Manual therapy is based on a biomedical model of illness and places considerable reliance on the patient's report of pain. Reported pain intensity is assumed to bear a close relationship with underlying nociception but research has shown that the experience of pain is also influenced by a wide range of psychological factors. Firstly, response to pain provocation (whether palpation or induction of biomechanical stress) can be affected by fear of an adverse outcome (such as pain) and fear of injury. Secondly, a patient's global rating of their pain may be widely influenced by factors in addition to nociception such as distress, fear and mistaken beliefs about the nature of pain and likely outcome of treatment. The manual therapist needs, therefore, to conduct and understand biomedical assessment within a biopsychosocial framework. In appraising the patient's response, the therapist may find it helpful to incorporate specific assessment of subjectively reported fear or behavioural indicators of fear such as guarded movements or behavioural signs. Therapists need to understand that in manual therapy, they are frequently managing the patient's pain behaviour and distress, rather than simply the nociceptive component of their pain.