More on Slow Responders | Modern Manual Therapy Blog

More on Slow Responders

Good news everyone! Most of the patients you see will not be slow responders, but a small percentage of them will be. Here are ways to differentiate as well as treat.

Slow responder characteristics
  • have a ROM in most if not all planes
  • have a chronic condition
  • may have an adjacent area that is rapidly responding
  • pain may still be modulated rapidly
  • ROM will eventually improve with light manual techniques and patient HEP
The first point, limited ROM in multiple planes is one of the first ways I distinguish it. True tissue/joint dysfunction, as in an actual contracture does not move well in general. In contrast, most rapid responders have a major loss of ROM in one plane only. If you think of a true frozen shoulder just like you do any area that has been immobilized for 6-8 weeks, there are the slow responders. In other words, if you do some "magic" and get a frozen shoulder/hip moving significantly better in one visit, it really was not a slow responder at all, unless you're superhuman, and just ruptured a lot of adhered tissues.

The good news about a slow responder is that you cannot make them worse rapidly any more than you can improve their ROM rapidly. Have you ever made a frozen shoulder more frozen? What about a ankle fracture that has just come out of immobilization? I didn't think so. Since they need true tissue deformation, you can smash them all you want, but you won't get anywhere fast, and in most cases, will only cause undue soreness. Tissue deformation happens like muscle hypertrophy during a workout. Small changes happen initially, from motor learning and other neurophysiologic changes, but the real tissue changes happen eventually. 

With this in mind, I treat slow responders with this general plan
  • education that progress in ROM will be slow, but steady
  • soft tissue work in as many patterns around the immobile area
  • soft tissue work in adjacent patterns proximal and distal to the area
  • light joint mobilization to the area, and adjacent areas
  • HEP of light multidirectional motions in mid-range
    • end range movement only causes soreness, but won't make the ROM come back faster
More good news about the slow responder, is that they are poky in ROM only. You may still modulate pain rapidly with pain education, and occasionally with end range loading strategies in a directional preference. I still try end range loading strategies to see if pain can be rapidly modulated, but do not expect rapid changes in ROM. Occasionally an adhesive capsulitis will respond rapidly for pain relief for cervical retraction and/or SB OP to the ipsilateral side.

The bottom line is patience, and education! Do not make false promises of dramatically increased ROM if a patient presents with ROM deficits in all planes after an immobilization or with the shoulder in particular. It does not seem to happen to other joints. Unlike pure MDT, we can do more for these dysfunctions than giving them an HEP and telling them it has to be slow and uncomfortable. The last part is where we come in. Manual therapy makes it more comfortable by working on the dysfunction itself and adjacent ones. The HEP will be adhered to better, the patient feels like you're helping them, rather than just giving advice only, so it's win/win!

Keeping it Eclectic!


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