elements of literature review worksheet

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• Research Guides

How to Write a Literature Review

• 6. Synthesize
• Literature Reviews: A Recap
• Reading Journal Articles
• Does it Describe a Literature Review?
• 1. Identify the Question
• 2. Review Discipline Styles
• Searching Article Databases
• Finding Full-Text of an Article
• Citation Chaining
• When to Stop Searching
• 4. Manage Your References
• 5. Critically Analyze and Evaluate

Synthesis Visualization

Synthesis matrix example.

• 7. Write a Literature Review

• Synthesis Worksheet

About Synthesis

Approaches to synthesis.

You can sort the literature in various ways, for example:

How to Begin?

Read your sources carefully and find the main idea(s) of each source

Look for similarities in your sources – which sources are talking about the same main ideas? (for example, sources that discuss the historical background on your topic)

Use the worksheet (above) or synthesis matrix (below) to get organized

This work can be messy. Don't worry if you have to go through a few iterations of the worksheet or matrix as you work on your lit review!

Four Examples of Student Writing

In the four examples below, only ONE shows a good example of synthesis: the fourth column, or  Student D . For a web accessible version, click the link below the image.

Long description of "Four Examples of Student Writing" for web accessibility

• Download a copy of the "Four Examples of Student Writing" chart

Click on the example to view the pdf.

From Jennifer Lim

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The Research Proposal

83 Components of the Literature Review

Krathwohl (2005) suggests and describes a variety of components to include in a research proposal.  The following sections present these components in a suggested template for you to follow in the preparation of your research proposal.

Introduction

The introduction sets the tone for what follows in your research proposal – treat it as the initial pitch of your idea.  After reading the introduction your reader should:

• Understand what it is you want to do;
• Have a sense of your passion for the topic;
• Be excited about the study´s possible outcomes.

As you begin writing your research proposal it is helpful to think of the introduction as a narrative of what it is you want to do, written in one to three paragraphs.  Within those one to three paragraphs, it is important to briefly answer the following questions:

• What is the central research problem?
• How is the topic of your research proposal related to the problem?
• What methods will you utilize to analyze the research problem?
• Why is it important to undertake this research? What is the significance of your proposed research?  Why are the outcomes of your proposed research important, and to whom or to what are they important?

Note : You may be asked by your instructor to include an abstract with your research proposal.  In such cases, an abstract should provide an overview of what it is you plan to study, your main research question, a brief explanation of your methods to answer the research question, and your expected findings. All of this information must be carefully crafted in 150 to 250 words.  A word of advice is to save the writing of your abstract until the very end of your research proposal preparation.  If you are asked to provide an abstract, you should include 5-7 key words that are of most relevance to your study. List these in order of relevance.

Background and significance

The purpose of this section is to explain the context of your proposal and to describe, in detail, why it is important to undertake this research. Assume that the person or people who will read your research proposal know nothing or very little about the research problem.  While you do not need to include all knowledge you have learned about your topic in this section, it is important to ensure that you include the most relevant material that will help to explain the goals of your research.

While there are no hard and fast rules, you should attempt to address some or all of the following key points:

• State the research problem and provide a more thorough explanation about the purpose of the study than what you stated in the introduction.
• Present the rationale for the proposed research study. Clearly indicate why this research is worth doing.  Answer the “so what?” question.
• Describe the major issues or problems to be addressed by your research. Do not forget to explain how and in what ways your proposed research builds upon previous related research.
• Explain how you plan to go about conducting your research.
• Clearly identify the key or most relevant sources of research you intend to use and explain how they will contribute to your analysis of the topic.
• Set the boundaries of your proposed research, in order to provide a clear focus. Where appropriate, state not only what you will study, but what will be excluded from your study.
• Provide clear definitions of key concepts and terms. As key concepts and terms often have numerous definitions, make sure you state which definition you will be utilizing in your research.

Literature Review

This is the most time-consuming aspect in the preparation of your research proposal and it is a key component of the research proposal. As described in Chapter 5 , the literature review provides the background to your study and demonstrates the significance of the proposed research. Specifically, it is a review and synthesis of prior research that is related to the problem you are setting forth to investigate.  Essentially, your goal in the literature review is to place your research study within the larger whole of what has been studied in the past, while demonstrating to your reader that your work is original, innovative, and adds to the larger whole.

As the literature review is information dense, it is essential that this section be intelligently structured to enable your reader to grasp the key arguments underpinning your study. However, this can be easier to state and harder to do, simply due to the fact there is usually a plethora of related research to sift through. Consequently, a good strategy for writing the literature review is to break the literature into conceptual categories or themes, rather than attempting to describe various groups of literature you reviewed.  Chapter V, “ The Literature Review ,” describes a variety of methods to help you organize the themes.

Here are some suggestions on how to approach the writing of your literature review:

• Think about what questions other researchers have asked, what methods they used, what they found, and what they recommended based upon their findings.
• Do not be afraid to challenge previous related research findings and/or conclusions.
• Assess what you believe to be missing from previous research and explain how your research fills in this gap and/or extends previous research

It is important to note that a significant challenge related to undertaking a literature review is knowing when to stop.  As such, it is important to know how to know when you have uncovered the key conceptual categories underlying your research topic.  Generally, when you start to see repetition in the conclusions or recommendations, you can have confidence that you have covered all of the significant conceptual categories in your literature review.  However, it is also important to acknowledge that researchers often find themselves returning to the literature as they collect and analyze their data.  For example, an unexpected finding may develop as one collects and/or analyzes the data and it is important to take the time to step back and review the literature again, to ensure that no other researchers have found a similar finding.  This may include looking to research outside your field.

This situation occurred with one of the authors of this textbook´s research related to community resilience.  During the interviews, the researchers heard many participants discuss individual resilience factors and how they believed these individual factors helped make the community more resilient, overall.  Sheppard and Williams (2016) had not discovered these individual factors in their original literature review on community and environmental resilience. However, when they returned to the literature to search for individual resilience factors, they discovered a small body of literature in the child and youth psychology field. Consequently, Sheppard and Williams had to go back and add a new section to their literature review on individual resilience factors. Interestingly, their research appeared to be the first research to link individual resilience factors with community resilience factors.

Research design and methods

The objective of this section of the research proposal is to convince the reader that your overall research design and methods of analysis will enable you to solve the research problem you have identified and also enable you to accurately and effectively interpret the results of your research. Consequently, it is critical that the research design and methods section is well-written, clear, and logically organized.  This demonstrates to your reader that you know what you are going to do and how you are going to do it.  Overall, you want to leave your reader feeling confident that you have what it takes to get this research study completed in a timely fashion.

Essentially, this section of the research proposal should be clearly tied to the specific objectives of your study; however, it is also important to draw upon and include examples from the literature review that relate to your design and intended methods.  In other words, you must clearly demonstrate how your study utilizes and builds upon past studies, as it relates to the research design and intended methods.  For example, what methods have been used by other researchers in similar studies?

While it is important to consider the methods that other researchers have employed, it is equally important, if not more so, to consider what methods have not been employed but could be.  Remember, the methods section is not simply a list of tasks to be undertaken. It is also an argument as to why and how the tasks you have outlined will help you investigate the research problem and answer your research question(s).

Tips for writing the research design and methods section:

• Specify the methodological approaches you intend to employ to obtain information and the techniques you will use to analyze the data.
• Specify the research operations you will undertake and he way you will interpret the results of those operations in relation to the research problem.
• Go beyond stating what you hope to achieve through the methods you have chosen. State how you will actually do the methods (i.e. coding interview text, running regression analysis, etc.).
• Anticipate and acknowledge any potential barriers you may encounter when undertaking your research and describe how you will address these barriers.
• Explain where you believe you will find challenges related to data collection, including access to participants and information.

Preliminary suppositions and implications

The purpose of this section is to argue how and in what ways you anticipate that your research will refine, revise, or extend existing knowledge in the area of your study. Depending upon the aims and objectives of your study, you should also discuss how your anticipated findings may impact future research.  For example, is it possible that your research may lead to a new policy, new theoretical understanding, or a new method for analyzing data?  How might your study influence future studies?  What might your study mean for future practitioners working in the field?  Who or what may benefit from your study?  How might your study contribute to social, economic, environmental issues?  While it is important to think about and discuss possibilities such as these, it is equally important to be realistic in stating your anticipated findings.  In other words, you do not want to delve into idle speculation.  Rather, the purpose here is to reflect upon gaps in the current body of literature and to describe how and in what ways you anticipate your research will begin to fill in some or all of those gaps.

The conclusion reiterates the importance and significance of your research proposal and it provides a brief summary of the entire proposed study.  Essentially, this section should only be one or two paragraphs in length. Here is a potential outline for your conclusion:

• Discuss why the study should be done. Specifically discuss how you expect your study will advance existing knowledge and how your study is unique.
• Explain the specific purpose of the study and the research questions that the study will answer.
• Explain why the research design and methods chosen for this study are appropriate, and why other design and methods were not chosen.
• State the potential implications you expect to emerge from your proposed study,
• Provide a sense of how your study fits within the broader scholarship currently in existence related to the research problem.

As with any scholarly research paper, you must cite the sources you used in composing your research proposal.  In a research proposal, this can take two forms: a reference list or a bibliography.  A reference list does what the name suggests, it lists the literature you referenced in the body of your research proposal.  All references in the reference list, must appear in the body of the research proposal.  Remember, it is not acceptable to say “as cited in …”  As a researcher you must always go to the original source and check it for yourself.  Many errors are made in referencing, even by top researchers, and so it is important not to perpetuate an error made by someone else. While this can be time consuming, it is the proper way to undertake a literature review.

In contrast, a bibliography , is a list of everything you used or cited in your research proposal, with additional citations to any key sources relevant to understanding the research problem.  In other words, sources cited in your bibliography may not necessarily appear in the body of your research proposal.  Make sure you check with your instructor to see which of the two you are expected to produce.

Overall, your list of citations should be a testament to the fact that you have done a sufficient level of preliminary research to ensure that your project will complement, but not duplicate, previous research efforts. For social sciences, the reference list or bibliography should be prepared in American Psychological Association (APA) referencing format. Usually, the reference list (or bibliography) is not included in the word count of the research proposal. Again, make sure you check with your instructor to confirm.

An Introduction to Research Methods in Sociology Copyright © 2019 by Valerie A. Sheppard is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Literature review

A general guide on how to conduct and write a literature review.

Please check course or programme information and materials provided by teaching staff, including your project supervisor, for subject-specific guidance.

What is a literature review?

A literature review is a piece of academic writing demonstrating knowledge and understanding of the academic literature on a specific topic placed in context.  A literature review also includes a critical evaluation of the material; this is why it is called a literature review rather than a literature report. It is a process of reviewing the literature, as well as a form of writing.

To illustrate the difference between reporting and reviewing, think about television or film review articles.  These articles include content such as a brief synopsis or the key points of the film or programme plus the critic’s own evaluation.  Similarly the two main objectives of a literature review are firstly the content covering existing research, theories and evidence, and secondly your own critical evaluation and discussion of this content. 

Usually a literature review forms a section or part of a dissertation, research project or long essay.  However, it can also be set and assessed as a standalone piece of work.

What is the purpose of a literature review?

…your task is to build an argument, not a library. Rudestam, K.E. and Newton, R.R. (1992) Surviving your dissertation: A comprehensive guide to content and process. California: Sage, p49.

In a larger piece of written work, such as a dissertation or project, a literature review is usually one of the first tasks carried out after deciding on a topic.  Reading combined with critical analysis can help to refine a topic and frame research questions.  Conducting a literature review establishes your familiarity with and understanding of current research in a particular field before carrying out a new investigation. After doing a literature review, you should know what research has already been done and be able to identify what is unknown within your topic.

When doing and writing a literature review, it is good practice to:

• summarise and analyse previous research and theories;
• identify areas of controversy and contested claims;
• highlight any gaps that may exist in research to date.

Conducting a literature review

Focusing on different aspects of your literature review can be useful to help plan, develop, refine and write it.  You can use and adapt the prompt questions in our worksheet below at different points in the process of researching and writing your review.  These are suggestions to get you thinking and writing.

Developing and refining your literature review (pdf)

Developing and refining your literature review (Word)

Developing and refining your literature review (Word rtf)

Writing a literature review has a lot in common with other assignment tasks.  There is advice on our other pages about thinking critically, reading strategies and academic writing.  Our literature review top tips suggest some specific things you can do to help you submit a successful review.

Literature review top tips (pdf)

Literature review top tips (Word rtf)

Our reading page includes strategies and advice on using books and articles and a notes record sheet grid you can use.

Reading at university

The Academic writing page suggests ways to organise and structure information from a range of sources and how you can develop your argument as you read and write.

Academic writing

The Critical thinking page has advice on how to be a more critical researcher and a form you can use to help you think and break down the stages of developing your argument.

Critical thinking

As with other forms of academic writing, your literature review needs to demonstrate good academic practice by following the Code of Student Conduct and acknowledging the work of others through citing and referencing your sources.  

Good academic practice

As with any writing task, you will need to review, edit and rewrite sections of your literature review.  The Editing and proofreading page includes tips on how to do this and strategies for standing back and thinking about your structure and checking the flow of your argument.

Editing and proofreading

Guidance on literature searching from the University Library

The Academic Support Librarians have developed LibSmart I and II, Learn courses to help you develop and enhance your digital research skills and capabilities; from getting started with the Library to managing data for your dissertation.

Searching using the library’s DiscoverEd tool: DiscoverEd

Finding resources in your subject: Subject guides

The Academic Support Librarians also provide one-to-one appointments to help you develop your research strategies.

1 to 1 support for literature searching and systematic reviews

Advice to help you optimise use of Google Scholar, Google Books and Google for your research and study: Using Google

Managing and curating your references

A referencing management tool can help you to collect and organise and your source material to produce a bibliography or reference list. 

Referencing and reference management

Information Services provide access to Cite them right online which is a guide to the main referencing systems and tells you how to reference just about any source (EASE log-in may be required).

Cite them right

Published study guides

There are a number of scholarship skills books and guides available which can help with writing a literature review.  Our Resource List of study skills guides includes sections on Referencing, Dissertation and project writing and Literature reviews.

Study skills guides

This article was published on 2024-02-26

• Introduction
• About Case Study Reports
• Section A: Overview

Section B: Planning and Researching

• Section C: Parts of a Case Study
• Section D: Reviewing and Presenting
• Section E: Revising Your Work

Section F: Resources

• Your Workspace
• Guided Writing Tools

• About Lab Reports
• Section C: Critical Features
• Section D: Parts of a Lab Report

• About Literature Review
• Section C: Parts of a Literature Review
• Section D: Critical Writing Skills

• About Reflective Writing
• Section B: How Can I Reflect?
• Section C: How Do I Get Started?
• Section D: Writing a Reflection

Literature Review Prepared by University of Waterloo

On this page, you will find a comprehensive list of resources provided within this guide. These resources include examples, printable handouts, and additional links.

Summary of Resources

Within this section, we have provided you with

• our literature review template,
• the typical structure of a literature review,
• all of the handouts and worksheets found within this guide, and
• two annotated examples of literature reviews.

Prepared by

Literature Review Template

Literature review sample guiding questions.

This outline sample of a Literature Review should serve as a useful guide to help you get started.

Download PDF

Download the Literature Review Sample Guiding Questions .

Preview: Sample Guiding Questions

Structure of a Literature Review

The components of a literature review will vary depending on your institution and your instructor’s preferences, as well as the style of literature review you are writing. Be sure to refer to your assignment instructions to find out what will be required.

Most literature reviews- regardless of whether they are stand-alone literature review or embedded literature reviews, will include the following major sections and components:

• Cover page includes basic student and class information
• Introduction demonstrates the importance of a topic and outlines the direction of the review, including the thesis, research question, scope, and purpose
• Body synthesizes and analyzes sources in a clear, logical manner
• Conclusion addresses the gaps in knowledge, indicates what your analysis tells you about the thesis or research question, and provides directions for future research
• References list all the sources you cited in your paper, but students using the Chicago Manual of Style will also need to include the works they consulted even if they did not cite them

Building Analytical Skills

Use this helpful handout for your Literature Review .

Download the Building Analytical Skills worksheet.

Preview: PDF Worksheet

Process Organization Chart

Use this helpful handout to organize your Literature Review .

Download the Process Organization Chart worksheet.

Blank Project Schedule

Use this blank worksheet to plan your Literature Review .

Download the Blank Project Schedule worksheet.

Sample: Completed Project Schedule Worksheet

Use this completed worksheet as an exampe for your Literature Review Project Schedule.

Download the Completed Project Schedule worksheet.

Research Question Checklist

Use this helpful worksheet for your Literature Review .

Download the Research Questions checklist.

Blank Review Matrix

Use this helpful worksheet for your Literature Review Review Matrix.

Download the Blank Review Matrix .

Download Spreadsheet

Download the Blank Review Matrix Spreadsheet .

Health Sciences Review Matrix

Use this completed worksheet for your Literature Review Review Matrix.

Download the Health Sciences Review Matrix .

Download the Health Sciences Review Matrix Spreadsheet .

Arts Review Matrix

Download the Arts Review Matrix .

Download the Arts Review Matrix Spreadsheet .

Annotated Literature Review

Stand-alone literature review, health sciences annotated literature review.

This annotated Literature Review is an example of a Stand-alone Literature Review .

Download the Health Sciences Annotated Literature Review .

Preview: Annotated Literature Review

Embedded Literature Review

History annotated literature review.

This annotated Literature Review is an example of an Embedded Literature Review .

Download the History Annotated Literature Review .

Next Section Overview

Now that you have reviewed this guide, you can try our interactive Guided Writing Tools , to draft an outline of your Literature Review.

Literature Reviews in STEM

• Introduction: Starting a Literature Review
• Literature Review Worksheet
• Step 1. Write your Question
• Step 2. Identify Keywords
• Step 3. Search a Database
• Step 4. Identify Subject Terms
• Step 5. Appraise Your Results
• Step 6: Writing and Next Steps

Engineering and Science Librarian

Use this Worksheet and Follow Along:

The worksheet linked to this page corresponds to the rest of the lesson. To follow along and try it yourself, click on the worksheet below!

Google Docs Version of the Worksheet:

BEGIN HERE: Copy this worksheet!

Please start by making an editable copy of this file for your own use! To do so, click “File” and “Make a Copy”

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• Next: Step 1. Write your Question >>

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Mini-Module: How to Write a Literature Review

• 1. What is a Literature Review?
• 2. Features of a Literature Review

3. Writing a Literature Review

• 4. Structuring a Literature Review
• 5. What Should I do Next?

Mini-Modules

Back to Skills for Success: Home

Academic Skills Home

Get ready for university, get ready for university, when writing a literature review, you should think about the following stages:  , thinking of ideas.

Brainstorm and source key literature in your area(s) — Books, papers, articles and so on written by key authors in the field — Policy and guidance documents

These are the stages when you find you are reading a lot – and it may not all make sense yet! Don’t worry, this is perfectly natural.

Identify journal and magazine articles appropriate to your area of study and check the indexes for suitable articles. Follow up references and bibliographies in books and articles. Browse the library catalogues, look at the shelves. Refer to specialist reader lists from other parts of your course.

Narrowing it down

After so much reading, you need to refine! There are four key elements to consider:

• Identify the focus of the field – this will be the general topic or subject area within which the problem of issue you are investigating is set.
• Select the appropriate sources of information – from what you have read, what can you use directly? Indirectly?
• Extract information of direct relevance – a Literature Review isn’t the time to show off how much you have read. Keep it relevant!
• Concentrate on those texts which provide information you need – you will need to have clarity in your writing

 Notes

Some top tips:

• Paraphrase 
• Ask questions and make comments – this is your criticality!
• Keep detailed referencing information in your notes – author, date, title, publisher

Sort and prioritise the literature you have already See which authors/ideas compliment each other See which authors/ideas disagree with each other.

Think about the best way to organise your literature Review: – Chronologically? – Thematically? – By ‘different schools of thought’?

Write, and rewrite

This stage can feel quite laborious and repetitive – but remember that high quality work is always the result of a careful drafting and redrafting process.

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• Next: 4. Structuring a Literature Review >>
• Last Updated: May 21, 2024 1:58 PM
• URL: https://library.lsbu.ac.uk/c.php?g=719086

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Common Assignments: Literature Review Matrix

Literature review matrix.

As you read and evaluate your literature there are several different ways to organize your research. Courtesy of Dr. Gary Burkholder in the School of Psychology, these sample matrices are one option to help organize your articles. These documents allow you to compile details about your sources, such as the foundational theories, methodologies, and conclusions; begin to note similarities among the authors; and retrieve citation information for easy insertion within a document.

You can review the sample matrixes to see a completed form or download the blank matrix for your own use.

• Literature Review Matrix 1 This PDF file provides a sample literature review matrix.
• Literature Review Matrix 2 This PDF file provides a sample literature review matrix.
• Literature Review Matrix Template (Word)
• Literature Review Matrix Template (Excel)

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Literature Review: Literary Elements - Test Prep

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Many stories have a plot structure that we can graph. It looks like a triangle. A conflict is introduced, tension rises, a major change occurs. This major change is called the climax. After the climax the tension falls. The protagonist, or main character, may face a final moment of suspense. Then the story is resolved.

This page features a bunch of little stories that I wrote to help teach students story structure. These are concise little tales that can be read in a few minutes and easily graphed on the story structure triangle. They will give students the ground work to understand how story structure affects momentum and mood. Plot structure can be more complicated than a simple triangle, but these stories are simple. I hope that these free story structure worksheets will help students learn to identify narrative structure.

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5th Grade CCSS: Reading: Literature

For fifth graders, this Common Core area helps students gain mastery of the deeper tasks involved in reading a fictional text. No matter what they are reading, the standards require students to increase the complexity in the texts they read and deepen their understanding of the connections within and between texts. Among the complete standards for this grade, fifth graders will be asked to: explain a text explicitly and accurately, using quotes, understand the theme of a piece of literature, be able to compare and contrast two or more part of a literary text such as characters, setting, or events, understand the use of similes, metaphors and other figurative language in a literary text, describe how narrator’s or character’s point of view is conveyed through the text, analyze the role of multimedia elements like graphics, illustrations or web based media contributes to a literary work, compare works in the same genre, read text appropriate to grade level while increasing in the level of text complexity throughout the year.

Cielito Lindo Pretty Darling Reading Activity

The famous Mexican folk song, Celito Lindo, became popular in the late 19th century. It is now considered the official anthem of Mexico, and it has been recorded by many popular artists. In this printable Hispanic Heritage activity, students will read through an English translation of the words and answer comprehension questions about the passage.

Classic Literature: The Road to Oz: The Deadly Desert

Students read this passage from L. Fank Baum’s The Road to Oz and work on accompanying reading worksheets. A great set to help with comprehension, vocabulary and more.

Classic Literature: Through the Looking-Glass

Help your students improve their reading skills with this activity set about the Through the Looking-Glass by Lewis Carroll.

Find the Rhyme Scheme

Ready for some rhyme scheme practice?

Jack and Jill: A Village Story — Sledding

This activity provides a great opportunity to practice reading comprehension skills. The worksheet asks students to read a passage in Louisa May Alcott’s, Jack and Jill and answer related questions.

Little Women: Helping Father

Students read a passage in Louisa May Alcott’s celebrated book, Little Women. After reading the passage, students answer related comprehension questions.

Narrator and Point of View

Here is a worksheet where students will learn the differences between a narrator and point of view,

Story Elements Form

This is a more detailed story elements form template that includes boxes for character, setting, theme, problem, solution and plot/actions.

A Christmas Fairy Reading Comprehension

“The Christmas Fairy” gives students a story to read and questions to answer. A great comprehension activity for the holiday season!

Alice in Wonderland Reading Comprehension Set

Students will have fun completing the worksheets and activities that go along with the story of Alice in Wonderland!

Casey at the Bat Reading Comprehension Set

Fun word search, idiom, and order of events are just a few of the worksheets students will do with this poem! “Casey at the Bat” is sure to be a favorite among students.

Change the Point of View: First Person and Third Person

Students will read a passage written from the first person perspective, and rewrite it to third person.

Change the Point of View: Third Person to First Person

In this activity, students will read the story told in 3rd person and then rewrite a part to make it a first person narrative.

Character Descriptions: Huck Finn from The Adventures of Tom Sawyer

Students will read a description of the colorful character, Huckleberry Finn, in The Adventures of Tom Sawyer by Mark Twain. They will then answer questions based on the description.

Character Traits Worksheet – Black Beauty

In this passage from Black Beauty, students will read an excerpt from Chapter 7 and list 10 character traits of Greer.

Classic Literature: Aesop’s The Fox and the Stork

Students will read one of Aesop’s fables and complete the accompanying worksheets. Included are comprehension and vocabulary activities.

Classic Literature: Black Beauty

Black Beauty is the story of a black horse in England in the 1800s. Written in 1877 by Anna Sewell, it tells the story from the horse’s viewpoint. Students read a passage from chapter 12 and then complete a series of worksheet activities.

Classic Literature: Captains Courageous

Help your students improve their reading skills with this activity set about Rudyard Kipling’s Captains Courageous.

Classic Literature: Lad: A Dog

Encourage your students to read and write with this fun “Lad: A Dog” worksheet series!

Classic Literature: Little Women

Here is a literature packet based on the novel “Little Women” by Louisa May Alcott. Students will read an excerpt and complete the activities.

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Literary Elements

Here are some activities to assist in the teaching of literary terms, plot structure, and other English-y stuff.

PLOT DIAGRAM CHART

Students can fill in this fun graphic with the stages of the plot diagram:  Exposition, rising action, climax, falling action, and resolution.

TEACHING LITERARY TERMS

This presentation outlines many commonly-tested literary elements and gives examples for each one. Also included is a student worksheet for recording the definitions.

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• STUDENT LITERARY TERMS WORKSHEET

SHORT STORY ANALYSIS WORKSHEET

Students can use this worksheet to analyze any short story for literary elements.

IRONY:  SITCOM ANALYSIS WORKSHEET

This activity asks students to analyze a sitcom television show for the different types of irony. (From time to time I will show an episode that demonstrates the types of irony to my class and ask them to fill out the worksheet as we watch.)

CLICHE GAME

Introduce the idea of avoiding cliches with this fun classroom activity.

TEACHING IDIOMS

This presentation uses humorous illustrations to teach idioms.

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Elements of Literature

9th - 12th grade.

16 questions

Introducing new   Paper mode

No student devices needed.   Know more

• 1. Multiple Choice Edit 30 seconds 1 pt The sequence of events in a story is  the main idea the plot the summary the review
• 2. Multiple Choice Edit 30 seconds 1 pt The story's time and place is tone plot setting voice
• 3. Multiple Choice Edit 30 seconds 1 pt An individual in a literary work is called setting plot narrator character
• 4. Multiple Choice Edit 30 seconds 1 pt The main character of the story is The antagonist The protagonist The exposition The action

Which part of the story is represented by this blue blob?

rising action

• 10. Multiple Choice Edit 30 seconds 1 pt In this element of plot the author introduces the characters and setting... Resolution Climax Exposition Rising Action 
• 11. Multiple Choice Edit 30 seconds 1 pt Where does the turning point of a story occur? Climax Exposition Denouement Falling Action
• 12. Multiple Choice Edit 30 seconds 1 pt Which part of the plot creates tension and suspense? rising action climax falling action resolution

The story is about a beautiful blonde princess who's trapped in a tower

The beautiful princess fights to get away from the witch who's keeping her captive

A prince fights the witch to save the princess

falling action

They live happily ever after

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2.4: Elements of Literature

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These are the Elements of Literature, the things that make up every story. This is the first of two videos.

A YouTube element has been excluded from this version of the text. You can view it online here: http://pb.libretexts.org/itl/?p=74

These are the elements of literature with Mr. Taylor.

Contributors and Attributions

• Elements of Literature with Mr. Taylor (Part 1). Authored by : Kenny Taylor. Located at : https://youtu.be/9E6JJojgCew . License : All Rights Reserved . License Terms : Standard YouTube License
• Elements of Literature with Mr. Taylor (Part 2). Authored by : Kenny Taylor. Located at : https://youtu.be/O7c_SjKcGbE . License : All Rights Reserved . License Terms : Standard YouTube License

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Literary Elements Worksheets

Related ela standard: rl.7.3, literary elements worksheets to print:.

Conner and the Winged Horse – A warrior's story.

Elements of Fiction – The is a pre-reading activity for students.

The Origin of the Green Ninja – The world always needs another ninja and another story of ninjas.

The Smash-up – We look at the perspective of two different drivers that are in a car accident between the two of them.

Literary Elements: Character – We look at the importance and value of a character.

Literary Elements: Setting – How does the setting affect what you think about the characters?

Crossing the Thames without the Aid of Bridge, Boat or Balloon – Discuss how the narrator and point of view affect the plot of the story.

The Hunt – How does the point of view of this story affect your understanding of the theme?

Book's Setting – Think about the book you have just read. Then fill out the chart to analyze how the setting shapes the other aspects of the story.

Was it the First Turtle? – How is the theme of the story interwoven with the character of Turtle?

The Interaction of Elements of Fiction – Then, on the next page, outline briefly how you think that these three elements might combine to create a plot. Include at least 3 events in your plot.

The Effect of Setting on Story – The novel Dracula tells the story of Count Dracula trying to move from Transylvania to England in search of new blood.

A Boy Among the Indians, As Told By Himself – Read the beginning of the story. On the next page, fill out the organizer, then discuss the interactions between literary elements.

The Interaction of Elements of Fiction – Three major elements of fiction are characters, setting and conflict.

Marty Michelson Always Gets the Best – Marty Michelson was used to having the best.

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• Open access
• Published: 21 May 2024

A modern way to teach and practice manual therapy

• Roger Kerry 1 ,
• Kenneth J. Young   ORCID: orcid.org/0000-0001-8837-7977 2 ,
• David W. Evans 3 ,
• Edward Lee 1 , 4 ,
• Vasileios Georgopoulos 1 , 5 ,
• Adam Meakins 6 ,
• Chris McCarthy 7 ,
• Chad Cook 8 ,
• Colette Ridehalgh 9 , 10 ,
• Steven Vogel 11 ,
• Amanda Banton 11 ,
• Cecilia Bergström 12 ,
• Anna Maria Mazzieri 13 ,
• Firas Mourad 14 , 15 &
• Nathan Hutting 16  

Chiropractic & Manual Therapies volume  32 , Article number:  17 ( 2024 ) Cite this article

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Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment , patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety , comfort , and efficiency . These practical elements are contextualised by positive communication , a collaborative context , and person-centred care . The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

Conclusions

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Musculoskeletal (MSK) conditions are leading contributors to the burden of global disability and healthcare [ 1 ]. Amongst other interventions, manual therapy (MT) has been recommended for the management of people with MSK conditions in multiple clinical guidelines, for example [ 2 , 3 ].

MT has been described as the deliberate application of externally generated force upon body tissue, typically via the hands, with therapeutic intent [ 4 ]. It includes touch-based interventions such as thrust manipulation, joint mobilisation, soft-tissue mobilisation, and neurodynamic movements [ 5 ]. For people with MSK conditions, this therapeutic intent is usually to reduce pain and improve movement, thus facilitating a return to function and improved quality of life [ 6 ]. Patient perceptions of MT are, however, vague and sit among wider expectations of treatment including education, self-efficacy and the role of exercise, and prognosis [ 7 ].

Although the teaching and practice of MT has invariably changed over time, its foundations arguably remain unaltered and set in biomedical and outdated principles. This paper sets out to review contemporary literature and propose a revised model to inform the teaching and practice of MT.

The aim of this paper is to stimulate debate about the future teaching and practice of manual therapy through the proposal of an evidence-informed re-conceptualised model of manual therapy. The new model dismisses traditional elements of manual therapy which are not supported by research evidence. In place, the model offers a structure based on common humanistic principles of healthcare.

Consenus methodology

We present the literature synthesis and proposed framework as a consensus document to motivate further professional discussion developed through a simple three-stage iterative process over a 5-year period. The consensus methodology was classed as educational development which did not require ethical approval. Stage 1: a change of teaching practice was adopted by some co-authors (VG, RK, EL) on undergraduate and postgraduate Physiotherapy programmes at a UK University in 2018. This was a result of standard institutional teaching practice development which includes consideration of evidence-informed teaching. Stage 2: Input from a broader spectrum of stakeholders was sought, so a group of experienced, internationally-based educators, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through discussions in an iterative process. Stage 3: Presentations were made by some of the co-authors (VG, RK, SV, KY) to multidisciplinary groups (UK, Europe, North America) and feedback via questions and discussions was incorporated into further co-author discussions on the development of the framework. Consensus was achieved through repeated discussion of relevant elements. Figure  1 summarises the consensus methodology.

Summary and timeline of iterative consensus process for development of framework (MT: Manual Therapy; UG: Undergraduate; PG: Postgraduate)

Clinical & cost effectiveness of manual therapy

Manual therapy has been suggested to be a valuable part of a multimodal approach to managing MSK pain and disability, for example [ 8 ]. The majority of recent systematic reviews of clinical trials report a beneficial effect of MT for a range of MSK conditions, with at least similar effect sizes to other recommended approaches, for example [ 9 ]. Some systematic reviews report inconclusive findings, for example [ 10 ], and a minority report effects that were no better than comparison or sham treatments, for example [ 11 ].

Potential benefits must always be weighed against potential harms, of course. Mild to moderate adverse events from MT (e.g. mild muscle soreness) are common and generally considered acceptable [ 12 ], whilst serious adverse events are very rare and their risk may be mitigated by good practice [ 13 ]. MT has been reported by people with MSK disorders as a preferential and effective treatment with accepted levels of post-treatment soreness [ 14 ].

MT is considered cost-effective [ 15 ] and the addition of MT to exercise packages has been shown to increase clinical and cost-effectiveness compared to exercise alone in several MSK conditions [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Further, manual therapy has been shown to be less costly and more beneficial than evidence-based advice to stay active [ 24 ].

In summary, MT is considered a useful evidence-based addition to care packages for people experiencing pain and disability associated with MSK conditions. As such, MT continues to be included in national and international clinical guidelines for a range of MSK conditions as part of multimodal care.

Principles of traditional manual therapy (TMT)

Manual therapy has been used within healthcare for centuries [ 4 ] with many branches of MT having appeared (and disappeared) over time [ 25 ]. In developed nations today, MT is most commonly utilised by the formalised professional groups of physiotherapy, osteopathy, chiropractic, as well as groups such as soft tissue therapists. All of these groups have a history that borrows heavily from traditional healers and bone-setters [ 26 ].

Although there are many elements of MT, three principles appear to have become ubiquitous within what we shall now refer to as ‘traditional manual therapy’ (TMT): clinician-centred assessment , patho-anatomical reasoning , and technique specificity [ 27 , 28 , 29 , 30 ]. These principles continue to influence the teaching and practice of manual therapy over recent years, for example [ 31 ].

However, they have become increasingly difficult to defend given a growing volume of empirical evidence to the contrary.

Traditional manual therapy (TMT) principles: origins and problems

Clinician-centred assessment.

TMT has long had an emphasis on what we shall refer to as clinician-centred assessments . Within this, we claim, is an assumption that clinical information is both highly accurate and diagnostically important, for example [ 32 ]. Clinician-centred assessments include, for example, routine imaging, the search for patho-anatomical 'lesions’ and asymmetries, and specialised palpation. Although the focus of this paper is on the ‘hands-on’ examples of client-centred assessment, the notion of imaging is presented below to expose some of the flaws in the underlying belief system for TMT.

The emphasis on clinician-centred assessments has probably been driven, in part, by a desire for objective diagnostic tests which align well with gold-standard imaging. Indeed, since the discovery of x-rays, radiological imaging been used as an assessment for spinal pain – and a justification for using spinal manipulation – particularly in the chiropractic profession [ 33 ]. Contrary to many TMT claims, X-ray imaging is not without risk [ 34 ]. Additionally, until relatively recently (with the advent of magnetic resonance imaging) it was not widely appreciated that patho-anatomical ‘lesions’ believed to explain MSK pain conditions were nearly as common in pain-free individuals as those with pain [ 35 ]. Accordingly, the rates of unnecessary treatments, including surgery, are known to increase when imaging is used routinely [ 36 ]. For patients with non-specific low back pain, for example, imaging does not improve outcomes and risks overdiagnosis and overtreatment [ 37 ]. Hence, despite being objective in nature, the value of imaging for many MSK pain conditions (particularly spinal pain) has reduced drastically with clinical guidelines across the globe recommending against routine imaging for MSK pain of non-traumatic origin [ 38 ]. Even so, the practice of routine imaging continues [ 39 ].

Hands-on interventions are inextricably related to hands-on assessment [ 40 ], and often associated with claims of ‘specialisation’ [ 41 ]. By this we mean where a great level of training and precision are claimed to be necessary for influencing the interpretation of assessment findings, treatment decisions, and/or treatment outcomes. Implicit within this claim is that therapists who are unable to achieve such precision are not able to perform MT to an acceptable level (and thereby are not able to provide benefit to patients).

There are numerous studies that cast doubt over claims of highly specialised palpation skills. Palpation of anatomical landmarks does not reach a clinically acceptable level of validity [ 42 ]. Specialised motion palpation does not appear to be a good method for differentiating people with or without low back pain [ 43 ]. Poor content validity of specialised motion tests have been reported, in line with a lack of acceptable reference standards [ 44 ]. Palpable sensations reported by therapists are unlikely to be due to tissue deformation [ 45 ]. Furthermore, the delivery of interventions based on specialised palpatory findings is no better than non-specialised palpation [ 46 ]. Generally poor reliability of motion palpation skills has been reported, for example [ 47 ] and appear to be independent of clinician experience or training, for example [ 48 ]. Notably, person-centred palpation—for pain and tenderness for example—has slightly higher reliability, but is still fair at best [ 49 ].

This does not mean that palpation is of no use at all though; just that effective manual therapy does not depend upon it. For example, expert therapists can display high levels of interrater reliability during specialised motion palpation [ 50 ]. Focused training can improve the interrater reliability of specialised skills [ 51 ]. However, the validity of the phenomenon remains poor. Given the weight of the evidence and consistency of data over recent decades, we suggest that the role of clinician-centred hands-on assessment is no longer central to contemporary manual therapy.

Patho-anatomical reasoning

The justification for selecting particular MT interventions has historically been based upon the patho-anatomical status of local peripheral tissue [ 52 , 53 , 54 , 55 ]. Patho-anatomical reasoning, we propose, is the framework that links clinician-centred assessments to the desire for highly specific delivery of MT interventionsKey to this is the relationship between a patho-anatomic diagnosis and the assumed mechanisms of action of the intervention employed.

Theories for the mechanisms of action of MT interventions are many. Some of the most prominent include reductions of disc herniations [ 56 ], re-positioning of a bone or joint [ 32 ], removal of intra-articular adhesions [ 57 ], changes in the biomechanical properties of soft tissues [ 58 ], central pain modulation [ 59 ], and biochemical changes [ 60 ]. These theories have been used to justify the choice of certain interventions: a matching of diagnosis (i.e., existence of a lesion) to the effect of treatment takes place. However, most of these mechanistic theories either lack evidence or have been directly contested [ 61 ].

The causal relationship between proposed tissue-based factors such as posture, ergonomic settings, etc. and painful experience has also been disputed [ 62 ]. Although local tissue stiffness has been observed in people with pain, this is typically associated with neuromuscular responses, rather than patho-anatomical changes at local tissue level [ 63 , 64 , 65 , 66 ]. Overall, although some local tissue adaptions have been identified in people with recurrent MSK pain, this is inconsistent and the evidence is currently of low quality [ 67 ] are generally limited to short-term follow-up measures [ 68 ].

Technique specificity

TMT techniques have been taught with an emphasis that a particular direction, ‘grade’ of joint movement, or deformation of tissue at a very specific location in a certain way, is required to achieve a successful treatment outcome.

One problem with a demand for technique specificity in manual therapy is that an intervention does not always result in the intended effect. For example, posteroanterior forces applied during spinal mobilization consistently induce sagittal rotation, as opposed to the assumed posteroanterior translation, for example [ 69 ]. Furthermore, irrespective of the MT intervention chosen, restricting movements to a particular spinal segment is difficult and a regional, non-specific motion is typically induced, for example [ 70 ].

To support technique specificity, comparative data must repeatedly and reproducibly show superiority of outcome from specific MT interventions over non-specific MT, which is consistently not observed [ 71 , 72 , 73 ]. Some studies have demonstrated localised effects of targeted interventions [ 74 ] but there appears to be no difference in outcome related to: the way in which techniques are delivered [ 75 ]; whether technique selection is random or clinician-selected [ 41 ]; or variations in the direction of force or targeted spinal level [ 76 ]. Conversely, there is evidence that non-specific technique application may improve outcomes [ 77 , 78 , 79 ]. Further, sham techniques produce comparable results to specialised approaches [ 11 ].

Passive movement and localised touch have been associated with significant analgesic responses [ 80 ]. These data indicate the presence of an analgesic mechanism. Unfortunately, mechanistic explanation for the therapeutic effects of MT upon pain and disability still remain largely in a ‘black box’ state [ 81 ]. Nevertheless, there are several plausible mechanisms of action to explain the analgesic action of MT interventions, including the activation of modulatory spinal and supraspinal responses [ 82 , 83 , 84 , 85 ]. In support of this, MT interventions have been associated with a variety of neurophysiological responses [ 61 ]. However, it must be acknowledged that these studies provide mechanistic evidence based on association, which is insufficient to make causal claims [ 86 ]. Importantly, none of these neurophysiological responses have been directly related to either the analgesic mechanisms or clinical outcome and may therefore be incidental.

There is evidence that MT does not provide analgesia in injured tissues [ 87 , 88 ]. Conversely, MT has been shown to decrease inflammatory biomarkers [ 89 , 90 , 91 , 92 , 93 ], although these changes have not been evaluated in the longer-term, nor associated with clinical outcomes.

A modern framework for manual therapy

We propose a new direction for the future of MT in which the teaching and practice of this core dimension of MSK care are no longer based on the traditional principles of clinician-centred assessment , patho-anatomical reasoning , and technique specificity .

In doing so, this framework places MT more explicitly as part of person-centred care and appeals to common principles of healthcare, best available evidence, and contemporary theory which avoids unnecessary and over-complicated explanations of observed effects. The framework is simple in terms of implementation and delivery and contextualised by common elements of best practice for healthcare, in line with regulated standard of practice, e.g., [ 94 , 95 , 96 , 97 ]. Our proposal simply illustrates the operationalisation of these common elements through manual therapy.

Too much emphasis has been given to clinician-centred assessments and this should be rebalanced with an increased use of patient-centred assessments, such as a thorough case history, the use of validated patient-reported outcome measures (PROMS), and real-time patient feedback during assessments.

The new framework considers fundamental and humanistic dimensions of touch-based therapies, such as non-specific neuromodulation, communication and sense-making, physical education, and contextual clinical effectiveness. This aligns to contemporary ideas regarding therapeutic alliance and a move towards genuinely holistic healthcare [ 98 , 99 ]. The framework needs to be “open” in order to represent and allow expression of the complexity of the therapeutic encounter. However, to prevent the exploitation of this openness the framework is underpinned by evidence, and any manual therapy approaches without plausible and measurable mechanisms are not supported.

To provide the best care, common healthcare elements such as the safety and comfort of the person seeking help and therapist must be considered, and care should be provided as efficiently as possible. Our framework embraces these dimensions and employs an integration of current evidence. It is transdisciplinary in nature and may be adopted by all MT professions. Figure  1 provides a graphical representation of the framework. It is acknowledged that all components overlap, relate, and influence each. There are two main components: the practical elements on the inside, comprised of safety, comfort, and efficiency, and the conceptual themes on the outer regions, consisting of communication, context, and person-centred care Fig. 2 .

Representation of a modern teaching and practice framework for manual therapy. The image is purposefully designed to be simple, and has been developed primarily to be used as a teaching aid. When displayed in a learning environment, learners and clinicians can quickly refer to the image to check their practice against each element. To keep the image clear, each element of the image is described in detail in the text below”

Practical elements

Safety for people seeking help is a primary concern for all healthcare providers, with the aims to “ prevent and reduce risks, errors and harm that occur to patients [sic] during provision of health care… and to deliver quality essential health services ” [ 100 ]. This, and the notion of safety more generally (including that of the therapist), should be central to way MT is taught and practised.

A fundamentally safe context should be created where there is an absence of any obvious danger or risk of harm to physical or mental health. Consideration should be given to ensuring that communication and consent processes are orientated towards the safety of both the person seeking help and the therapist. The therapist should pay attention to any sense of threat that could be present in the physical, emotional, cognitive and environmental domains of the clinical encounter, and use skilful communication to mitigate anxiety about the assessment or therapeutic process.

Safety should also be considered in the clinical context of the assessment and treatment approach, ensuring that relevant and meaningful safety screenings have been undertaken [ 67 , 101 ]. There remains a need for good, skilful practice and development of manually applied techniques, but this can be achieved without reference to the principles of TMT and without the dogma of a proprietary therapeutic approach.

Comfort suggests that both the person seeking help and the therapist are physically and emotionally content during the assessment and therapeutic process. For example, the person seeking help is agreeable with any necessary state of dress (sociocultural difference should be considered); the person is relaxed and untroubled in whatever position they are in, and is adequately supported whether sitting, standing or recumbent during assessment and treatment; the therapist is comfortable with their positioning and posture; any discomfort produced by the therapeutic process is negotiated and agreed. Any physical mobilisation or touch should be applied with respect to the feedback from the person in relation to their comfort, rather than a pre-determined force based on the notion of resistance. This process requires clinical phronesis, sensitivity, responsivity, dexterity, and embodied communication [ 102 ].

The therapeutic process should be undertaken in a well-organised, competent manner aiming to achieve maximum therapeutic benefit with minimum waste of effort, time, or expense. To enhance the efficiency dimension, the assessment and therapeutic process should be an integral part of a holistic educational and/or activity-based approach to the management of the people which might also address psychological, nutritional, or ergonomic aspects of care, while being aware of social determinants to health. Recommendations exist which serve as a useful guide for enhancing care and promoting self-management in an efficient way [ 103 ].

A principle of this new model of MT is that therapists should not lose sight of the goals they develop with the people they help and ensure that there is coherence between their management aims and their techniques. Therapists should aim to support a person’s self-efficacy and use active approaches to empower them in their recovery. The overall number of therapeutic applications should be made in the context of fostering therapeutic alliance and supporting people to make sense of their situation and symptoms. This should be informed by contemporary views of the effects of manual therapy, emphasising a “physical education process” to promote sense-making and self-efficacy in alliance with the people they aim to help.

Clinical interactions need to be reproducible under a person’s own volition, serving to enhance self-empowerment. For example, someone could be taught how to “self-mobilise” if a positive effect is found with a particular therapeutic application. This should be appropriately scaffolded with behavioural change principles and functional contextualism that promote autonomy and self-management, rather than inappropriate reliance on the therapist [ 103 , 104 ].

An important and emergent notion from the proposed model is to question what constitutes indications for MT given that the model excludes traditional factors which would have informed whether manual therapy is indicated or not for a particular person. The response to this sits within the efficiency and safety dimensions: MT can be beneficial as part of a multi-dimensional approach to management across a broad population of people with musculoskeletal dysfunction, with no evidence to suggest any clinician-centered or patho-anatomical finding influences outcomes. The choice of whether or not to include MT as part of a management strategy should therefore be a product of a lack of contraindications and shared-decision making.

This framework aligns with evidence-based propositions that effectiveness and efficiency in assessment, diagnosis, and outcomes are not reliant on the therapist’s skill set of specialised elements of TMT, but rather other factors—for example variations in pain phenotypes [ 5 ].

Conceptual themes

Communication.

Communication is the overriding critical dimension to the whole therapeutic process and should be aimed at addressing peoples’ fundamental needs to make sense of their symptoms and path to recovery. The delivery and uptake of the therapy should therefore be operationalised in a communication process that meaningfully represents shared-decision making and the best possible attempt to contextualise the therapy in positive and evidence-informed explanations of the process and desired effects [ 105 ].

Within a therapeutic encounter, practitioners must give the time to listen to peoples’ accounts and explanations of their symptoms, including their ideas about their cause [ 106 ]. The assessment and diagnostic process should be a shared endeavour, for example, the negotiation of symptom reproduction. This should be done in a manner that facilitates sense-making, and which simultaneously encourages people to move on from unhelpful beliefs about their symptoms [ 107 , 108 ], encouraging understanding of the uncertain nature of pain and injury. Person-centered communication requires attention to what we communicate and how we communicate across the entire clinical interaction including interview, examination, and management planning [ 109 ]. Therapists need to be open, reflective, aware and responsive to verbal and non-verbal cues, and demonstrate a balance between engaging with people (e.g. eye-gaze) and writing/typing notes during the interview [ 110 , 111 , 112 ].

People should be given the opportunity to discuss their understanding of the diagnosis and options for treatment and rehabilitation. The decision-making process is dialogical, in which alternative options to the offered therapy should also be discussed with the comparative risks and benefits of all available management options, including doing nothing [ 113 , 114 ].

The therapist must fully appreciate the potential consequences of touch without consent. Continual dialogue should ensure that all parties are moving towards mutually agreed goals. The context of the therapy should be explicitly communicated to give appropriate context for any particular intervention as part of a holistic, evidence-based approach [ 115 , 116 , 117 ]. Therapists should be aware that their own beliefs can affect the way they communicate with their people; in the same way, a person’s context affects how they communicate what they expect from their treatment [ 107 , 118 , 119 , 120 ]. The construction of contextual healing scenarios which support positive outcomes, whilst minimising nocebic effects, is critical to effective healthcare [ 121 , 122 , 123 ].

There is a growing academic interest in the nature, role, and purpose of social and affective touch, and any re-framing of MT should consider touch as a means of communication to develop and enhance cooperative communications and strengthen the therapeutic relationship [ 124 , 125 , 126 , 127 , 128 , 129 ]. It can be soothing for a person in pain to experience the caring touch of a professional therapist [ 130 ]; on the other hand, probing, diagnostic, and touch can be experienced as alienating [ 131 , 132 , 133 ]. Touch can alter a person’s sense of body ownership and their ability to recognise and process their emotions by modulating interoceptive precision [ 129 , 134 , 135 ], and intentional touch may be perceived differently from casual, unfocussed touch [ 136 , 137 ]. There is also a thesis that touch generates shared understanding and meaning [ 138 , 139 , 140 ]. This wider appreciation of touch should be embedded in modern MT communication.

The contextual quality of a person’s experience of the therapeutic encounter can affect satisfaction and clinical outcomes [ 141 , 142 , 143 , 144 , 145 ]. The context in which therapeutic care takes place should therefore be developed to enhance this experience. There could be very local, practical aspects of the context, such as the type of passive information available in the clinical space, e.g. replacing biomedical and pathological imagery and objects with positive, active artefacts; judicious and thoughtful organisation and use of treatment tables to discourage a sense of passivity and disempowerment; allocating a comfortable space where communication can take place; colour schemes and light sources which facilitate positivity; ensuring consistency through all clinical and administrative staff promoting encouraging and non-nocebic messages. Importantly, the way the therapist dresses influences peoples’ perception of their healthcare experience [ 146 , 147 ], and that in turn should be contextually and culturally sensitive [ 148 , 149 , 150 ].

Beyond the local clinical space is the broader social environment. The undertaking of MT should serve a role in a person’s engagement with their social environment. For example, someone returning home after engaging with their therapist and disseminating positive health messages within their home and social networks; people acting as advocates for self-empowered healthcare. Furthermore, early data have demonstrated that aligning treatment with the beliefs and values of culturally and linguistically diverse communities enhances peoples’ engagement with their healthcare [ 151 ].

Person-centred care

Here we borrow directly from one of the most established and clinically useful definitions of Person-Centered Medicine [ 152 ]:

“(Person-Centered Medicine is) an affordable biomedical and technological advance to be delivered to patients [sic] within a humanistic framework of care that recognises the importance of applying science in a manner that respects the patients [sic] as a whole person and takes full account of [their] values, preferences, aspirations, stories, cultural context, fears, worries and hopes and thus that recognises and responds to [their] emotional, social and spiritual necessities in addition to [their] physical needs” [ 152 ] , p219.

Person-centred care incorporates a person’s perspective as part of the therapeutic process. In practice, therapists need to communicate in a manner that creates adequate conversational space to elicit a person’s agenda (i.e. understanding, impact of pain, concerns, needs, and goals), which guides clinical interactions. This approach encourages greater partnership in management [ 109 , 153 , 154 ].

A roadmap outlining key actions to implement person-centeredness in clinical practice has been outlined in detail elsewhere [ 155 ]. This includes screening for serious pathology, health co-morbidities and psychosocial factors; adopting effective communication; providing positive health education; coaching and supporting people towards active self-management; and facilitating and managing co-care (when needed) [ 154 ].

It is critical and necessary now to make these features explicit and central to the revised model of MT proposed in this paper. We wish to identify common ground across all MT professions in order to achieve a trans-disciplinary understanding of the evidence supporting the use of MT.

We acknowledge that our arguments here are rooted in empiricism and deliberately based on available research data from within the health science disciplines. We also acknowledge that there is a wider debate about future directions in person-centred care arising from the current evolution of the evidence-based health care movement, which has pointed to the need to learn more about peoples’ lived experiences, to redefine the model of the therapeutic relationship. Although beyond the scope of this paper, a full exploration of modern health care provision involves reconsideration of the ethics and legal requirements of communication and shared decision-making [ 156 , 157 , 158 , 159 ]. The authors envision this paper as a stimulus for self-reflection, stakeholder discussions, and ultimately change that can positively impact outcomes for people who seek manual therapy interventions.

Manual therapy has long been part of MSK healthcare and, given that is likely to continue. Current evidence suggests that effectiveness does not rely on the traditional principles historically developed in any of the major manual therapies. Therefore, the continued teaching and practice based on the principles of clinician-centred palpation , patho-anatomical reasoning , and technique specificity are no longer justified and may well even limit the value of MT.

A revised and reconceptualised framework of MT, based on the humanistic domains of safety, comfort and efficiency and underpinned by the dimensions of communication, context and person-centred care will ensure an empowering, biopsychosocial, evidence-informed approach to MSK care. We propose that the future teaching and practice of MT in physiotherapy, osteopathy, chiropractic, and all associated hands-on professions working within the healthcare field should be based on this new framework.

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Kerry, R., Young, K.J., Evans, D.W. et al. A modern way to teach and practice manual therapy. Chiropr Man Therap 32 , 17 (2024). https://doi.org/10.1186/s12998-024-00537-0

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DOI : https://doi.org/10.1186/s12998-024-00537-0

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