Manual therapists and people living with borderline personality disorder (BPD): a commentary on building safety, trust, and therapeutic effectiveness in physical care

BACKGROUND: Borderline personality disorder (BPD) is a complex and often stigmatised mental health condition frequently comorbid with chronic pain and musculoskeletal disorders. Despite regularly encountering individuals with BPD, manual therapists (e.g., physiotherapists, chiropractors, osteopaths, and massage therapists) receive limited training on how emotional dysregulation, trauma, and relational sensitivity may influence physical-care encounters. DISCUSSION: This clinically informed commentary explores how BPD's psychological and neurobiological features intersect with bodily pain, therapeutic touch, and clinical communication. It highlights the potential for both therapeutic benefit and unintended harm within manual therapy interactions, and identifies a need for trauma-informed, psychologically attuned care. Drawing primarily on the National Institute for Health and Care Excellence (NICE) guideline for BPD (CG78, 2024 update), this paper cautiously adapts selected principles-such as collaboration, continuity, clear boundaries, and support for clinicians-to manual therapy contexts. The National Health and Medical Research Council (NHMRC) guideline (2012) is used selectively to provide additional operational detail where not explicitly addressed in NICE. CONCLUSION: While these considerations offer a pragmatic framework for enhancing safety and therapeutic engagement, their application requires careful adaptation to context, scope of practice, and resource availability. Further research, particularly co-designed with people with lived experience of BPD, is needed to evaluate feasibility and refine these approaches within manual therapy settings.