskeletal pain by improving pain and function and thus show potential to reduce the individual and societal burden imposed by musculoskeletal conditions. However, systematic reviews report the certainty of this evidence as low [8,9,10,11,12,13,14,15]. One important limitation is that most systematic reviews pooled results across a range of interventions (e.g., physical and psychological therapies, education, multimodal), so there is high clinical heterogeneity. Consequently, there is uncertainty around the best approach regarding telehealth delivery, and it is still uncertain what is the best modality of telehealth for specific conditions and therapies in terms of effectiveness, cost and adherence. Nonetheless, patients have reported excellent satisfaction and acceptance of telehealth initiatives [16, 17]. A 2022 systematic review and meta-analysis of the effectiveness of digital health interventions for musculoskeletal pain did not identify enough studies evaluating the cost-effectiveness of these interventions, and this will be a priority for future trials[18]. Nevertheless, a recent trial on telehealth-delivered exercise and dietary weight loss programs for knee osteoarthritis reported that telehealth are likely to be cost-effective ($45,500 per QALY)[19].

Examples of telehealth strategies in musculoskeletal care

As an example of a successful telehealth intervention, Bennell and colleagues tested the effectiveness of a real-time internet-delivered exercise and pain-coping skills training intervention delivered online in people with chronic knee pain [20]. The intervention comprised three different elements; 1) educational material delivered via a website, 2) an interactive automated Pain-coping skills training program (pain COACH) and finally, 7 Skype sessions over 12 weeks, with a duration of 30–45 min, versus having access to the website only. The trial showed that participants in the interactive arm reduced pain (mean difference and 95% CI: 1.6 points, 0.9 to 2.3 points, NRS 0–10 scale) and improved function at 3 months (mean difference and 95% CI: 9.3 points, 5.9 to 12.7, WOMAC 0–68 scale) and the effect was sustained at 9 months. Interviews with physiotherapists revealed that they were initially uncomfortable with being unable to touch their patients. However, they also reported that the project stimulated self-reflection on their delivery of care and a stronger focus on the most important and effective treatment for the patient’s knee osteoarthritis, namely exercise, education, and self-management skills, rather than hands-on examination and clinical findings [21].

Telehealth interventions utilizing no direct interaction between patients and clinicians are also becoming frequent, especially when delivered via smartphone applications [22, 23]. Using low back pain as an example, many of the available mHealth apps have not been comprehensively tested with appropriate trial designs [24]. However, evidence-based interventions underpinned by research are growing rapidly [23, 25]. The selfBACK app is an example of a digital decision system that supports patients with low back pain in their self-management [26]. In selfBACK, the patient continuously provides information about their symptoms and reports of exercise and physical activity via the app, which the digital system then uses to provide individually tailored and evidence-based content to the patient using artificial intelligence and machine learning [26]. Low back pain patients who used the selfBACK system as an adjunct to usual care had reduced pain-related disability at 3 months, with 52% in the intervention group achieving a clinically significant improvement versus 39% in the control group. While the average improvement in pain-related disability was moderate in both the intervention (3.7 (SD: 4.5) RMDQ points) and the control groups (3.0 (SD: 4.5) RMDQ points), the between-group difference was small and of uncertain clinical significance, but sustained at 9 months and consistently seen in secondary outcomes [27]. Importantly, the selfBACK intervention was an adjunct to usual care as a tool to support self-management, not as a substitution for clinical care.

Another example is the Reabilitador program, an asynchronous system of telerehabilitation based on exercise, education, and coaching designed for people with chronic musculoskeletal pain [28]. The program utilizes a website with a tailored patient area secured by login and password. Each week the program is updated according to the patient progress. Patients have reported high levels of satisfaction and acceptability and found the content appropriate for their condition [29]. The program was associated with a reduction in pain intensity after 8 weeks, but no significant changes in function were seen [29].

Barriers and enablers to broader use of telehealth in musculoskeletal care

According to the literature, one of the main barriers to using telehealth is the reliability of technologies, with users emphasizing that trustworthy connections and audio-visual quality are important considerations [30, 31]. Clinicians should understand the technology available and make sure they can provide a reliable experience for patients while also planning for backup contingencies in case of technical problems [32]. Also, feeling comfortable with technologies, i.e., using standard and familiar platforms, can enhance adherence and uptake [33]. Some patients have also expressed concerns regarding data- and privacy protection [31, 34]. Therefore, health systems and clinicians must secure privacy and adhere to data protection rules and regulations such as the European General Data Protection Regulation (GDPR) or the Brazilian General Law on Protection of Personal Data (LGPD). These concerns can be addressed with end-to-end encryption and authentication to create a secure communication environment.

The clinician-patient relationship is different in the digital environment and may be perceived as a barrier to many telehealth solutions. The lack of physical presence, no touch, and lack of non-verbal communication are contributing factors to lower engagement in telehealth interventions [31]. Surprisingly, participants in a telehealth trial for knee osteoarthritis perceived the telehealth intervention to be more personal rather than less compared to physical consultations [21], a finding confirmed by subsequent studies [30]. In addition, just like for a clinical encounter, one size does not fit all, so a person-based approach to the tailoring of telehealth interventions that promote autonomy, competence, and adherence is preferred, whereas telehealth interventions that are impersonal, with limited flexibility and less interactive are seen as less engaging and not likely to meet the patient's needs [31].

A strong barrier to delivering telehealth interventions is digital health literacy, which is the ability to seek, find, understand, and appraise health information from electronic sources and apply this knowledge to a health problem [35]. Digital health literacy is a dynamic concept that is influenced by many factors, such as the patient underlying health condition, educational background, health status, motivation for seeking information, and the technologies used [36, 37]. Low digital health literacy can be associated with poor engagement in telehealth interventions, feeling of frustration and dependence on others [31]. Further, a person that is generally low engaged with digital technologies is likely to be less actively participating in their health decisions, have less control of their problem and be less able to keep up with technological advances [38]. By considering these digital skills, a clinician can open new opportunities to better engage and interact with patients during telehealth encounters.

The strongest enabler of telehealth is its convenience and flexibility. Telehealth usually requires less or no travel time and less or no time off work compared to in-person care because the patient can access telehealth services in the convenience of their own home and not in a clinical environment [30, 31]. Receiving exclusive attention from the clinician in videoconferencing and easy-to-use platforms are also positive components for improving engagement in telehealth interventions [31]. Patients also appreciate the ability to track their progress electronically, set goals, and receive continuous feedback. The use of evidence-based information can also be seen as a facilitator since it improves knowledge, self-efficacy and self-management [31]. There is also emerging evidence that telehealth can reduce costs; however, savings may not apply to healthcare consultations but rather be related to time and travel and time off work or out of daily duties while travelling [39]. Table 1 presents common challenges in telehealth with potential solutions.

Table 1 Challenges and potential solutions in telehealth for musculoskeletal care that clinicians should be aware of


Access to telehealth services may be suboptimal, especially in low- and middle-income countries, but every day more than 600,000 people access the internet for the first time, and there are now more than 7 billion users of mobile phones—about equal to the number of people on the planet [4, 40]. Access to online information, therefore, is everywhere and will continue to grow, making it the most powerful vehicle to spread information, including health information and potentially healthcare for individuals. We suggest that practitioners of manual medicine make telehealth part of their clinical toolbox where it makes sense and where there is evidence that it is beneficial for people who seek their care.

Availability of data and materials

Not applicable.


  1. World Health Organisation. Global diffusion of eHealth: making universal health coverage achievable: report of the third global survey on eHealth. Geneva: World Health Organization; 2016.

    Google Scholar 

  2. Conrath DW, Dunn EV, Bloor WG, Tranquada B. A clinical evaluation of four alternative telemedicine systems. Behav Sci. 1977;22(1):12–21.

    Article  CAS  PubMed  Google Scholar 

  3. House AM, Roberts JM. Telemedicine in Canada. Can Med Assoc J. 1977;117(4):386–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  4. Roser M, Ritchie H, Ortiz-Ospina E. Internet. Our world in data. 2015.

  5. Africa Health Agenda International Conference. The state of universal health coverage in africa. African Union: AHAIC; 2021.

  6. Malliaras P, Merolli M, Williams CM, Caneiro JP, Haines T, Barton C. “It’s not hands-on therapy, so it’s very limited”: telehealth use and views among allied health clinicians during the coronavirus pandemic. Musculoskelet Sci Pract. 2021;52:102340.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. De la Ruelle LP, de Zoete A, de Boer MR, van Tulder MW, Ostelo R, Rubinstein SM. Management of people with low back pain: a survey of opinions and beliefs of Dutch and Belgian chiropractors. Chiropr Man Therap. 2022;30(1):29.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Seron P, Oliveros MJ, Gutierrez-Arias R, Fuentes-Aspe R, Torres-Castro RC, Merino-Osorio C, et al. Effectiveness of telerehabilitation in physical therapy: a rapid overview. Phys Ther. 2021;101(6):pza053.

    Article  Google Scholar 

  9. Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clin Rehabil. 2017;31(5):625–38.

    Article  PubMed  Google Scholar 

  10. Gava V, Ribeiro LP, Barreto RPG, Camargo PR. Effectiveness of physical therapy given by telerehabilitation on pain and disability of individuals with shoulder pain: a systematic review. Clin Rehabil. 2022;36(6):715–25.

    Article  PubMed  Google Scholar 

  11. de Oliveira Lima L, Saragiotto BT, Costa LOP, Nogueira LC, Meziat-Filho N, Reis FJJ. Self-guided web-based pain education for people with musculoskeletal pain: a systematic review and meta-analysis. Phys Ther. 2021;101(10):pza167.

    Article  Google Scholar 

  12. Chen M, Wu T, Lv M, Chen C, Fang Z, Zeng Z, et al. Efficacy of mobile health in patients with low back pain: systematic review and meta-analysis of randomized controlled trials. JMIR Mhealth Uhealth. 2021;9(6):e26095.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Wang X, Hunter DJ, Vesentini G, Pozzobon D, Ferreira ML. Technology-assisted rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1):506.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Jackson LE, Edgil TA, Hill B, Owensby JK, Smith CH, Singh JA, et al. Telemedicine in rheumatology care: a systematic review. Semin Arthritis Rheum. 2022;56:152045.

    Article  PubMed  Google Scholar 

  15. Hewitt S, Sephton R, Yeowell G. The effectiveness of digital health interventions in the management of musculoskeletal conditions: systematic literature review. J Med Internet Res. 2020;22(6): e15617.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open. 2017;7(8): e016242.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Grona SL, Bath B, Busch A, Rotter T, Trask C, Harrison E. Use of videoconferencing for physical therapy in people with musculoskeletal conditions: a systematic review. J Telemed Telecare. 2018;24(5):341–55.

    Article  PubMed  Google Scholar 

  18. Valentijn PP, Tymchenko L, Jacobson T, Kromann J, Biermann CW, AlMoslemany MA, et al. Digital health interventions for musculoskeletal pain conditions: systematic review and meta-analysis of randomized controlled trials. J Med Internet Res. 2022;24(9):e37869.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Harris A, Hinman RS, Lawford BJ, Egerton T, Keating C, Brown C, et al. Cost effectiveness of telehealth-delivered exercise and dietary weight loss programs for knee osteoarthritis within a 12-month randomised trial. Arthritis Care Res (Hoboken). 2022.

  20. Bennell KL, Nelligan R, Dobson F, Rini C, Keefe F, Kasza J, et al. Effectiveness of an internet-delivered exercise and pain-coping skills training intervention for persons with chronic knee pain: a randomized trial. Ann Intern Med. 2017;166(7):453–62.

    Article  PubMed  Google Scholar 

  21. Hinman RS, Nelligan RK, Bennell KL, Delany C. “Sounds a bit crazy, but it was almost more personal:” a qualitative study of patient and clinician experiences of physical therapist-prescribed exercise for knee osteoarthritis via skype. Arthritis Care Res (Hoboken). 2017;69(12):1834–44.

    Article  CAS  Google Scholar 

  22. Aitken M, Nass D. Digital health trends 2021: innovation, evidence, regulation, and adoption. Parsippany: The IQVIA Institute of Human Data Science; 2021.

    Google Scholar 

  23. Aitken M, Clancy B, Nass D. The growing value of digital health—Evidence and impact on Human Health and the Healthcare system. Parsippany: The IQVIA Institute for Human Data Science; 2017.

    Google Scholar 

  24. Machado GC, Pinheiro MB, Lee H, Ahmed OH, Hendrick P, Williams C, et al. Smartphone apps for the self-management of low back pain: A systematic review. Best Pract Res Clin Rheumatol. 2016;30(6):1098–109.

    Article  PubMed  Google Scholar 

  25. Rintala A, Rantalainen R, Kaksonen A, Luomajoki H, Kauranen K. mHealth apps for low back pain self-management: scoping review. JMIR Mhealth Uhealth. 2022;10(8):e39682.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Mork PJ, Bach K. A decision support system to enhance self-management of low back pain: protocol for the selfBACK project. JMIR Res Protoc. 2018;7(7):e167.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Sandal LF, Bach K, Overas CK, Svendsen MJ, Dalager T, Stejnicher Drongstrup Jensen J, et al. Effectiveness of App-delivered, tailored self-management support for adults with lower back pain-related disability: a selfBACK randomized clinical trial. JAMA Intern Med. 2021;181(10):1288–96.

    Article  PubMed  Google Scholar 

  28. Fioratti I, Saragiotto BT, Reis FJJ, Miyamoto GC, Lee H, Yamato TP, et al. Evaluation of the efficacy of an internet-based pain education and exercise program for chronic musculoskeletal pain in comparison with online self-management booklet: a protocol of a randomised controlled trial with assessor-blinded, 12-month follow-up, and economic evaluation. BMC Musculoskelet Disord. 2020;21(1):404.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Fioratti I, Miyamoto GC, Fandim JV, Ribeiro CPP, Batista GD, Freitas GE, et al. Feasibility, usability and implementation context of an internet-based pain education and exercise program for chronic musculoskeletal pain: a pilot trial of the REABILITADOR program. JMIR Form Res. 2022;6:e35743.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Wallace LM, Falla D, Rushton A, Heneghan NR. Group and individual telehealth for chronic musculoskeletal pain: A scoping review. Musculoskeletal Care. 2022;20(2):245–58.

    Article  CAS  PubMed  Google Scholar 

  31. Fernandes LG, Devan H, Fioratti I, Kamper SJ, Williams CM, Saragiotto BT. At my own pace, space, and place: a systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain. Pain. 2022;163(2):e165–81.

    Article  PubMed  Google Scholar 

  32. Eccleston C, Blyth FM, Dear BF, Fisher EA, Keefe FJ, Lynch ME, et al. Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020;161(5):889–93.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Fioratti I, Fernandes LG, Reis FJ, Saragiotto BT. Strategies for a safe and assertive telerehabilitation practice. Braz J Phys Ther. 2021;25(2):113–6.

    Article  PubMed  Google Scholar 

  34. Pool J, Akhlaghpour S, Fatehi F, Gray LC. Data privacy concerns and use of telehealth in the aged care context: an integrative review and research agenda. Int J Med Inform. 2022;160:104707.

    Article  PubMed  Google Scholar 

  35. van Kessel R, Wong BLH, Clemens T, Brand H. Digital health literacy as a super determinant of health: more than simply the sum of its parts. Internet Interv. 2022;27:100500.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Norman CD, Skinner HA. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res. 2006;8(2):e9.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Manganello J, Gerstner G, Pergolino K, Graham Y, Falisi A, Strogatz D. The relationship of health literacy with use of digital technology for health information: implications for public health practice. J Public Health Manag Pract. 2017;23(4):380–7.

    Article  PubMed  Google Scholar 

  38. Lupton D. The digitally engaged patient: self-monitoring and self-care in the digital health era. Soc Theory Health. 2013;11(2):256–70.

    Article  Google Scholar 

  39. Rennie K, Taylor C, Corriero AC, Chong C, Sewell E, Hadley J, et al. The current accuracy, cost-effectiveness, and uses of musculoskeletal telehealth and telerehabilitation services. Curr Sports Med Rep. 2022;21(7):247–60.

    Article  PubMed  Google Scholar 

  40. Statista Search Department. Forecast number of mobile users worldwide from 2020 to 2025: Statista.

Download references


BTS is supported by the Sao Paulo Research Foundation (FAPESP/ Grant Number 2016/24217-7).



Author information

Authors and Affiliations



BTS developed an initial draft, organized and distributed it to the other authors. LFS and JH contributed to each section of the draft, providing references, content revision and writing. The manuscript was circulated to each author, who provided further input. BTS developed the final version of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Bruno T. Saragiotto.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

LFS and JH were part of the selfBACK project that was funded by the European Union through the Horizon 2020 program. BTS is part of the Reabilitador trial funded by the Sao Paulo Research Foundation (FAPESP/Grant number 2016/24217-7). None of the authors have commercial interests or outcomes from selfBACK or Rehabilitador projects.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Saragiotto, B.T., Sandal, L.F. & Hartvigsen, J. Can you be a manual therapist without using your hands?. Chiropr Man Therap 30, 48 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: