There Are Two Types of Patients | Modern Manual Therapy Blog

There Are Two Types of Patients


Regular readers know I am all about efficiency and simplifying the clinical decision making process.

Here are two more guidelines that you can use based on my experience. Essentially, there are two types of patients, those who are

  1. Rapid Responders
  2. Slow Responders
You can call them patients who fall into the CPR for thrust manipulation, or derangement syndrome. Either way, for the fast responders, end range loading absolutely helps. The end range loading into the direction of limitation will often rapidly increased the ROM and also reduce the pain. This is for the HEP, more often than the Tx. How you get there may be the use of IASTM, FR, and spinal manipulation if needed, or it may be patient generated end range loading per the MDT paradigm. End range loading works well, IF you are assertive enough to get the patient to load sometimes into a very painful movement! MDT Dips are excellent at this without ever touching a patient.

Plausible mechanisms why certain patients respond rapidly
  • education and interaction with an empathetic clinician decreases perceived threat
  • end range loading fires mechanoreceptors bombarding the CNS with proprioceptive input, thus increasing the movement tolerance in the painful direction
  • acutely locked or deranged joints like a TMJ, tibiofemoral, facet, or UMT (wrist) are reduced and are thus able to move
Expect these patients to improve if they are acute and compliant with the HEP in 4-6 visits.

The slow responders normally DO NOT respond to aggressive end range loading. Ironically, cases like total knee replacements, true frozen shoulders/hips, or persistent pain states with severe motion loss, respond better to graded pain free movement within the available range. The treatments should still involve IASTM, but lighter for neuro effects, mobilization with movement with Mulligan rules, functional release to tolerance, neurodynamic sliders progressing to light tensioners.

Plausible mechanisms why certain patients respond slowly
  • highly sensitized CNS, which guards all movements/activities and lowers pain threshold
  • lower pain tolerance, less likely to be compliant if the HEP is too aggressive or even perceived to be too aggressive
  • severe mechanical tissue, joint, and/or neurodynamic dysfunction
  • generalized deconditioned state
  • lack of understanding of why PT may help
A recent example of this, s/p TKA 2 weeks ago, stated he would "see stars" as the PT forced him to 90 degrees daily. He came straight from subacute to my clinic. He started at only for knee flexion 30-60, mainly due to being very irritated. We did light IASTM along the quads, hamstrings, gastroc, and mobilized his hip and ankle. We gave him light heel slides, and short arcs on the bike for HEP. He left feeling much better with 10 degrees gained in both directions. He especially liked when I explained to him and my current student what the best predictor of TKA was in the long term! (hint, it's NOT ROM or MMT scores)

His main complaint "I KNEW the other PT was being too aggressive!" Here's the bottom line with this one, if they think you're being too aggressive, AND you are not seeing changes in function/ROM, maybe it's time to lighten up.

Another example, I saw two bilateral TKAs two summers ago. The only treatment for both was IASTM to the restricted LE muscles, light ankle and hip mobs. Their HEP consisted of mini-lunges, mini-squats, and step-up/downs. That's IT. Everything to tolerance. Both better in 12 visits. Not bad for bilateral!

This approach works well with frozen shoulder and hips as well. Hope you learn not to push some patients as aggressively. Maybe they'll gain range from the force regression!

6 comments:

  1. And the best predictor long term is ?

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  2. For predicting pain and function in 1 year follow ups of 120 pts, it was psychological factors, like catastrophizing and fear avoidance. We could say this for all patients. Always seems to be better outcomes when patients have a better outlook in themselves and their rehab programs.

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  3. Erson, in regards to manipulation, how much a factor would you say that the CPR plays in helping you determine the need for manipulation? Do you think that the manipulation CPR helps to predict a fast responder? If so, what aspect of the CPR do you think is most important? Do you feel that a fast or slow responder relates to Maitland's concept of stiff or pain dominance?

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  4. HarrisonvaughanptJune 6, 2012 at 7:34 PM

    Great way to summarize here E. I tell my students and practice myself that patients will only respond to your treatments if you pass one test, the Likeability Test! This seems to correspond very closely to the TKA example.

    BTW, I think I have all slow responders where I work in a rural area!

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  5. Rural = my last point! Lol! I am fortunate enough to work in a white collar area. But agreed, the likability test makes for good outcomes!

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  6. The aspects of the CPR that are more important, if I had to rank them are the low FABQ and the acute timeframe. I actually do not manipulate a lot, as I spend a lot of time on soft tissue. If someone still has abberrant movement after soft tissue, I will consider it.

    I'm not formally trained in Maitland, but even looking at those as categories of patients, it seems like stiff dominance vs pain dominance seems like the same thing I am saying. Stiff should be easy to treat, pain may have other psychological factors to consider. The SFMA also tells you to go after your dysfunctional non-painful areas first.

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