A Little Force Goes a Long Way | Modern Manual Therapy Blog

A Little Force Goes a Long Way

I used to call my manual therapy "appropriately aggressive." While I still may be more aggressive than most, I don't push on people's first rib, or use STM and grade 4 mobs to tolerance.

When I started teaching manual therapy 13 years ago, the force progressions were based strictly on mechanical theory for grade 3-4 and neurological (gaiting and inhibition) for grades 1-2. I did not see a point to grades 1-2. Using Wolf's law applied to tissues, I did not want to make restricted joint capsules more restricted by applying light forces, potentially making them "tougher." That is what I learned and therefore what I passed on during my courses. Don't get me wrong, I still made changes back then with positive outcomes and have patients finding me at my new practice that I treated 8-10 years ago, most likely by wailing on their first rib and cervical downglides.

I learned several years ago that you do not have to be as aggressive with joint mobs to make changes. However, since adding STM to my repertoire and doing at least 20 minutes of tissue work per session, I find myself not using joint work as much as I used to.

Almost 1 year ago, Tim Flynn and I had a conversation regarding EIM using the EDGE in their IASTM courses. He said my video for the ITB on youtube was too aggressive and it looked like I was "lacerating" my buddy's ITB. He told me about ASTYM's theory of creating a mild inflammation around the area to promote healing. I told him I would experiment in using lighter forces. Truth be told, that video was demonstrating an entire force progression that I only find myself using on less than 5% of my patients.

I started experimenting with using less and less force for superficial work. The EDGE basics DVD and my newer streaming vids reflect this. Not only have I been able to use IASTM with more patients, but it causes much less bruising and even petechiae. I still inform patients it's a possible outcome of treatment however, along with soreness that should not be a worsening of their symptoms. I am still getting ROM improvement and movement quality improvements with much lighter forces.

In lieu of research like this, which those in the anti-fascia camp often refer to, I would say that much of what we see with STM is neurological changes. (Btw, that study has too much math in it for me to analyze the methods!) This makes more sense than just saying your are promoting inflammation to kick start a healing process. HOWEVER, I do absolutely think there are still mechanical reasons why any manual therapy can work, even with much lighter forces than I used 10 years ago.

The Directional Preference, or DP, is not just something for MDT. We can choose techniques that either do not make our patient better, or make them worse. We can change the direction of STM, or the direction of a glide and have improvement in motion, or decrease in pain. If EVERYTHING were neurologic, or CNS mediated, there would be no clinical decision making as to what to treat.

It is similar to studies showing one exercise approach not being superior to another. That may be true, but the lack of a homogenous population prevents all exercises and thus techniques from working equally. Anyone who has actually worked with patients can see that.

In conclusion, despite some cases that would not have gotten better had I not gone for broke, I would say the majority of patients respond just as well to lighter forces during JM, STM, and of course neurodynamic techniques. Greater treatment tolerance often leads to improved treatment effects and thus better outcomes!


  1. I enjoy reading your blog. I want to become a master manual therapist, however, I feel that I am lacking direction. Do you have any suggestions for a fairly new therapist (2yrs) like myself so that I am not wasting time? Thank you Dr. E.

  2. "If EVERYTHING were neurologic, or CNS mediated, there would be no clinical decision making as to what to treat."

    There's more to the nervous system than just central sensitization and brain perception.
    What about neurodynamics? What about cutaneous branches of deeper lying nerves? What about mechanoreceptors in the skin?

    These could all play a critical role in nociceptive signalling.

  3. Dr. Erson Religioso IIIJune 9, 2012 at 9:51 PM

    Max, I absolutely agree. That particular comment was for the hardcore pain science devotees who believe there is no mechanical nor periphal components to manual therapy or pain. I teach and address neurodynamics in all my patients.

  4. Dr. Erson Religioso IIIJune 9, 2012 at 9:53 PM

    1) You need a system that can lead you to treatments like the SFMA or MDT 2) Take Institute of Physical Art courses, great functional release/STM that are immediately applicable 3) traditional OMPT like Maitland, Paris also helps but tend to be overwhelming and make you chase pain. 4) mulligan is simple and easy to use. Hope this helps.

  5. Find a AAOMPT approved manual residency program. There are a lot to choose from now, I myself went through MTI (The manual therapy institute). They progress through body regions, with evaluation and treatment techniques. A good one will take 2-3 years of your time, but is well worth it!

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