Gabriela F. Carvalho, Wacław M. Adamczyk, Carine S. Ludes, Rachel Scharbach, Andres Jung, Sven Karstens, Kerstin Lüdtke, Tibor M. Szikszay

• Background: Manual therapy (MT) is a widely utilized approach for managing musculoskeletal pain and functional disorders, particularly through joint mobilizations. Traditionally explained by immediate biomechanical processes, a paradigm shift has occurred in the last few decades, recognizing neurophysiological mechanisms as crucial contributors. Objectives: To evaluate whether this shift is also reflected by clinicians, this study explores the beliefs and perceptions of physical therapists regarding the mechanisms underlying MT through an online survey design. The focus was if dominantly peripheral biomechanical model or a neurophysiological explanatory model prevails. Methods: The study involved a national cross-sectional survey of 569 physical therapists, average age 36.5y (9.7), and 58 % female. Based on a fictitious case scenario, participants rated on a scale from 0 % to 100 %, the involvement of anatomical structures and physiological mechanisms and provided additional suggestions. Results: The majority of responders attributed significant involvement to the brain (75 %), myofascial structures (71 %), peripheral nervous system (68 %), and cervical joints (60 %). Mechanisms such as endogenous pain modulation (73 %), placebo effects (72 %), muscle activity (68 %), and neuromuscular responses (62 %) were commonly endorsed. The data indicated that socio-demographic and work-related characteristics are weakly associated to specific beliefs, emphasizing the complex nature of these perspectives. The findings underscore the diversity in physical therapists' beliefs and highlight the importance of understanding the mechanisms, as they significantly contribute to the perceived effectiveness of MT. Conclusion: This study provides valuable insights into the current landscape of beliefs among German physical therapists, contributing to the ongoing dialogue between basic research and clinical practice in MT.