Top 5 Fridays! 5 Issues Patients Have Trouble Understanding and How I Educate Them | Modern Manual Therapy Blog

Top 5 Fridays! 5 Issues Patients Have Trouble Understanding and How I Educate Them

Here are 5 common issues patients have trouble understanding and how I deal with them.

This idea was submitted by a reader and the others are from other suggestions in my social media. Would love to have your suggestions as well for how you deal with them or other common educational issues.

1) It hurts to do my exercises

Clear education and demonstration is what is needed here. We are most likely talking about MDT derangement reduction or resetting exercises. Going to end range is often painful the first several reps or even sets. This is why preparation of the areas with OMPT techniques is key. Making the DP more comfortable makes the patient get to end range easier, thus increasing compliance. Also, demonstration of an exercise (say getting someone to go further into extension in standing) and showing that it may hurt during the motion, but repetition and the excursion make the difference. For example, I saw a painful lateral shift today, acute, former patient, but was last shifted 1.5 years ago. After 45 minutes of shift correction progressing to extension in standing (with Mulligan SNAGs) he went from antalgic gait shifted 8/10 to normal gait 2/10. Trust me, there was a ton of moaning and groaning, but the further he went, the better he got. I kept encouraging him saying he could go farther. He saw that going farther reduced his complaints and improved his function. Demonstration and education are key for this. It's one of the biggest failures of MDT, improper patient education.

2) Referred pain - or I'm here because my leg hurts, why are you addressing my back?

Use examples! Many people have heard of arm pain possibly signaling a heart attack, so I use that as an example. The other example I use is a repeated motion exam. Either reproducing distal Sx with cervical or lumbar movements is a sure fire way to get someone to realize the origin of the pain may be from some other place. Demonstration that an area of referred pain has full strength and ROM often helps as well, though that may not be the case as there is often dysfunction along the chain/neural container.

3) Why do I have to do home exercises, can't you just fix me?

All that nothing you've been doing, how's that working out for you? Time for a change! The passive treatments you've been getting with the let me fix you approach, if they worked you wouldn't be here, or returning to practitioner x ad nauseum.

Recent manual therapy research identifies the temporal effects of manual therapy and a single mobilization as being 5-45 minutes (two separate studies) and up to 24 hours for analgesic effects. That's why MDT and education is so key. Why do I tell someone 10 times/hour? To keep up with the same neurophysiologic effects that we get with our treatments. That is the ONLY thing that matters. Our treatments and interaction help them get moving better, but only their performance of the HEP keeps the effects of treatments locked in. The CNS is not easily convinced. What better way to convince it than to keep up with "the movement is ok" with end range loading?

4) Do I need an MRI, or why won't you look at my MRI?

Chances are if you've had an MRI, and there is no sinister lesion I have no business treating, like cancer or a fracture, it tells me you only have - insert body part here. It tells me nothing about your movement, function, strength, or coordination. If it was something more serious, your doc wouldn't have referred you!

Do you need one? I already know you have a shoulder! However, if we see no changes within 6 visits in anything measurable, we'll talk about it then. Even then, I would refer out for something else that may help such as TrP injections or cortisone, which may improve movement and pain, then reschedule.

5) Will Wondrous Modality X help me?

Cold Laser - with no contraindications, how can it be strong enough to have indications?
DRX 9000 - almost 80% effective in non-randomized, dependent studies - almost as effective as time, but quite a bit more expensive!
Botox - it's a TOXIN, should I say more?
Heel lift - that would possibly either do nothing, or cause small biomechanical changes up your entire lower half of the body with each step
custom orthotics - often not better than over the counter orthotics, and like most braces make the area weaker. Very few individuals need custom orthotics.
an adjustment, craniosacral, unwinding - anything that claims to help EVERYTHING can't possibly work as well as the claims. Otherwise there would be no problems and we would all be doing those techniques

So... no... if it sounds to good to be true....

This list could go on and on... how about chiming in below?


  1. All great points. Could not agree with you more. Keep up the great posts.

  2. Just curious, how do you handle the statement: "my friend had this knee problem and the therapist used Ultrasound. He/She swears by it. I think it would probably help me too"

  3. I tell them it does the same thing whether it's on or off. Also it's not an option at my clinic. We have no modalities.

  4. Appreciate the quick follow through, Dr E! My 2 cents regarding referred pain - I like to whip out a textbook showing common pain referral patterns. Works great with supraspinatus impingement, and the patient almost always has a light bulb moment "that's exactly where I feel it!" Otherwise I spend weeks trying to convince them there's nothing wrong with their deltoid.

    This also works well with the centralization/peripheralization graphics from the MDT texts. I've found this to be very helpful for reduction of fearfulness and that patient who "feels crazy" because the pain is always moving all over.