Top 5 Fridays! 5 Rules for Resets | Modern Manual Therapy Blog

Top 5 Fridays! 5 Rules for Resets


As requested by a reader, what do you do with all the new motion/function now that the patient has it? Here are the 5 Rules for the Reset
What makes the best reset? Something that improves the patient rapidly and more importantly, something they can do repeatedly at home, without you.

When reset properly, rapid responders can improve
  • ROM
  • function
  • pain (centralize, and/or abolish)
  • neuro signs (absent to NER DTRs)
  • motor control
  • strength
  • any concordant sign you can think of testing
Reset Rules

1) Choose the direction contrary to what the patient repeatedly performs or opposite the position they are habitually in
  • i.e. right neck/upper trap pain, pt frequently side bends to the left, the DP is often cervical retraction with SB to right
  • knee pain with flexion and closed chain ADLs, squat, lunge etc
    • try repeated knee extension loading

2) end range
  • pain and discomfort may be temporary and rapidly improved, only if you get the patient to end range
  • if getting there actively with passive overpressure is too painful, that's what OMPT is for
    • IASTM
    • joint mobs, manip, MWM

3) repetition
  • the neurophysiologic window for reset whether it's by a motion, position, or "magic hands" technique is 1-2 hours, sometimes less
  • the CNS tends to go back to "high alert" mode if the "safety" window of decreased perceived threat is not reinforced
  • keep the pain threshold up, and the perceived threat level low by repeatedly performing the reset as much as possible
  • this may be 10 times/hour, more or less depending on how the patient is doing, or how often they are moving into/sustaining anti-reset positions and movements

4) sustained position
  • don't forget about holding the position/motion of preference 
  • if end range loading reduces Sx and improves the function, but the improvements are not held, AND the patient is very compliant, they may need increased duration
  • UQ example - sustained cervical retraction into a pillow in supine for 5-10 minutes, or against a headrest in the car at every stoplight for the entire redlight
  • LQ example, prone "roadkill" or modified hips offset position for unilateral LQ complains held 10-20 minutes when flared up, or if the patient cannot tolerate repeated loading in WB
  • the sustained holds should be thought of as a regression leading to eventual repeated loading in WB which is more functional
how's that for some awesome bookends?

5) Bookend each reset with education
  • patients need a treatment to empower them
  • rapid improvements seen on the first visit, and maintained through the second visit normally lead to very successful outcomes
    • the maintaining to the second visit is up to them
    • why it is key to follow up immediately on consecutive days for 1-2 more visits to reinforce the resets and tinker with the motions or positions
    • use any manual technique at your disposal to make the movements the make up the reset as comfortable as possible
      • IASTM
      • thrust manipulation
      • MWM, etc
  • teach them a self screen to assess on how to proceed 
    • UQ spine example: if all UE pain is now gone and cervical SB is now equal and pain free in both directions, progress to cervical retraction with overpressure or with extension for maintenance
    • UQ extremity example: if shoulder pain and function have now returned in all planes, maintain repeated shoulder extension prior to workouts or activities
      • if any discomfort persists, or a loss of shoulder extension is noted compared to the uninvolved side, double down on the HEP until symmetry in ROM/pain/function is restored
    • LQ spine example: if all LE pain is centralized and abolished and SGIS is full and pain free bilaterally with symmetrical movement, continue with occasional REIS or REIL for maintenance
      • periodically check SGIS for symmetry and go back to that if movement asymmetry or painful block returns
    • LQ extremity example: painful ankle dorsiflexion reset by repeated end range loading into plantarflexion
      • periodically check half knee ankle df test against the wall (5" away)
      • any loss, repeat the loads - this is one of my 4 pre-workout resets - gives me 1-2 hours to workout with symmetrical motion!  

2 comments:

  1. I'm coming off of @DrDunning's cervico-thoracic thrust course this previous weekend, where he offered a different perspective regarding the transient effects of manual therapy, and the need to couple manual techniques with exercise. A couple individuals in the course appeared to support this, with one gal receiving an AA HVLAT by him at a course 4 months ago, which eliminated her headaches for 3 months. Another female in the class was experiencing SIJ pain with referral down her lower extremity distal to the knee, which she reports had been abolished following a SIJ HVLAT 3 months ago (I cannot recall if these were acute or chronic symptoms).

    Both of these are certainly low level evidence, likely have high expectations regarding HVLAT, and are most likely a good patient population for these techniques. Based on clinical experience offered in class as well as the supportive literature presented, he doesnt combined cervical manual therapy with exercise, but finds a larger role for exercise with low back pain. This view was in opposition to what most of us have been trained in, and maybe his group of patient's are just ideal responders to this treatment method. This was my impression of his take on the 20-30 minute effect window of manual therapy, which it appears he didnt necessarily agree with. Certainly someone more involved in his course work can likely attest to this better than myself.

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  2. I've never taken his courses, so I do not know about what he recommends for HEP. I find unless it's MDT based, most traditional systems of manual therapy in all disciplines seem to think the lasting effects of manual therapy are longer than what is currently reported in the literature. I tend to agree with your assumptions that the expectation of a great treatment, plus being an healthier population with generally good body awareness are what you experienced in class.

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