elements of literature review ppt

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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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10 Best Literature Review Templates for Scholars and Researchers [Free PDF Attached]

Imagine being in a new country and taking a road trip without GPS. You would be so lost. Right? Similarly, think about delving into a topic without having a clue or proper understanding of the reason behind studying it. 

That’s when a well-written literature review comes to the rescue. It provides a proper direction to the topic being studied. 

The literature review furnishes a descriptive overview of the existing knowledge relevant to the research statement. It is a crucial step in the research process as it enables you to establish the theoretical roots of your field of interest, elucidate your ideas, and develop a suitable methodology. A literature review can include information from various sources, such as journals, books, documents, and other academic materials. This promotes in-depth understanding and analytical thinking, thereby helping in critical evaluation.

Regardless of the type of literature review — evaluative, exploratory, instrumental, systematic, and meta-analysis, a well-written article consists of three basic elements: introduction, body, and conclusion. Also its essence blooms in creating new knowledge through the process of review, critique, and synthesis.

But writing a literature review can be difficult. Right?

Relax, our collection of professionally designed templates will leave no room for mistakes or anxious feelings as they will help you present background information concisely. 

10 Designs to Rethink Your Literature Reviews

These designs are fully customizable to help you establish links between your proposition and already existing literature. Our PowerPoint infographics are of the highest quality and contain relevant content. Whether you want to write a short summary or review consisting of several pages, these exclusive layouts will serve the purpose. 

Let’s get started.

Template 1: Literature Review PPT Template

This literature review design is a perfect tool for any student looking to present a summary and critique of knowledge on their research statement. Using this layout, you can discuss theoretical and methodological contributions in the related field. You can also talk about past works, books, study materials, etc. The given PPT design is concise, easy to use, and will help develop a strong framework for problem-solving. Download it today.

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Template 2: Literature Review PowerPoint Slide

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Template 3: Literature Review Template

Craft a literature review that is both informative and persuasive with this amazing PPT slide. This predesigned layout will help you in presenting the summary of information in an engaging manner. Our themes are specifically designed to aid you in demonstrating your critical thinking and objective evaluation. So don't wait any longer – download our literature review template today.

Template 4: Comprehensive Literature Review PPT Slide

Download this tried-and-true literature review template to present a descriptive summary of your research topic statement. The given PPT layout is replete with relevant content to help you strike a balance between supporting and opposing aspects of an argument. This predesigned slide covers components such as strengths, defects, and methodology. It will assist you in cutting the clutter and focus on what's important. Grab it today.

Template 5: Literature Review for Research Project Proposal PPT

Writing a literature review can be overwhelming and time-consuming, but our project proposal PPT slides make the process much easier. This exclusive graphic will help you gather all the information you need by depicting strengths and weaknesses. It will also assist you in identifying and analyzing the most important aspects of your knowledge sources. With our helpful design, writing a literature review is easy and done. Download it now.

Template 6: Literature Review for Research Project Proposal Template

Present a comprehensive and cohesive overview of the information related to your topic with this stunning PPT slide. The given layout will enable you to put forward the facts and logic to develop a new hypothesis for testing. With this high-quality design, you can enumerate different books and study materials taken into consideration. You can also analyze and emphasize the technique opted for inquiry. Get this literature review PowerPoint presentation template now.

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Lay a strong foundation for your research topic with this impressive PowerPoint presentation layout. It is easy to use and fully customizable. This design will help you describe the previous research done. Moreover, you can enlist the strengths and weaknesses of the study clearly. Therefore, grab it now.

Template 8: Literature Review for Research Paper Proposal PPT

Download this high-quality PPT template and write a well-formatted literature review. The given layout is professionally designed and easy to follow. It will enable you to emphasize various elements, such as materials referred to, past work, the list of books, approach for analysis, and more. So why wait? Download this PowerPoint design immediately.

Template 9: Literature Review for Academic Student Research Proposal PPT

With this exclusive graphic, you'll have everything you need to create a well-structured and convincing literature review. The given design is well-suited for students and researchers who wish to mention reliable information sources, such as books and journals, and draw inferences from them. You can even focus on the strong points of your study, thereby making an impactful research statement. Therefore, grab this PPT slide today.

Template 10: Literature Review Overview for Research Process PPT

Demonstrate your analytical skills and understanding of the topic with this predesigned PowerPoint graphic. The given research overview PPT theme is perfect for explaining what has been done in the area of your topic of interest. Using this impressive design, you can provide an accurate comparison showcasing the connections between the different works being reviewed. Get it right away.  

Creating an effective literature review requires discipline, study, and patience. Our collection of templates will assist you in presenting an extensive and cohesive summary of the relevant works. These PPT layouts are professionally designed, fully editable, and visually appealing. You can modify them and create perfect presentations according to your needs. So download them now!

P.S. Are you looking for a way to communicate your individual story? Save your time with these predesigned book report templates featured in this guide . 

Download the free Literature Review Template PDF .

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Archer Library

Qualitative research: literature review .

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Exploring the literature review 

Literature review model: 6 steps.

Adapted from The Literature Review , Machi & McEvoy (2009, p. 13).

Your Literature Review

Step 2: search, boolean search strategies, search limiters, ★ ebsco & google drive.

1. Select a Topic

"All research begins with curiosity" (Machi & McEvoy, 2009, p. 14)

Selection of a topic, and fully defined research interest and question, is supervised (and approved) by your professor. Tips for crafting your topic include:

• Be specific. Take time to define your interest.
• Topic Focus. Fully describe and sufficiently narrow the focus for research.
• Academic Discipline. Learn more about your area of research & refine the scope.
• Avoid Bias. Be aware of bias that you (as a researcher) may have.
• Document your research. Use Google Docs to track your research process.
• Research apps. Consider using Evernote or Zotero to track your research.

Consider Purpose

What will your topic and research address?

In The Literature Review: A Step-by-Step Guide for Students , Ridley presents that literature reviews serve several purposes (2008, p. 16-17).  Included are the following points:

• Historical background for the research;
• Overview of current field provided by "contemporary debates, issues, and questions;"
• Theories and concepts related to your research;
• Introduce "relevant terminology" - or academic language - being used it the field;
• Connect to existing research - does your work "extend or challenge [this] or address a gap;" 
• Provide "supporting evidence for a practical problem or issue" that your research addresses.

★ Schedule a research appointment

At this point in your literature review, take time to meet with a librarian. Why? Understanding the subject terminology used in databases can be challenging. Archer Librarians can help you structure a search, preparing you for step two. How? Contact a librarian directly or use the online form to schedule an appointment. Details are provided in the adjacent Schedule an Appointment box.

2. Search the Literature

Collect & Select Data: Preview, select, and organize

AU Library is your go-to resource for this step in your literature review process. The literature search will include books and ebooks, scholarly and practitioner journals, theses and dissertations, and indexes. You may also choose to include web sites, blogs, open access resources, and newspapers. This library guide provides access to resources needed to complete a literature review.

Books & eBooks: Archer Library & OhioLINK

Databases: scholarly & practitioner journals.

Review the Library Databases tab on this library guide, it provides links to recommended databases for Education & Psychology, Business, and General & Social Sciences.

Expand your journal search; a complete listing of available AU Library and OhioLINK databases is available on the Databases  A to Z list . Search the database by subject, type, name, or do use the search box for a general title search. The A to Z list also includes open access resources and select internet sites.

Databases: Theses & Dissertations

Review the Library Databases tab on this guide, it includes Theses & Dissertation resources. AU library also has AU student authored theses and dissertations available in print, search the library catalog for these titles.

Did you know? If you are looking for particular chapters within a dissertation that is not fully available online, it is possible to submit an ILL article request . Do this instead of requesting the entire dissertation.

Newspapers:  Databases & Internet

Consider current literature in your academic field. AU Library's database collection includes The Chronicle of Higher Education and The Wall Street Journal .  The Internet Resources tab in this guide provides links to newspapers and online journals such as Inside Higher Ed , COABE Journal , and Education Week .

Search Strategies & Boolean Operators

There are three basic boolean operators:  AND, OR, and NOT.

Used with your search terms, boolean operators will either expand or limit results. What purpose do they serve? They help to define the relationship between your search terms. For example, using the operator AND will combine the terms expanding the search. When searching some databases, and Google, the operator AND may be implied.

Overview of boolean terms

About the example: Boolean searches were conducted on November 4, 2019; result numbers may vary at a later date. No additional database limiters were set to further narrow search returns.

Database Search Limiters

Database strategies for targeted search results.

Most databases include limiters, or additional parameters, you may use to strategically focus search results.  EBSCO databases, such as Education Research Complete & Academic Search Complete provide options to:

• Limit results to full text;
• Limit results to scholarly journals, and reference available;
• Select results source type to journals, magazines, conference papers, reviews, and newspapers
• Publication date

Keep in mind that these tools are defined as limiters for a reason; adding them to a search will limit the number of results returned.  This can be a double-edged sword.  How? 

• If limiting results to full-text only, you may miss an important piece of research that could change the direction of your research. Interlibrary loan is available to students, free of charge. Request articles that are not available in full-text; they will be sent to you via email.
• If narrowing publication date, you may eliminate significant historical - or recent - research conducted on your topic.
• Limiting resource type to a specific type of material may cause bias in the research results.

Use limiters with care. When starting a search, consider opting out of limiters until the initial literature screening is complete. The second or third time through your research may be the ideal time to focus on specific time periods or material (scholarly vs newspaper).

★ Truncating Search Terms

Expanding your search term at the root.

Truncating is often referred to as 'wildcard' searching. Databases may have their own specific wildcard elements however, the most commonly used are the asterisk (*) or question mark (?).  When used within your search. they will expand returned results.

Asterisk (*) Wildcard

Using the asterisk wildcard will return varied spellings of the truncated word. In the following example, the search term education was truncated after the letter "t."

Explore these database help pages for additional information on crafting search terms.

• EBSCO Connect: Searching with Wildcards and Truncation Symbols
• EBSCO Connect: Searching with Boolean Operators
• EBSCO Connect: EBSCOhost Search Tips
• EBSCO Connect: Basic Searching with EBSCO
• ProQuest Help: Search Tips
• ERIC: How does ERIC search work?

★ EBSCO Databases & Google Drive

Tips for saving research directly to Google drive.

Researching in an EBSCO database?

It is possible to save articles (PDF and HTML) and abstracts in EBSCOhost databases directly to Google drive. Select the Google Drive icon, authenticate using a Google account, and an EBSCO folder will be created in your account. This is a great option for managing your research. If documenting your research in a Google Doc, consider linking the information to actual articles saved in drive.

EBSCO Databases & Google Drive

EBSCOHost Databases & Google Drive: Managing your Research

This video features an overview of how to use Google Drive with EBSCO databases to help manage your research. It presents information for connecting an active Google account to EBSCO and steps needed to provide permission for EBSCO to manage a folder in Drive.

About the Video:  Closed captioning is available, select CC from the video menu.  If you need to review a specific area on the video, view on YouTube and expand the video description for access to topic time stamps.  A video transcript is provided below.

• EBSCOhost Databases & Google Scholar

Defining Literature Review

What is a literature review.

A definition from the Online Dictionary for Library and Information Sciences .

A literature review is "a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works" (Reitz, 2014). 

A systemic review is "a literature review focused on a specific research question, which uses explicit methods to minimize bias in the identification, appraisal, selection, and synthesis of all the high-quality evidence pertinent to the question" (Reitz, 2014).

Recommended Reading

About this page

EBSCO Connect [Discovery and Search]. (2022). Searching with boolean operators. Retrieved May, 3, 2022 from https://connect.ebsco.com/s/?language=en_US

EBSCO Connect [Discover and Search]. (2022). Searching with wildcards and truncation symbols. Retrieved May 3, 2022; https://connect.ebsco.com/s/?language=en_US

Machi, L.A. & McEvoy, B.T. (2009). The literature review . Thousand Oaks, CA: Corwin Press: 

Reitz, J.M. (2014). Online dictionary for library and information science. ABC-CLIO, Libraries Unlimited . Retrieved from https://www.abc-clio.com/ODLIS/odlis_A.aspx

Ridley, D. (2008). The literature review: A step-by-step guide for students . Thousand Oaks, CA: Sage Publications, Inc.

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ELEMENTS OF LITERATURE

Nov 16, 2014

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ELEMENTS OF LITERATURE. 1) Short Story. A short form of fiction with characters, a setting, and a plot. It presents a sequence of events, or plot. It resembles longer forms of fiction because it provides the reader with a theme or lesson. 2) Plot.

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• rising action
• main character
• minor character
• story takes place
• rising action eventually leads

Presentation Transcript

1) Short Story A short form of fiction with characters, a setting, and a plot. It presents a sequence of events, or plot. It resembles longer forms of fiction because it provides the reader with a theme or lesson.

2) Plot Plot is the pattern of events in a story. Plot development usually consists of these elements: 1.Exposition 2. conflict (rising action) 3. Climax 4. falling action 5. resolution. 3 4 2 5 1

3) Exposition The beginning of the story. This is where the reader meets and learns about the main character and setting.

4) Rising Action This is when most of the events take place. The character and conflict is developed. The rising action eventually leads to the climax.

5) Climax This the turning point in the story. It is the high point of the action of the plot. It is the moment of greatest tension. The outcome of the plot depends on the climax.

7) Falling Action The story begins to “wrap up” as the mysteries are explained and the characters return to their own lives.

8) Resolution This is the end of the story. The conflict of the story has been resolved in some way.

Putting It All Together 1. Exposition 2. Rising Action 3. Climax 4. Falling Action 5. Resolution Beginning of Story Middle of Story End of Story

http://www.youtube.com/watch?v=ffAOkGg2Lr4

9) Character? A character is a person, animal, or object that takes part in the action of a literary work. Types of characters: 1. Protagonist 2. Antagonist 3. Main Character 4. Minor Character

10)Protagonist • The Protagonist is the main character, the hero. (The good guy) • Look at the ROOT • ‘Pro’ means for • The protagonist is generally who the audience roots for

11) Antagonist The Antagonist is the character or force that works against the protagonist. The antagonist can be viewed as the “bad guy”, villian or the source of conflict. Look at the ROOT ‘Anti’ means against The antagonist is against the protagonist reaching their goal

12) Main Character The Main Character is the most important character in the story, poem, or play. Example… Harry Potter, Ron Weasly and Hermione Granger are the MAIN CHARACTERS in the story Harry Potter. These characters are all important to the plot of the story The story could not be told with out these characters.

13) Minor character The Minor Character is the one who takes part in the action, but is not the focus of attention Example… The stepsisters in the story Cinderella These characters take part in the story but they are NOT the main focus. The story can still go on with out them.

On your paper take a few moments to write down a list of Protagonists, Antagonists, Main character and Minor Character that you can recall from movies, television shows, and video games. Protagonist Antagonist Main Minor Character Character

15) Setting

The setting tells the reader where and when a story takes place. What time Of day is it? What is the Weather like? Where is the Location? What is the time period? Hot Rainy Cold Morning Afternoon Night City Neighborhood State Region Era (ex: Great Depression) Time Period

Why is the setting important? For example: A story that takes place in the South during the Civil War would be different than a story that take in New York during the civil war. For example: A story set in the dark woods at night will probably have a scary, eerie feeling. The beliefs and actions of characters Effects The Setting Effects The Setting Feeling or Mood

16) Conflict Conflict is the dramatic struggle between two forces in a story. Without conflict, there is no plot.

Man vs. Man Man vs. Nature Man vs Society Man vs Self What are the different types of Conflict? occurs when one person struggles against another person. occurs when a person struggles against the forces of nature (ex: storm, disease, starvation, wild animals) occurs when a character struggles against the rules, laws, or customs that surround him (ex: a victim of racism, a social outcast, or criminal. occurs when a character struggles with his own fears, ignorance, or conscience.

Man vs. Man • occurs when one person struggles against another person.

Man vs. Nature Man vs. Nature • occurs when a person struggles against the forces of nature (ex: storm, disease, starvation, wild animals)

Man vs. Society • occurs when a character struggles against the rules, laws, or customs that surround him (ex: a victim of racism, a social outcast, or criminal)

Man vs. Self • occurs when a character struggles with his own fears, ignorance, or conscience.

What is Point of View? • Point of view determines who is telling the story. It is the perspective the author chooses to tell the story • There are three types of point of view: • First person • Third person limited • Third person omniscient.

First Person Point of View • Definition: The story is told by one of the characters. The narrator uses the word “I” to refer to that character. The events in the story are interpreted by this character. • Example: As I placed a carefully wrapped package on the park bench, I looked up and saw Molly walking across the street. I hoped that she hadn’t seen me.

Third Person Limited • Definition: Someone outside the story tells the story. The reader know the thoughts and feelings of only one or two characters • Example: As George placed the carefully wrapped package on the park bench, he looked up and saw Molly walking across the street.

Third Person Omniscient • Definition: The narrator provides the thoughts and feelings of many different characters. The reader can “get inside the head” of all the main characters. • Example: George anxiously hoping that no one was watching him, placed a carefully wrapped package on an empty park bench. But Molly, who was walking home, saw him and couldn’t help thinking that he was acting strangely.

What is Foreshadowing? • Foreshadowing is when the author gives clues or hints about what might happen later on in a story. • Writers use foreshadowing to build their readers’ expectations and to create suspense. • Example: Nothing could go wrong on such a perfect day. Or so I, in my childlike innocence thought. • Example: When you hear scary music in a movie, something scary is probably going to happen.

What is Theme? Theme is the central message, concern, or purpose of a story. It is the lesson of the story. A theme can usually be expressed as a general statement about human beings or about life. 2 Types General Themes Specific Themes • The “big ideas” in a piece of literature. • Example: love, friendship, or good vs. evil. • The message the author is trying to communicate to the reader. • Example: Beauty is in the eye of the beholder. • Example: Love conquers all. • Example: Money can’t buy happiness.

What is Tone? • Tone is the feeling that the story gives to the reader. • Some words that are used to describe tone are: light dark scary spooky mysterious joyful Example: Tale Tell Heart http://www.youtube.com/watch?v=t8So5ZyFtWU

What are the three types of literarture? 1. Short Story 2. Novel 3. Poetry

What is a Novel? • A long work of fiction. • It has a plot or a sequence of events that explores the characters facing a problem in specific time and place. • May introduce subplots or minor stories within a larger one. • May have several themes.

What is Poetry? Each word has meaning Poetry uses: Imagery Figurative language - simile, metaphor, personification Sound Devices Such as rhyme.

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Elements of Literature

Elements of Literature. Character. The people (or animals, things, etc. presented as people) appearing in a literary work. Character. Protagonist : main character who experiences conflict: Cinderella, Luke Skywalker, Frodo, Hamlet.

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You will be learning about the following folktales:. FablesMythsLegendsFairy talesTall tales. Fables. What is a fable exactly?Definition:A fable a fictitious (not real) story or tale, intended to instruct some useful truth (lesson or moral) or to amuse. . Fables. What distinguishes a fabl

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Elements of Literature. 1.Tone : . Dreamy, mysterious, magical. 2.Setting (place):. An island in the Mediterranean sea, probably off the coast of Italy. 3.Protagonist : . Prospero. 4.Major conflict:.

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Elements of Literature. TAKE NOTES IN YOUR BINDER – YOU WILL BE RESPONSIBLE FOR KNOWING THIS INFORMATION!. Plot. Plot is simply a way of referring to the sequence of events that make up a story.

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Elements of Literature. Literature is composed of several common elements. Elements. Setting Characters Conflict Plot Point of View Tone Mood Theme. Setting. Where it takes place When it takes place—time of day, season, era. The Functions of a Setting.

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Elements of Literature. and Rhetorical Strategies. Types of Literature. Prose- Fiction Prose- Nonfiction Poetry Drama. Prose - Fiction. Also known as narrative fiction consists of stories based in the imagination of the author, which use narration. Includes: Myths Parables

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Elements of Literature. Notes. 1. Title. The name of the book, article, story, etc. Examples: The Three Little Bears , or Harry Potter and The Deathly Hallows . 2. Author. Person or people who wrote the book, article, story, etc. 3. Setting.

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Elements of Literature. Elements of Literature. Story. Story = the sum total of the whole work Applies to ANY narrative, fiction or not. “Watergate Story,” “Bible Story,” Etc. Includes plot, conflict, settings, characters, style and tone. Action. Anything which happens within a story

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Elements of Literature . We will be using these literary terms throughout the school year. You will be using these in your extended response answers and you will see them on the end of the year tests.

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By: Leslie Valdivia. Elements of Literature. Story . http://www.eastoftheweb.com/short-stories/UBooks/Inte.shtml This is the link to the story “The Interlopers” by Saki. Plot.

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Elements of Literature. p.49. Alliteration and Kennings. Anglo-Saxon oral poets or scops were assisted by two poetic devices: alliteration and the kenning. Alliteration.

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ELEMENTS OF LITERATURE. PLOT LINE. EXPOSITION. A brief description of the setting of the book. This is just the initial setting (the beginning). Do not list every single setting throughout your novel. CHARACTERS. Tell the main character(s) and give a brief description of each .

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ELEMENTS OF LITERATURE. These six elements form the basis of all forms of literature, but their importance varies with the type of literature. Short Stories. Screenplays. Poetry. Novels. Plays. PLOT. CONFLICT. CHARACTERS. SETTING. POINT OF VIEW. LANGUAGE. WWW.DRWRITE.COM.

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Elements of Literature. Plot – the events that occur in a novel, short story, poem, or play. Setting – where and when a story takes place. Setting also creates mood or atmosphere. Characterization – the development of the characters in a work of literature.

2.83k views • 18 slides

Elements of Literature. Plot – Setting – Characters – Conflict-Theme. Plot Diagram. 5 Parts of Setting. Place – Where the story takes place Time – When the story takes place Mood – atmosphere, surroundings Weather – climate, precipitation = mood

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Elements of Literature. September 2011. Elements of Plot. Exposition Introduction that presents the setting, characters, and facts necessary to understand the story. Creates the tone. Foreshadowing The use of hints or clues to suggest what will happen later in the story. Plot Continued.

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Elements of Literature. Introduction. Setting. Time and place of the action View the following picture. What can you tell about the story just from studying the setting?. Point of View. First person: told by a character using “I”. The narrator is a character in the story.

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Elements of Literature. By Laura B. Page Library Media Specialist. Objective. Students will recognize elements of recognized literature to facilitate the composition of original stories. (Alabama Courses of Study for English Language Arts: 7.23, 8.21).

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ELEMENTS OF LITERATURE. PART TWO: PLOT &amp; SETTING English I Honors Mr. Popovich. Preview Activity. As you prepare to take lecture notes, think about what is required in order to tell a good story. On the card provided, write the world’s shortest short story– in 140 characters !

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Elements of Literature. Student Notes. Plot (definition). Plot is the organized pattern or sequence of events that make up a story. Every plot is made up of a series of incidents that are related to one another. Plot Diagram. 3. 4. 2. 1. 5. 1. Exposition.

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Elements of literature

Elements of literature. Allusion. An indirect reference to another literary work or to a famous person, place or event. Audience. The person or persons who are intended to read a piece of writing. The intended audience of a work determines its form, style, tone and the details included.

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Elements of Literature. Character. Character. An animal or person who takes part in the action of a literary work. Types of Characters. Protagonist: the main character Antagonist: the force that works against the main character. Static character: an unchanging character.

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Short Stories- English I Honors

Elements of Fiction Short Story Unit.

Identifying the Elements of A Plot Diagram. Plot Diagram

Short Stories Terms & More! Fiction - Prose writing that tells about imaginary characters and events.

Short Story Unit Notes.

Elements of a Short Story

Short Story Literary Elements

Short Story Literary Elements. What is a short story? A short story is a brief work of fiction.

Novels/Short Stories.

Literary Terms 2.

OBJECTIVES: What is Tone? What is Mood? How are Tone and Mood Effective in Writing?

WHAT ARE THEY AND HOW DO WE TELL THE DIFFERENCE?

A short story is a work of fiction that can be read in one sitting. Elements of a Short Story.

Elements of Fiction Literary Elements – Part II. Plot, Exposition, Complications Plot: A series of related events that make up a story Exposition: The.

Novels/Short Stories. NOVEL A long fictional story, whose length is normally somewhere between one hundred and five hundred pages Uses the elements of.

Short Story Terms. What is a Short Story? A short story is : a brief work of fiction where, usually, the main character faces a conflict that is worked.

Short Stories.

Literary Terms English I. Genre A form or type of literary work. A form or type of literary work. –Short story –Novel –Lyric –Narrative –Non-fiction –Autobiography.

Introduction to Short Story Elements of Fiction. What is a Short Story? A short story is: a brief work of fiction where, usually, the main character faces.

PIB/Honors English 9 LITERARY TERMS. CHARACTERS Protagonist: the main character in a literary work; often the “good guy,” but not always Antagonist: the.

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Elements of literature plot: the organizing principle; the author s deliberate arrangements of incidents and events which tell the story. flashbacks events prior ... – powerpoint ppt presentation.

• Plot the organizing principle the authors deliberate arrangements of incidents and events which tell the story.
• FlashbacksEvents prior to the story.
• Plot Structure
• Exposition the background information about the story and the current situation introduces us to the characters, conflicts, and setting.
• Rising action the conflicts become more pronounced, complications may occur introduces us to additional characters/supporting characters.
• Climax the moment of greatest emotional tension everything changes afterwards when two opposing forces go head to head and only one comes out a winner.
• Falling Action events right after the climax.
• Resolution/Denoument the loose ends are tied up the conflict is resolved.
• EpiphanyAn enlightenment or revelation leading to a change in character.
• ForeshadowingA hint of what is to come.
• Character a fictional person within a story.
• Characterization The method by which an author creates the appearance and personality of an imaginary person. It may be accomplished by an author showing us or telling us about the character.
• Protagonist the main or central character(s) who engage(s) our interest/sympathy.
• Antagonist The person or force working against the protagonist (can be an aspect of the characters persona or personality).
• Foil a contrast or opponent to the protagonist.
• Dynamic character a character who changes as a result of the events in the story.
• Static character a character who does not change.
• Flat character a character who has only one or two characteristics.
• Round character a well-developed character, a character who has more complexity/depth
• Point of view who tells the story and how it is told can be first person, second person, or third person (I went, you went, she went. May be
• Omniscient inside all characters minds.
• Limited from the single perspective of one major or minor character.
• Objective detached and impersonal.
• Conflicts the struggle between opposing forces.
• External conflict physical struggles with a formidable foe or the ever present dangers of nature, society, or individuals.
• Internal conflict a moral or psychological issue that must be resolved.
• Man vs. man (society) the struggle of the main character against another character (external conflict).
• Man vs. naturethe main character is in conflict against nature physical struggle against nature(external conflict).
• Man vs. selfthe main character struggles against himself or herself (internal conflict).
• Setting the time, place, atmosphere, and social environment in which the story takes place.
• Tone The authors attitude towards the people, places, and events in the story.
• Symbol Anything that signifies, or stands for, something else. Symbols can be an object, a place, a character, or an action that stands for or suggest something abstract.
• Conventional symbol One familiar to everyone, such as a flag or a cross.
• Literary symbol Only in the context does this symbol have a deeper meaning
• Irony an event, thing, person that is not what it seems to be. May include
• Verbal irony Saying one thing, but meaning another.
• Situational irony the difference between what is expected and what really happens.
• Dramatic irony Difference between what is believed or said in the story and what the reader knows (we may know more than the character).
• Theme May be called the moral or purpose of the story. The unifying point of organization .
• Imagery the making of pictures with words through a collection of images. Imagery appeals to the sense of taste, smell, hearing, touch, sight, as well as internal feelings.

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Core Infection Prevention and Control Practices for Healthcare

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Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered

This document concisely describes a core set of infection prevention and control practices that are required in all healthcare settings, regardless of the type of healthcare provided. The practices were selected from among existing CDC recommendations and are the subset that represent fundamental standards of care that are not expected to change based on emerging evidence or to be regularly altered by changes in technology or practices, and are applicable across the continuum of healthcare settings. The practices outlined in this document are intended to serve as a standard reference and reduce the need to repeatedly evaluate practices that are considered basic and accepted as standards of medical care. Readers should consult the full texts of CDC healthcare infection control guidelines for background, rationale, and related infection prevention recommendations for more comprehensive information.

The core practices in this document should be implemented in all settings where healthcare is delivered. These venues include both inpatient settings (e.g., acute, long-term care) and outpatient settings (e.g., clinics, urgent care, ambulatory surgical centers, imaging centers, dialysis centers, physical therapy and rehabilitation centers, alternative medicine clinics). In addition, these practices apply to healthcare delivered in settings other than traditional healthcare facilities, such as homes, assisted living communities, pharmacies, and health fairs.

Healthcare personnel (HCP) referred to in this document include all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances, contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air.

CDC healthcare infection control guidelines 1-17 were reviewed, and recommendations included in more than one guideline were grouped into core infection prevention practice domains (e.g., education and training of HCP on infection prevention, injection and medication safety). Additional CDC materials aimed at providing general infection prevention guidance outside of the acute care setting 18-20 were also reviewed. HICPAC formed a workgroup led by HICPAC members and including representatives of professional organizations (see Contributors in archives for full list). The workgroup reviewed and discussed all of the practices, further refined the selection and description of the core practices and presented drafts to HICPAC at public meeting and recommendations were approved by the full Committee in July 2014. In October 2022, the Core Practices were reviewed and updated by subject matter experts within the Division of Healthcare Quality Promotion at CDC. The addition of new practices followed the same methodology employed by the Core Practices Workgroup but also included review of pathogen-specific guidance documents 21-22 that were created or updated after July 2014. These additions were presented to HICPAC at the November 3, 2022 meeting. Future updates to the Core Practices will be guided by the publication of new or updated CDC infection prevention and control guidelines.

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• 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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