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Combining Manual Therapy and Strength Training

Physical therapists have been utilizing manual therapy techniques for decades, and rightly so. With the benefits of increasing mobility and reducing pain, why wouldn’t you use such a powerful tool? However, many clinicians and researchers question the efficacy of manual therapy, providing the rationale that since it is most likely NOT promoting long-lasting structural change, why use it?

Here’s the Truth. Manual therapy is not SUPPOSED to make long-lasting structural change. We are simply decreasing threat perception to allow the client to solidify these transient changes with proper exercise! For strength training athletes participating in sports such powerlifting, weightlifting, or Crossfit, manual therapy can be especially beneficial. To explain, let me propose to you a scenario:

Joe the Weightlifter
Your patient Joe is a competitive weightlifter. He comes to your clinic complaining of neck “tightness and pain” during the overhead position of his snatches and jerks. You perform your examination and find that there are no strength deficits and his form is spot on. The only motion that reproduces his pain is cervical retraction and extension. What do you do? Joe is already strong. Simply telling him to “go get stronger” may not be the best approach here. Something needs to be done first.

Incorporate Manual Therapy 
You realize that manual therapy could be an excellent choice here. You decide to utilize isometric holds at his current end range of cervical retraction and extension to try and transiently increase threat-free ROM. You have some success but can’t get him quite where he needs to be. Next, you perform a cervicothoracic manipulation to further open his window of opportunity.

After the manipulation, you re-test cervical retraction and extension and find that Joe now has full threat-free ROM. For the strength athlete, this next step is PIVOTAL. Now that Joe has full threat-free ROM, you take him over to the squat rack and have him perform a snatch or jerk! This is how we solidify our manual therapy techniques!

Pain Science Education
You explain to Joe that although his neck hurt in the overhead position, his form is spot on and he’s actually as strong as an ox. He does NOT have any muscular imbalances, mobility restrictions, or scar tissue buildup, (insert more though viruses here). You simply helped him reset his nervous system so that his brain no longer associates the overhead lockout position with pain. It’s now HIS job to keep the window of opportunity open. You tell him to perform cervical retraction/extension utilizing isometric holds for pain modulation prior to his training sessions and Joe now presses overhead pain-free. His brain no longer associates this overhead position with pain. 

Manual therapy is not intended to promote long-lasting results, it simply opens the window of opportunity to allow the patient to exercise pain-free. Decrease threat perception with manual therapy, then SOLIDIFY these transient results with strength training to promote true structural adaptation. This is how we combine manual therapy and strength training!

Dr. Michael Mash, DPT, CSCS, FMS is a physical therapist and strength coach located in Pittsburgh, PA. He started his company, Barbell Rehab, with the mission to promote strength training in physical therapy by implementing more barbell lifts into clinical practice. You can follow him on Facebook and Instagram and contact him at his website

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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