Apr 5, 2013

Friday 5: 5 Ways Clinicians Fail at MDT



I have seen MDT practiced at a very high level. Traditionally trained manual therapists would not believe that over 80% of patients do not require hands on techniques. 

However, when you train MDT Diplomats in your practice, you get to see how this is accomplished. One of the basic tenets of MDT is not to make the patient reliant on the practitioner. Education on self treatment is key. Here are 5 ways I have seen other clinicians struggle with patients using MDT as their method

1) Choosing the wrong direction
  • one of the biggest misconceptions of MDT is that it's all extension
  • while common things happen commonly, if a patient has unilateral complaints, would you first try unilateral P/A's or central P/A's?
  • If central P/A techniques were not working after a few visits, would you try unilateral?
  • Apply this same thought process to MDT
  • instead of only using cervical retraction with extension or repeated extension in lying, make sure you try cervical retraction with SB to the involved side or sidegliding in standing to the involved side
    • cervical HA or Sx that do not radiate into the arm = try cervical retraction with rotation and overpressure
    • not able to make lasting changes with sidegliding in standing, try hips offset in lying
2) Sustained pressures
  • An intern in my clinic was evaluating another PT student who came in for mid thoracic pain and paraesthesia
  • he cleared the cervical spine with repeated retraction, and repeated retraction with SB to the side of the pain that was more distal
  • since this was not working, he went to the SFMA to find asymmetries in movement and stability
    • this is not incorrect, but he forgot to try sustained
    • the patient sitting upright, started to have paraesthesia around the inferior angle of the right scapula
    • after completing upper half SFMA, he found DN in movement for cervical rotation/flexion, MRE, MSR, and lumbar locked upper and lower thoracic rotation
    • most of the DN were symmetrical losses of motion
    • he was just about to start doing P/A on the thoracic spine, as the patient still had complaints of paraesthesia after the movement assessment
    • I sat her a bit more upright, had her actively go into cervical retraction, then held it at end range with overpressure, after 20 seconds, all of the pain and paraesthesia abolished
    • this told us to focus manual techniques on the cervical spine first and not the thoracic spine
    • the moral of the story, do not forget to try sustained postures/positions before moving on to an adjacent area
    3) Assertiveness

    • the best clinicians are not only confident, but they are also assertive while maintaining compassion
    • the HEP is everything when it comes to locking in the improvements made during the session with the clinician
    • from the beginning, make sure the patient knows the effects of your treatments are transient and they need to maintain those effects
    • “if you walk out of here feeling better, but do not maintain some of that improvement between visits, assuming I chose the right directions/treatments, whose fault is that?”
    • if they do not answer, “mine” you have some splainin' to do!
    • Do not give them an option
      • their excuse – my reaction
      • I don't have time – It takes less than a minute to do these exercises, EVERYONE has the time
      • I can't do these during the day – You're not telling me you can't, you're telling me you won't, you're perfectly able to do them
      • Can't you just fix me – No, unless you mean temporarily
      • People will think I look funny – No one really cares about what you're doing, they may think for a few seconds, what the heck is that guy doing, then they forget about you. If someone asks what you're doing, just tell them.
      • Do I really have to do these hourly? - No, you only have to do them enough to get better, depending on how much you're doing to reverse the effects, you may have to do them more or less.
      • Seriously? I really have to do these exercises? - Only if you want to get better.
    4) progressing the patient
    • if a patient continues to get better each visit, with rapid changes, very little progressions are needed
    • if a patient improves and then plateaus you need to progress the program
    • common progressions
      • patient generated overpressure
      • externally generated overpressure – belting down the hips for REIL, or having a someone stand on a tower over the hips during REIL
      • using manual techniques around adjcent DN areas to make it easier for the patient to get to and maintain end ranges throughout the day
        • decreased REIL/REIS – use psoas, QL, thoracolumbar release, paraspinal release, hip and thoracic mobilizations then recheck REIL
        • decreased cervical retraction with SB – use paraspinal IASTM, upper trap, levator IASTM – ipsilateral more than contralateral, 1st rib mobs, ipsilateral cervical downglide mob/thrust, then recheck the motion
    5) reviewing the patient's program

    • this seems obvious, but sometimes when a patient was responding, then stop responding, review their ther ex again
    • just today, a patient who was feeling better for the past 3 visits, came in stating the exercises were no longer working
    • asking her to demonstrate the cervical retraction with patient generated overpressure, her hand was shaking
    • for some reason, she was pushing back forward isometrically against her hand
    • I demonstrate it should be active retraction to end range with light pressure to push farther, not harder!
    • if all else was equal, and no new activities or injuries occur, a patient should not regress, they may plateau, but should not regress
      • if they do regress, review the HEP form, frequency, intensity, and duration
    I hope some of these tips help! I'm off to teach The Eclectic Approach UQ in the Chicago area, and if anyone sees a huge box of EDGE, EDGEility, and EDGE Mobility Bands lying around unclaimed, contact me! The USPS lost them! Luckily I had enough EDGEility in stock to fly in my suitcase, but "guaranteed" overnight delivery really means nothing when it doesn't arrive. Cross your fingers that they arrive by lab tomorrow afternoon!

    4 comments:

    Matthew VanSlyke said...

    Great tips regarding implementation of the MDT principles! I especially liked #3 which can be applied to any patient you are treating regardless of the technique or intervention that you choose. The majority of people seek physical therapy because they want to get better such as reduce pain, move better, or do more physically demanding activities. It is always interesting to me the human behavior aspect of therapy of what motivates people to take control of their rehab or on the flip side what fails to motivate them to do things that can help them get better. While a good therapist may have access to some very effective interventions and tools a great therapist can "sell" the treatment. Bottom line always is that physical therapy can ultimately only help those who help themselves right?

    Alison Cupini McLean said...

    Great tips! Always love the reminders, and examples.

    Dr. Erson Religioso III, DPT said...

    Thanks Alison! Hope to come out to CA and do a course soon!

    Dr. Erson Religioso III, DPT said...

    That is the bottom line, and many of the principles apply to different techniques/methodologies. Thanks Matthew!

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