Treatment Modes or I'm All Flared Up With Nowhere to Go! | Modern Manual Therapy Blog

Treatment Modes or I'm All Flared Up With Nowhere to Go!

I often instruct my patients to perform their MDT based HEP 10 times an hour. This is to keep the CNS alarm reset long enough so that perceived threat eventually changes and pain thresholds raise.

However, like any treatment, the resets can be modified by frequency, intensity (end range or mid ranges), and an often forgotten one, duration.

Why is duration important?

When a patient flares up, the first thing to do is remind them that everything is going to be ok. I often tell them

  • great news! Rapid onset = rapid resolution according to the research
  • if we were able to improve your complaints in the first place working together, you absolutely have it in you to improve again
  • don't get discouraged
However, that flareup often comes with an inability and anxiety to not only repeated motions, but any motion. This is where duration comes in. There are two modifications that I recommend to help alleviate sudden, intense pain with movement
  1. go NWB
  2. progress the motion over time into end range
  • most of the MDT resets I instruct are WB like REIS, and cervical retraction with overpressure for example
  • WB is easier to perform while at work or out in public
  • however, WB is a more threatening position
  • example 1 - flared up right sided cervical pain
    • have patient perform cervical retraction over a pillow and hold it for 3-5 minutes
    • eventually they may need to be passively sidebent to the involved side or gradually move themselves over to the involved side every 1-2 minutes until they get to end range
    • this may take 20 minutes, but they'll get there
    • often a small increase in SB may temporarily increase the pain, but it should calm down after the CNS realizes everything is ok
    • instructed them on a hold relax SB into the directional preference often helps
  • example 2 - flared up lumbar pain
    • have patient get prone, progressing to prone on elbows
    • if they have unilateral pain, have them get into roadkill if the straight prone on elbows is not reducing their complaints
    • when a patient is really flared up and can barely move without pain increase, help them on the table, then progress them into lumbar extension, with or without hips shifted away from the pain (SB toward)
    • you may do this with moist heat applied to relax the position and modulate the pain
    • every 4-5 minutes, gradually extend, looking for yellow lights, and talking your way through it
The HEP is the same and the goal of course is to get them feeling much better, good enough to hold the position of relief at home for as long as they need to. I would follow up immediately the next day in case tweaks need to made and for more encouragement.

Keeping it Eclectic and empowering the patient...

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