Top 5 Fridays! 5 Mistakes I Have Learned From | Modern Manual Therapy Blog

Top 5 Fridays! 5 Mistakes I Have Learned From

I always tell new grads and students how lucky they are. You have access to a ton of great information from social media, instantly!
You also get to learn from our mistakes, which is a huge part of experience. Jesse Awenus suggested that I post about 5 mistakes that I was able to learn from. Some of them are flat out mistakes, some are cases I learned from. By no means are these my top 5, but these are ones that are memorable.

1) Trying too much for too long

  • We all want to make patients better, but experience and plenty of failed cases told me when enough was enough
  • like many clinicians, I would often try with certain patients 2-3 times/week for 6-8 weeks with little to no change in the way a patient feels
  • even slow responders like frozen shoulders should see a change within that time frame!
  • Frank Ward, a MDT Diplomat who I mentored over the past year told me research that was done sometime in the 80s (not able to find citation) that cases that took longer than 6 visits ended up being very difficult
  • when I thought about this compared to current MDT research - 87% are rapidly responding across an entire caseload and not just acute, it made sense
  • you should make MAJOR changes within 1-2 visits, if not, change things up, within 6 visits, if you have not made a huge breakthrough AND the patient is compliant, refer out and have a plan B for the patient
    • my plan B are other providers that I trust, usually smaller practices where I know they will get the same quality care and attention
  • I normally tell patients, if there are NO changes in 4-6 visits, I will refer out, but lately, I want to see major changes in 2 visits
    • a least 3 evals in the past week, I have referred out, or sent them back to their referring neurologist because there were zero changes in 2 visits
    • another case was worse after just this week was worse after 3 visits, so I referred her to a neurologist for her HA
  • moral of this story: Trust your gut and know when to call it quits
2) Everyone deserves a fair shot
  • I will never forget one of the meanest, crankiest, impatient TMD patients ever
  • she was short tempered, and rude, starting off with rubbing my former secretary on the phone call, proceeded to upset my intern, and also my other PT
  • after a few short visits, we all started being very short with her as well
  • she would sign in, we would call her back, I'd basically tell her that heat was waiting for her on the table, I would run and do SOAPs
  • I would DREAD going back to the table, pretty much ask a VAS, do a few measurements, treat her and send her on her way
    • this was about 13 years ago, so this probably went on for 4-5 weeks at 2-3 times/week, possibly longer
  • one day, she says something like, "Maybe I'd feel better if you people showed me a bit of compassion, I am in serious pain!"
  • that made me feel like a real a-hole... and this was before Explain Pain... so I actually made sure to go out of my way to be extra special nice to her (staff was directed to as well)
  • she eventually turned around to our sugary approach and started responding, started smiling at each visit, and although she did not get more than 50% better (phantom tooth pain after all teeth extracted except 2), she was grateful for our services and any improvement she could get
  • moral of this story: Kill em with kindness!
3) Acting Like The Case is Simple
  • again, this was very early in my career
  • I saw an older gentleman with shoulder pain, and a separate time for lumbar pain
  • both cases resolved well (back then, that probably meant 20-30 visits!)
  • he then came back with a referral from his neurologist for headaches that were constant and unremitting
  • he had objective findings consistent with cervicogenic HA - loss of upper cervical mobility, tenderness in the occiput, general loss of cervical mobility
  • anything I tried at that time, which was probably a lot of joint mobilization and suboccipital release - I was only 1 year out, did not help
  • I was dumbfounded because he responded so well to PT with his other conditions
  • He thanked me for trying, and I never forgot that because he was so genuine about his gratitude
  • several years later, I just finished up getting certified by Dr. Rocabado, and felt like I could handle any cervicogenic HA
  • the patient came back, with the same complaint of headaches, and I basically stated I just learned a whole new form of assessment and treatment, so you'll surely get some relief
  • light tissue work, postural correction, MDT, subcranial shear distractions, after 3 weeks, still no change
  • each time he reported no change, I felt terrible, because he was such a nice older guy, and each visit, he thanked me for trying
  • on his last visit, I asked him how he was feeling and he broke down crying saying, "I just miss my wife so much! She passed away shortly before I started getting these headaches. I miss her every day."
  • I knew then that I could not help him with my skill set, and referred him back to his neurologist
  • I didn't think I'd see him again, but I did see him a few years later, for his opposite shoulder, which responded well to PT, he still had his HA, and thanked me for asking
  • moral of the story: Absolute certainty of case simplicity will have you eating your words
4) Cranking on slow responders
  • a true slow responder, like a frozen shoulder will NOT improve ROM quickly
  • they act like a patient coming out of a cast for 6-8 weeks, stiff in all directions
  • assuming I could somehow break up scar tissue and deform the fascia and joint capsule with superhuman strength, I would crank on patients and nicely tell them to suck it up
  • I now liken tissue deformation to muscle hypertrophy... it will happen gradually over time given the right stimulus and conditions, just not rapidly
  • you will have more compliant patients if you do light soft tissue work, plus joint mobilizations, then have them move regularly and often in mid ranges
  • moral of the story: Slow and steady wins the race
5) Good PT/Bad PT
  • this is not a case from over 1 decade ago, but just 6 months ago!
  • as you know, I am hard on my patients, and it gets results, but this is when I got schooled by Southern Hospitality by the aforementioned Frank Ward
  • moral of this story: Everyone has something that motivates them, and it's usually not someone being a hard ass
 That's all for now! I hope everyone has a great weekend! Does anyone else have a memorable case or mistake that taught them something they would like to share?

Keeping it Eclectic...


  1. Good write up Dr. E.
    I am learning the value of calling it quits can be hard sometimes when you have that little voice in your head saying "what if I try this or that next time"...2 visits is a short leash, but I too like seeing big changes fast

  2. Great post! "Trying too much for too long"...I am still guilty of this at times, even after 8 years. I feel like I have so many "tools in the toolbox" that something is bound to work.

  3. We are all guilty of that because we only want to help. That's why it's always great to go by a guideline of zero changes in 3-4 weeks. If you think about all of the cases you've ever seen, very few have a breakthrough after that time period.

  4. I normally give 4-6 visits, but those were exceptions, one got worse after 2, the others were comp patients who have been out of work for 20+ years... I didn't feel like seeing them and wasting time on both ends.