How to choose the right technique: Tissue, healing phase, ANS tone & joint restriction.

Many manual therapists struggle with knowing when to use the techniques they have learnt, which often leads to a cookie-cutter approach to treatment. Without a clear framework for when and why to apply techniques, treatment can feel uncertain, practitioners can lack confidence, and patients may plateau or fail to reach their goals. This uncertainty isn’t usually about skill—it’s about knowing how and when to match the right intervention to the person in front of you.

Shifting your focus from simply performing techniques to understanding the patient’s physiology and treatment needs allows for more precise, effective care. When you know which tissues to target, how the body is healing, and how to respond to nervous system and joint considerations, your interventions become more strategic. The result is quicker recovery, better outcomes, and a stronger sense of confidence in your clinical decisions.

In this blogpost I will give you a framework you can use to guide technique selection, through four key filters.

1. Target Tissue
2. Phase of Healing
3. Autonomic Nervous System Tone
4. Joint Restriction

This framework is based on the book Osteopathy: Models for Diagnosis, Treatment and Practice by Jon Parsons and Nicholas Marcer (2005). Their text lays out the different ways to think about tissues, joints, fascia, and how the nervous system interacts with them. I’ve taken those ideas and turned them into a practical approach for manual therapists to use the information in the clinic setting.

Target Tissue: What structure actually needs influence?

Muscle:
Goal – Reduce tone, restore length, improve contractile efficiency.
Useful Techniques

• Soft tissue (Cross/longitudinal & Inhibition) – great for releasing tension and neurovascular relaxation
• Trigger point – use for irritable bands within a muscle (hyper local)
• Muscle Energy Technique (MET) – Increase recruitment & improves ROM via reciprocal inhibition and post isometric stretch.

Fascia & connective tissue:
Goal – Reduce densification, restore glide, downregulate sympathetic tone, improve proprioception.
Useful techniques

• Soft tissue (slow, sustained)
• Balance Ligamentous technique (BLT) - unloads a joint by positioning it in a point of ease, allowing ligamentous reflexes to rebalance tension and reduce protective guarding.
• Recoil - Elastic impulse to restore fascial spring and stimulate the nervous system

Joint:
Goal – Restore glide, decompress, enhance mechanoreceptor input.
Useful techniques

• HVLA/HVT – for firm end feel barriers (not at end of normal joint range)
• Articulation – rhythmic joint mobility for sticky or guarded joints
• Traction – Decompression, pain modulation and fluid exchange.

Neuro-membranous systems:
Goal – reduce dural tension, improve CSF motility, downregulate sympathetic tone, decrease CNS sensitisation.

• Balance membranous technique (BMT) - A gentle cranial technique that eases strain within the dural and membranous system, helping to down-regulate the CNS and restore fluid, rhythmic motion.
• Biodynamic Craniosacral Technique - non-directive approach that supports the body’s inherent motility and self-regulating forces, helping the nervous system settle into safety and reorganise.

Phase of Healing: What can the tissue tolerate right now?

Acute Phase (0–72 hrs)
Priorities: calm inflammation, protect tissue, modulate pain
Best techniques:

• Traction
• Gentle soft tissue / inhibition
• BLT / BMT
• Craniosacral

Avoid:

• Strong trigger point work
• End-range MET
• High-velocity techniques (unless clearly non–tissue-irritable)

Subacute Phase (3 days – several weeks)
Priorities: restore mobility, normalise tone, encourage circulation
Best techniques:

• MET
• Light–moderate soft tissue
• Articulation
• Recoil
• Low-grade traction

Re-modelling Phase (6 weeks – several months)
Priorities: improve load capacity, restore full ROM, challenge barriers
Best techniques:

• MET
• Articulation
• Trigger point
• HVLA/HVT
• Fascia-specific work

Caution – even in this phase, technique intensity should reflect irritability and capacity, not time elapsed.

Chronic Pain (Persistent Pain > 3 months)
This is not a tissue-healing phase, it’s a nervous system state.
Here, the CNS, ANS, and fascial system are the priority, not the mechanical barrier.

Aim to down-regulate CNS and sympathetic dominance, Improve sensory processing and interoception, reduce dural load and fascial strain from long-term compensation, build safety, predictability, and tolerance to movement

Best techniques:

• Craniosacral
• BLT / BMT
• Gentle soft tissue / inhibition
• Light, graded articulation
• MET (gentle, non-threatening, not end of range but to point of muscle tension)
• Trigger point (only if well-tolerated and non-threatening)

Avoid:

• HVLA/HVT (may spike sympathetic tone in sensitized systems)
• High-pressure soft tissue
• Any technique framed as “breaking down” tissue (threatening language increases CNS output)

ANS TONE: What state is the nervous system in?

The hyper-sympathetic patient
A hyper-sympathetic system results in tissue guarding, lowered pain thresholds, increased global tension and poor tolerance to aggressive techniques.

For a patient with a hyper-sympathetic tone we can use

• Craniosacral
• BMT/BLT
• Slow/gradual inhibition
• Traction
• Gentle, low grade articulation

Avoid:

• HVLA/HVT
• High pressure triggerpoints
• Fast or jarring movements
• Deep or strong soft tissue

Hypo-sympathetic Patient
When the nervous system does not have enough sympathetic tone, the patient will have a sluggish presentation and lack drive. This will present with low muscle tone, a slumped posture, slow movement initiation, poor spring in their joints, uncoordinated movements (vagness). There patients do best when you give their system something to respond to, techniques that stimulate, activate and re-engage the neuromuscular system.

• HVT/HVLA
• Trigger point
• Articulation
• Recoil
• MET
• Deeper soft tissue

DO NOT – confuse hypo-sympthetic with depression, chronic fatigue, peripheral neuropathy or low blood pressure thought there may be overlap. This is a STATE not a diagnosis.

Joint restriction: What is the barrier telling you?
Hard/firm end feel
Often responds well to articulation and HVLA/HVT

Soft tissue/muscular end feel
Use MET, soft tissue and trigger point

Guarded/protective barrier
Start with BLT/BMT, traction and craniosacral, then progress into articulation and MET once safety is restored.

Non-mechanical pain
Prioritise regulation of the ANS and reduce mechanical loading to create neural safety.

PUTTING IT TOGETHER: A SIMPLE CLINICAL DECISION FLOW

1. What’s the tissue?
   muscle, joint, fascia, ligament, membrane, neural?
2. What’s the irritability?
   acute = gentle
   re-modelling = progressive load
   chronic = improve sensory processing
3. What’s the ANS tone?
   hyper = slow & supported
   hypo = stimulate & mobilise
4. What’s the joint doing?
   firm = articulation/HVLA
   soft = MET/soft tissue
   guarded = BLT/cranial/traction
5. What’s your treatment goal today?
   reduce pain, improve ROM, restore load, shift ANS?

When you align all five, the technique becomes obvious.