It's Always Something! | Modern Manual Therapy Blog

It's Always Something!

When patients flare up "for no reason," there is often a reason, whether they know it or not.

Here are specific examples from my experience. Many times, patients can be extremely compliant and your treatment can be right on the mark; however, problematic cases are often doing one or more things absentmindedly.

The first patient was being treated for lower back and hip pain, after 2-3 weeks, was about 80% resolved everywhere except around the greater trochanter of the involved side. All the normal habits were addressed, lying on that side, sleeping on the contralateral side without the involved hip being supported with a pillow in a neutral position, HEP, etc. Around visit 7-8, I stated, "I want you to really think if there is something that you are doing to repeatedly aggravate your hip. It may be something or many things. Try to be more aware of one sided activities throughout the day."

She came back the next visit and said, "Do you know what? I have a side garage door that sticks open and every day, twice a day, I slam it shut by bumping it with my hip!" She started kicking it shut instead, and her hip then became 100%. Just for safety, I showed her how to safely kick it so she wouldn't come back as a foot/ankle patient.

The second patient was referred for TMD, cervical and radiating left UE complaints. He is also someone who improved rapidly after 2 weeks, but then would actually flareup every other visit. I asked him each time if he had done anything out of the ordinary, or anything we was not supposed to do. At first it was, "No, not anything I can think of." I then planted the seed of awareness and ask him to think of anything he does every 2-3 days repeatedly that would aggravate his condition. After more poking and prodding, he would come in and say
  • "Is smoking stogies bad for my jaw?"
  • "I fall asleep watching TV and it's off to my left, so my head is often bent to the left for hours until I wake up - do you think that's aggravating my neck?"
  • "Does popcorn count as a crunchy food?"
  • "I talk on the phone and tilt my head to the left for an hour or so at least once a week to catch up with a buddy of mine - my response, "Get a headset!"
They sound like obvious things to us, but to him, they were weekly or daily occurrences. We're talking about an older football coach who told me he used to give his athletes salt tablets in the heat! After taking away his vices, he was discharged with all goals met for pain and function and is now just on a maintenance schedule because he likes the manual work.

The third patient was referred for left lumbar/hip pain. Again, she was mostly better after a few weeks, but had recurrent tightness. She realized after being very observant, that she got out of EVERY chair by flexing and rotating to the left. We practiced a few different ways, to the right, with hip hinges, straight up ala MDT instruction, and the manual work and HEP improvements lasted between visits for a net effect of improvement.

The moral of the story is, with flareups, or patient plateaus, trust your gut. Some patients with sensitized nervous systems can have spontaneous firing of AIGs, or there may be emotional/stress overlays that you or the patient cannot control in their lives. However, we can control and give the patient awareness of repetitive habits, positions, or activities that may be contributing to their condition. Do not just settle on sitting, standing, lying, bending, lifting, etc... 


  1. I liked this post. It brings out the point of we as PTs are also educaters. Usually on my initial evaluation I try to think of things that the pt may be doing wrong that might agravate their symptoms. I watch most LBP pts have a sense of fear avoidance with transfers. I always teach them about proper sit<>stand transfers with hip hinging and they are always amazed that they can stand up without extra pain. People don't realize that the simple things they do dozens of times a day can have a negative effect on them if they do it wrong. Sure manual therapy can help but if they are using horrible mechanics when lifting things several times a day they are going to end up in pain despite what was done in the clinic.
    I always tell a pt there is 168 hours in a week. If they come to me 2-3 times a week for @ 1 hour a visit, that leaves them 165-166 hours during the week that if they are not careful they could exasterbate there symptoms. Sometimes people don't have a clue what that is.

  2. Education is our biggest resource! The HEP is everything, even for acute cervical and lumbar that get better after 1-2 treatments, the HEP is preventative and also when to call us and schedule or double up on the preventative exercises to see if self treatment works.