Atlas›Domain X · Body, movement, breath & physical›Guide 047
Guide X-047

Joint mobilisation and traction

Geoffrey Maitland
A 25 · L 65 · M 1013 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: joint mobilisation as described in the physiotherapy grading system attributed to Maitland (grades I–IV, with grade V equated with manipulation), the IFOMPT Cervical Framework (Rushton et al., 2020) for cervical safety and consent, and manual and mechanical spinal traction as described in NHS physiotherapy patient information (Royal Berkshire NHS Foundation Trust, 2022 and 2024). Evidence status follows Cochrane reviews and NICE guideline NG59. This guide is written for the psychotherapist, who does not deliver these techniques.

What it is. Joint mobilisation is a skilled, passive movement that a clinician applies to a painful or stiff peripheral joint (for example shoulder, knee, ankle) or spinal segment, usually as gentle rhythmical oscillations of graded size and depth into the available range. It is distinguished from manipulation, which is a high-velocity, low-amplitude thrust (sometimes called grade V) [source: WikiMSK, Joint Mobilisation; Gulick, PhysicalTherapy.com course 3491]. Traction is a sustained or intermittent stretch applied along the long axis of the spine, either manually by the clinician's hands (or a belt) or mechanically through a harness attached to a pulley, weights or a traction bed [source: Royal Berkshire cervical and lumbar traction leaflets]. Both are delivered by physiotherapists, and also within chiropractic and osteopathic practice; manipulation and the Maitland and McKenzie approaches are covered in tab 046 Manual physiotherapy and orthopaedic manual therapy, which names Kaltenborn–Evjenth and Mulligan methods but does not describe them.

How change is thought to happen. Practitioners describe low-grade mobilisation as aimed at reducing pain and irritability, and higher-grade mobilisation as aimed at stretching the joint capsule and passive tissues to increase range of movement [source: WikiMSK]. Mobilisation is also described as restoring small accessory (gliding) joint movements so that ordinary movement improves, and as reducing protective muscle guarding [source: Gulick]. Traction is described by NHS physiotherapy services as offering pain relief, stretching of soft tissues, reduced muscle spasm and improved movement [source: Royal Berkshire leaflets]. These are the providers' stated rationales; the evidence for traction in particular is weak (see Section 2, Evidence status).

The psychotherapist's place. You will meet these methods when clients are already receiving them, when a client with pain asks whether they should see a physiotherapist, chiropractor or osteopath, or when hands-on care stirs up trauma-related reactions. Your role is to: know what the client is likely to experience; know who is regulated to deliver it; prepare trauma-affected clients for being touched, positioned or strapped in; help them use consent and the right to stop; integrate body experiences into psychotherapy; and recognise adverse effects and boundary violations and route them to the right place [synthesis].

2. Framework

2a. Who delivers it and how they are regulated

  • UK physiotherapists: "physiotherapist" and "physical therapist" are titles protected by law; anyone using them must be on the Health and Care Professions Council (HCPC) register, which the public can search with the HCPC's Check the Register tool. HCPC handles misuse-of-title cases and concerns [source: HCPC, The professions].
  • UK chiropractors: the General Chiropractic Council (GCC) is an independent statutory body; the title "chiropractor" is protected, and using it without GCC registration is a criminal offence. The GCC publishes a Code of Professional Practice and a public register, and investigates concerns [source: GCC, What we do].
  • UK osteopaths: regulated by the General Osteopathic Council (GOsC), with "osteopath" a protected title [uncertain: not verified].
  • Australia: "chiropractor" and "osteopath" are protected titles under the National Law; the Chiropractic Board and Osteopathy Board of Australia set national registration standards with AHPRA, and using the titles without registration has been prosecuted [source: AHPRA/Osteopathy Board media release, 14 May 2015]. Physiotherapists are registered through the Physiotherapy Board of Australia [uncertain: not verified].
  • United States and Canada: physical therapists and chiropractors are licensed at state or provincial level, and osteopathic physicians (DOs) are fully licensed physicians, unlike non-physician osteopaths elsewhere [uncertain: not verified].
  • International standards: the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) publishes the Cervical Framework for examining the neck for possible vascular pathology before orthopaedic manual therapy, and states that it applies to mobilisation and exercise as well as manipulation [source: IFOMPT Cervical Framework 2020].

Practical point: before suggesting a practitioner, check the relevant public register [synthesis].

2b. Typical course of care (as providers describe it)

  1. Assessment and screening. History and physical examination, including checks for features that make treatment unsuitable (Section 2d). For the neck, IFOMPT asks clinicians to reason across the whole history and examination (blood pressure, neurological and cranial nerve testing among other things), rather than relying on any single test, and to keep a high index of suspicion for acute neck or head pain described as unlike any other [source: IFOMPT 2020].
  2. Explanation and consent. IFOMPT recommends shared decision-making and express (verbal or written) consent before treatment begins. Clients can withdraw consent at any time; any change of treatment requires the consent process again; consent is revisited when the same treatment continues [source: IFOMPT 2020].
  3. Trial treatment and reassessment. Clinicians apply a short trial of mobilisation and then reassess range of movement and pain. If the response is poor or worse they change one variable (grade, amplitude or amount), and if there is still no improvement they consider a different treatment [source: Gulick]. Traction is applied slowly with the client supported, followed by a few minutes' rest [source: Royal Berkshire leaflets].
  4. Course length. NHS leaflets say traction "may need more than one visit" but give no fixed number; no standard session count was found in the sources [uncertain].
  5. Context. For low back pain, NICE advises considering manual therapy (manipulation, mobilisation or soft-tissue techniques) only as part of a treatment package that includes exercise, not on its own [source: NICE NG59, rec. 1.2.7].

Criteria for moving on: providers progress, change or stop according to reassessed pain and movement; worsening or new neurological symptoms are a reason to stop and review [source: Gulick; Cochrane CD003010 on adverse effects] [synthesis for the stopping rule as a general principle].

2c. Evidence status

  • Traction for low back pain: Cochrane review (Wegner et al., 2013; 32 trials, 2,762 participants; manual and mechanical traction) found traction "may make little or no difference" for mixed low back pain and "probably has no impact" for sciatica compared with placebo, sham or no treatment; certainty was low to moderate [source: Cochrane CD003010]. NICE recommends: "Do not offer traction for managing low back pain with or without sciatica" [source: NICE NG59, rec. 1.2.6].
  • Traction for neck pain: Cochrane review (Graham et al., 2008; 7 trials, 958 participants) found no high-quality evidence for or against continuous or intermittent mechanical traction for chronic neck pain with or without radiating arm symptoms [source: Cochrane CD006408].
  • Mobilisation for neck pain: Cochrane review (Gross et al., 2015) found stand-alone mobilisation "may not reduce pain more than an inactive control" (very low to low quality evidence) and that manipulation and mobilisation gave similar results; "No high-quality evidence was found" [source: Gross et al. 2015, CD004249].
  • Low back pain packages: see NICE rec. 1.2.7 above. A secondary report states that NICE amended NG59 in July 2026, withdrawing recommendations 1.2.13 and 1.2.14 on psychological therapy and removing psychological therapy from the manual-therapy package wording [source: Physitrack report]; the 2016 wording is quoted above [uncertain: not verified against the current NICE text].
  • Peripheral joint mobilisation (shoulder, knee, ankle and so on): evidence status not established here [uncertain: not verified].

None of these methods treats cancer, infection or other systemic disease; they are offered for musculoskeletal pain and stiffness [synthesis].

2d. Contraindications, precautions and documented risks (as sources state them)

  • Mobilisation, listed as absolute contraindications in one physiotherapy course: medically unstable joint hypermobility, malignancy, cauda equina lesions, bowel or bladder dysfunction, vertebrobasilar insufficiency (for the region treated), bone disease, joint fusion, deteriorating central nervous system disease, acute inflammation and joint effusion. Relative contraindications or precautions: connective tissue disorders and ligamentous laxity (for example Ehlers–Danlos), joint replacement, pregnancy and postpartum, recent trauma, early tissue healing, long-term steroid use, osteopenia or osteoporosis, systemic connective tissue disorders, open growth plates in children, open wounds, and communication or cognitive difficulties that limit feedback [source: Gulick].
  • Cervical traction may not be suitable for people with rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis; osteoporosis or current or past long-term steroid use; recent trauma with possible fracture; previous neck surgery; pregnancy; cancer or suspected cancer in the area; recent radiotherapy to the area; epilepsy; stroke or TIA; jaw problems; drop attacks, fainting or dizziness; anticoagulants or bleeding disorders [source: Royal Berkshire cervical leaflet].
  • Lumbar traction may not be suitable for people with bowel or bladder disturbance; pins and needles or numbness in both legs or the groin; bony spinal abnormalities; inflammatory arthritis (rheumatoid, ankylosing spondylitis, psoriatic); osteoporosis; joint laxity or instability; hiatus hernia or abdominal problems; recent trauma; previous back surgery; severe heart failure or respiratory problems; claustrophobia; long-term steroid use; pregnancy; cancer in the area; recent radiotherapy; epilepsy; stroke or TIA; anticoagulants or bleeding disorders [source: Royal Berkshire lumbar leaflet].
  • Rheumatoid cervical spine: inflammatory arthritis is listed among conditions for which neck traction may be unsuitable [source: Royal Berkshire cervical leaflet]; specific guidance on upper cervical instability in rheumatoid disease is not covered here [uncertain: not verified].
  • Neck and vascular risk: IFOMPT describes serious adverse events after neck manual therapy as extremely rare; causation is not established and the working hypothesis is that an underlying vascular pathology may be "aggravated by treatment". Listed risk factors for dissection include recent trauma, vascular anomaly, smoking, migraine, high cholesterol, recent infection, hypertension, oral contraception and family history of stroke; an absence of risk factors "does not necessarily rule out" serious events [source: IFOMPT 2020]. Gross et al. (2015) report only temporary, benign side effects of mobilisation in trials, while noting that rare serious events have been linked to manipulation [source: CD004249].
  • Documented adverse effects of traction: increased pain, worsening neurological signs and subsequent surgery (low back trials) [source: Cochrane CD003010]; headache, nausea, fainting and tissue injury (neck) [source: Cochrane CD006408]; temporary worsening of symptoms, dizziness or faintness [source: Royal Berkshire leaflets].

Screening is the treating clinician's job; medical clearance is sought where these conditions are present or suspected [synthesis].

3. Guiding principles

  • Consent is express, informed and ongoing. Practical meaning: the client agrees before treatment, again when the technique changes, and can withdraw at any moment [source: IFOMPT 2020].
  • The right to stop is concrete. Practical meaning: in mechanical traction the client holds a safety release button; in manual work they say stop and the clinician stops [source: Royal Berkshire leaflets].
  • Touch is never sexual. Practical meaning: genital or sexual touch is always inappropriate; any sexualised touch or comment is a reportable boundary violation [source: USABP Code of Ethics, section VIII (body-psychotherapy code)] [synthesis for application to manual therapists].
  • Screen before treating. Practical meaning: contraindications and red flags are checked before every new technique, and the client discloses conditions such as osteoporosis, anticoagulants, inflammatory arthritis or recent neck trauma [source: IFOMPT 2020; Royal Berkshire leaflets].
  • Treatment is response-led. Practical meaning: each trial is reassessed; no improvement means change or stop, not more of the same [source: Gulick].
  • Passive treatment sits inside an active plan. Practical meaning: for back pain, manual therapy is part of an exercise-based package; traction is not recommended [source: NICE NG59].
  • Be honest about evidence. Practical meaning: help clients hold realistic expectations, especially for traction [source: Cochrane CD003010, CD006408] [synthesis].
  • Stay within your competence. Practical meaning: the psychotherapist does not mobilise joints or apply traction; codes require offering only forms of therapy one is trained in and referring when appropriate [source: UKCP Code 2019, items 23–24; BACP Ethical Framework 2018, para 13].
  • Do not mix hands-on work and talk therapy without the right code and training. Practical meaning: body-psychotherapy codes that permit touch require assessment of whether touch is appropriate, informed consent (written recommended), periodic re-consent and the right to refuse at any time; when a client sees another practitioner in parallel, the therapist considers the implications with the client [source: USABP Code VIII; EABP Ethics Guidelines 2020, Principle 7 and 6.b]. Mainstream talk-therapy codes contain no explicit touch provision [source: BACP 2018 and 2026; UKCP 2019; BPS 2009; HCPC Standards of Proficiency; APA; AAMFT 2015].
  • Trauma-informed adaptation. Practical meaning: predictability, choice over position and clothing, and explicit stop signals reduce the chance that being held, lying supine or being strapped in becomes a trauma cue [synthesis].

4. Intervention inventory

Part A describes the techniques as providers publish them, so that you can prepare clients and recognise problems. They are not instructions; forces, frequencies, durations and weights are deliberately left out. Part B gives the psychotherapist's own interventions.

Part A. What the client will meet

4.1 Peripheral joint mobilisation (graded passive movement)

  • Purpose and when used: for painful or stiff limb joints, to ease pain (lower grades) or to regain range by stretching the capsule and passive tissues (higher grades), and to restore small accessory glides that ordinary movement depends on [source: WikiMSK; Gulick].
  • What happens (descriptive): the client lies or sits supported; the clinician stabilises one side of the joint and moves the other with broad hand contact close to the joint line. Movements are rhythmical. The Maitland-attributed grades describe size and position in range: grade I, small movement at the start of range; grade II, larger movement within range, short of the end; grade III, large movement into the end of range; grade IV, small movement at the end of range; grade V equals manipulation, a high-velocity, low-amplitude thrust (see tab 046) [source: WikiMSK; Gulick]. Kaltenborn's separate grading system is [uncertain: not verified] and is not covered in 046. After a short trial the clinician rechecks movement and pain [source: Gulick].
  • Example language (psychotherapist, illustrative): "From what you've told me, the physio will move your shoulder for you in small, gentle rocking movements and then check how it feels. You can ask them to explain each step before they do it."
  • Watch for: the client reports feeling powerless while a limb is held; pain that stays worse after sessions; a clinician who does not reassess or explain. Signs it is going well: the client describes the movements as predictable and tolerable and reports improving movement [synthesis].

4.2 Spinal mobilisation (including the neck)

  • Purpose and when used: for spinal pain and stiffness; for the neck, a Cochrane review found low or very low quality evidence and no clear advantage over inactive control for stand-alone mobilisation [source: Gross et al. 2015].
  • What happens (descriptive): the client usually lies face down, on their back or on their side; the clinician applies graded oscillating pressure or movement to spinal segments. For the neck, IFOMPT expects a pre-treatment history and examination for possible vascular pathology and express consent [source: IFOMPT 2020; Gulick].
  • Example language (illustrative): "Neck treatment usually starts with quite a lot of questions about headaches, dizziness and your general health. That's routine safety checking, not a sign that something's wrong."
  • Watch for: new dizziness, visual disturbance, unusual headache, facial or limb tingling, difficulty walking or speaking after neck treatment: these features belong to the IFOMPT screening list and need urgent medical assessment [source: IFOMPT 2020]. Lying face down with the face in a table hole, or having the head and neck held, can be a trauma cue for some clients [synthesis].

4.3 Manual traction (neck or lower back)

  • Purpose and when used: offered for neck or back pain and muscle spasm; for the neck the clinician supports the back of the head and under the chin and applies a slow pull with the client lying down; for the lower back the pull goes through the pelvis or legs, by hand or with a special belt, in lying [source: Royal Berkshire leaflets]. For low back pain NICE advises against offering traction [source: NICE NG59, rec. 1.2.6].
  • What happens (descriptive): slow application of the stretch, the client supported and kept comfortable, a few minutes' rest afterwards; the client tells the clinician straight away if the stretch is uncomfortable or they feel unwell [source: Royal Berkshire leaflets].
  • Example language (illustrative): "Having someone hold your head and chin might feel very exposing given what you've been through. It's fine to tell the physio that and ask what alternatives there are."
  • Watch for: chin and throat contact, or being held still, can be especially hard for survivors of strangulation, restraint or assault [synthesis]. Dizziness or faintness during or after treatment needs reporting at once [source: Royal Berkshire cervical leaflet].

4.4 Mechanical traction (neck or lower back)

  • Purpose and when used: as for manual traction; evidence for the neck is inconclusive and for the lower back shows little or no benefit [source: Cochrane CD006408; CD003010].
  • What happens (descriptive): for the neck, a harness attached to a pulley with weights or a traction bed, sitting or lying; for the lower back, a harness around the pelvis and lower ribs attached to a traction unit on a bed that may slide open, often lying on the back with the legs raised. The client holds a safety release button that switches the traction off [source: Royal Berkshire leaflets].
  • Example language (illustrative): "Before the session, could you ask to see the harness and practise pressing the release button while nothing is attached? Knowing you can stop it yourself often makes the difference."
  • Watch for: claustrophobia is listed as a reason traction may be unsuitable [source: Royal Berkshire lumbar leaflet]; feeling strapped down may provoke panic or freezing; side effects such as headache, nausea, fainting and worsened pain or neurological signs [source: Cochrane CD006408; CD003010].

Part B. The psychotherapist's interventions

4.5 Deciding when to suggest a musculoskeletal assessment

  • Purpose and when to use: when a client's pain, stiffness or reduced movement is affecting mood, sleep, work or therapy, and they have not had a physical assessment [synthesis].
  • Steps: (1) Ask whether the problem has been assessed by a GP or a registered physiotherapist, chiropractor or osteopath. (2) If not, suggest a GP or registered physiotherapist as the first stop rather than a particular technique. (3) If the client asks specifically about traction for back pain, share that NICE advises against it and that reviews find little or no benefit [source: NICE NG59 1.2.6; Cochrane CD003010]. (4) Note any features that need same-day medical help rather than a routine referral (see 4.11) [synthesis].
  • Example language (illustrative): "It sounds like your back has a lot of say over your days at the moment. Has anyone examined it? A GP or registered physiotherapist can work out what's going on and what might help."
  • Watch for: clients seeking a hands-on fix to avoid active rehabilitation or emotional work; clients who have had many passive treatments without change [synthesis]. Working: the client books an assessment and reports back.

4.6 Making and coordinating the referral

  • Purpose and when to use: when the client agrees to see, or already sees, a manual therapist [synthesis].
  • Steps: (1) Help the client check the practitioner on the relevant register (HCPC, GCC, GOsC or national equivalent) [source: HCPC; GCC]. (2) Obtain the client's written consent before any contact with the practitioner and agree what will be shared, for example that the client has a trauma history and may need extra explanation, without disclosing details [synthesis]. (3) Discuss with the client how parallel treatments fit together, as body-psychotherapy codes ask when a client receives similar services elsewhere [source: EABP 2020, 6.b]. (4) Never take fees for referrals [source: EABP 2020, 5.d].
  • Example language (illustrative): "Would it help if I let the physio know, in general terms, that you'd like each step explained before they touch you? I'd only say what you and I agree on."
  • Watch for: over-sharing; the client feeling talked about; unregistered practitioners using protected-sounding titles. Working: the client reports feeling expected and respected at the first appointment.

4.7 Preparing a client with a trauma history for hands-on care

  • Purpose and when to use: before a first appointment for mobilisation or traction, when the client has trauma related to touch, restraint, medical procedures or assault [synthesis].
  • Steps: (1) Describe what typically happens (positions, hand contact, harness, release button) using Part A. (2) Identify likely cues: lying face down, head and chin held, pelvis strapped, undressing, a closed room. (3) Help the client write a short list of requests: explanation before each technique, keeping clothing on or wearing loose sportswear where possible, door or position preferences, a chaperone or companion, a stop word. Chaperones and companions should be requested in advance; the practitioner's own policy applies [synthesis]. (4) Remind the client that consent can be withdrawn at any time and must be sought again whenever treatment changes [source: IFOMPT 2020]. (5) Practise saying the stop word and asking a question in session.
  • Example language (illustrative): "Let's plan what you'll say if you want them to pause. Could you try it out loud now: 'Can we stop for a moment, please?'"
  • Watch for: the client agreeing to everything to please you or the clinician; avoidance of the appointment; anticipatory dissociation. Working: the client can name two or three requests and a stop signal and reports using one [synthesis].

4.8 Supporting consent and the right to stop during treatment

  • Purpose and when to use: for clients who freeze, fawn or dissociate in medical settings [synthesis].
  • Steps: (1) Agree a simple non-verbal stop signal the client can also use (raising a hand), and suggest telling the clinician about it at the start. (2) Explain that in mechanical traction the safety release button is theirs to use [source: Royal Berkshire leaflets]. (3) Rehearse grounding the client can do while lying down, such as noticing the table under them or naming objects in view. (4) Plan what happens if the client stops: ask for the treatment to be explained again or discontinued; they do not owe an explanation [synthesis].
  • Example language (illustrative): "Stopping isn't failing the treatment. It's you using the control that's built into it."
  • Watch for: reports of a clinician continuing after a request to stop, or dismissing discomfort; this is a consent breach and can be raised with the regulator (4.12). Working: the client describes having used or felt able to use the stop signal [synthesis].

4.9 Debriefing and integrating body experiences

  • Purpose and when to use: in the session after a manual-therapy appointment, especially if the client was moved, distressed, or surprised by their own reactions [synthesis].
  • Steps: (1) Ask open questions about what it was like before asking about pain. (2) Separate the physical account (what was done, what hurt, what eased) from the emotional one (fear, shame, relief, memories). (3) Normalise strong reactions to being held or positioned without interpreting them as proof of past events. (4) Link what happened to the client's existing therapy goals, such as assertiveness, tolerating care or noticing body signals. (5) Agree whether anything should be fed back to the clinician [synthesis].
  • Example language (illustrative): "What did you notice in your body when they were holding your neck? And what were you saying to yourself at that moment?"
  • Watch for: practitioners or clients describing emotional reactions during treatment as "released memories" stored in tissue; treat such accounts with the cautions from memory research and do not use body sensations to confirm or uncover memories [synthesis] [uncertain: not verified]. Working: the client can describe the experience coherently and decide what to do next.

4.10 Shaping realistic expectations and an active plan

  • Purpose and when to use: when a client pins hopes on passive treatment, or feels they have "failed" treatment [synthesis].
  • Steps: (1) Explore what the client expects mobilisation or traction to do. (2) Share, in plain terms, that guidelines place manual therapy inside an exercise-based plan and do not recommend traction for low back pain, and that neck traction evidence is inconclusive [source: NICE NG59 1.2.6–1.2.7; Cochrane CD006408]. (3) Encourage the client to discuss the overall plan and goals with the treating clinician. (4) Address beliefs such as "my spine is out of place" or "I must not move" by inviting the clinician's explanation rather than giving your own physical advice [synthesis].
  • Example language (illustrative): "It makes sense to want something done to you when you're in pain. What has the physio said about the exercises being part of it?"
  • Watch for: demoralisation after a lack of response; repeated courses of the same passive treatment; your own drift into giving physical advice. Working: the client engages with the active parts of their plan.

4.11 Recognising and passing on adverse effects

  • Purpose and when to use: whenever a client mentions symptoms during or after treatment [synthesis].
  • Steps: (1) Ask what was done, when, and what changed. (2) Urgent, same-day medical assessment (emergency services if severe or sudden): sudden severe head or neck pain unlike any before, new dizziness, visual disturbance, facial or limb numbness or tingling, problems walking, speaking or swallowing after neck treatment [source: IFOMPT 2020 screening features]; new bowel or bladder disturbance, or numbness in the groin or both legs [source: listed as contraindications in Gulick and Royal Berkshire lumbar leaflet; urgency is synthesis]. (3) Prompt report to the treating clinician: increased pain, fainting, nausea, headache or worsening nerve symptoms [source: Cochrane CD003010, CD006408; Royal Berkshire leaflets]. (4) Encourage the client to tell the clinician about relevant conditions they may not have disclosed (for example osteoporosis, steroid use, anticoagulants, inflammatory arthritis, pregnancy, recent radiotherapy) [source: Royal Berkshire leaflets]. (5) Record what you advised.
  • Example language (illustrative): "The dizziness and the numbness in your face since yesterday's neck treatment need checking today. I'd like you to call [emergency number / NHS 111 or local equivalent] now, from here if you'd like."
  • Watch for: clients minimising symptoms to avoid fuss; delayed onset after treatment. Working: the client gets assessed and the clinician is informed.

4.12 Recognising boundary violations and supporting a complaint

  • Purpose and when to use: when a client describes touch, comments, undressing or positioning that felt sexual, unexplained or non-consented [synthesis].
  • Steps: (1) Listen, believe, and avoid leading questions. (2) Name that sexual touch by any practitioner is never part of treatment and that touch without consent, or continuing after a request to stop, is a consent breach [source: USABP Code VIII on sexual touch; IFOMPT 2020 on consent withdrawal]. (3) Explain routes: the HCPC for physiotherapists, the GCC for chiropractors, the GOsC for osteopaths [uncertain: GOsC process not verified], AHPRA and the relevant national board in Australia [source: HCPC; GCC; AHPRA release], and the police where a crime may have occurred. (4) Offer practical help: writing a timeline, finding the regulator's concerns page, support during the process. (5) Follow your own safeguarding duties and consult your supervisor [synthesis].
  • Example language (illustrative): "What you've described is not part of any legitimate treatment. You have choices about what to do next, and I can help you with whichever you choose."
  • Watch for: self-blame; pressure from the practitioner; the client's wish not to report, which they have the right to unless safeguarding duties apply [synthesis]. Working: the client feels in control of the next steps.

4.13 Keeping within your own scope

  • Purpose and when to use: when you, or a client, are tempted to combine talk therapy with hands-on joint work [synthesis].
  • Steps: (1) Do not mobilise joints, apply traction or demonstrate techniques on clients. Codes require offering only forms of therapy you are trained in and staying within competence [source: UKCP 2019 items 23–24; BACP 2018 para 13; APA 2.01(a)]. (2) If you are a body psychotherapist whose code permits touch, follow its requirements: assessment of suitability, informed consent (written recommended), periodic re-consent, right to refuse, documentation [source: USABP Code VIII]; joint mobilisation and traction remain outside body-psychotherapy competence unless you also hold a registered manual-therapy qualification [synthesis]. (3) Keep roles separate if you hold dual qualifications and discuss in supervision [synthesis].
  • Example language (illustrative): "I'm not the right person to work on your neck physically, but I can help you get the most out of seeing someone who is."
  • Watch for: requests to "just have a look" at a sore joint; dual-relationship risks. Working: clear roles for you and the clinician.

5. Handling problems

All guidance in this section is [synthesis] unless a source is named.

  • Client panics or freezes when strapped into mechanical traction. Prepare with 4.7 and 4.8; suggest asking for a demonstration of the harness and release button before it is attached; claustrophobia is itself listed as a reason traction may not be suitable, so the client can ask about alternatives [source: Royal Berkshire lumbar leaflet].
  • Dissociation on the treatment table. Afterwards, debrief (4.9) and plan grounding cues and a non-verbal stop signal; suggest the client tells the clinician that they may go quiet when overwhelmed, so silence is not read as consent.
  • Pain flare after treatment. Temporary worsening is a recognised effect [source: Royal Berkshire leaflets]; the client reports it to the clinician. Red-flag features go to urgent care (4.11).
  • Client wants traction for low back pain despite guidance. Respect the choice, share the NICE recommendation and Cochrane findings without pressure, and suggest discussing alternatives with the clinician [source: NICE NG59 1.2.6; CD003010].
  • Client fears stroke after reading about neck treatment. IFOMPT describes serious events as extremely rare, with causation not established; the client can ask about screening and about non-thrust or non-neck options [source: IFOMPT 2020].
  • Dependence on passive treatment. Use 4.10; explore what being cared for means to the client, and how that might be met in other ways.
  • The practitioner dismisses the client's distress or ignores a stop request. Validate, discuss whether to change practitioner, and offer 4.12.
  • Practitioner offers emotional or "release" interpretations. Help the client separate physical treatment from claims outside that practitioner's competence; apply memory cautions (4.9) [uncertain].
  • Hypermobile or connective tissue disorder clients. Such conditions are listed as precautions for mobilisation [source: Gulick]; encourage disclosure to the clinician.
  • Non-attendance at physical appointments. Explore avoidance linked to touch, undressing, shame about the body or medical trauma; rehearse the first appointment.
  • Rupture in your relationship after you suggested referral. The client may hear it as dismissal ("you think it's all physical" or "you don't want to deal with my pain"); name the intent, invite the reaction, and stress that psychotherapy continues alongside.
  • Older clients, inflammatory arthritis, osteoporosis, anticoagulants. These appear in contraindication lists [source: Royal Berkshire leaflets; Gulick]; encourage a GP or specialist review before manual treatment.
  • Children and adolescents. Open growth plates are listed as a precaution [source: Gulick]; parental consent and the young person's assent and safeguarding apply; refer to paediatric-trained clinicians.

Sources

Web sources

Related tab: 046 Manual physiotherapy and orthopaedic manual therapy (Maitland, McKenzie).

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