Clinical Pearl: A Little (Skin) Slack Goes a Long Way | Modern Manual Therapy Blog

Clinical Pearl: A Little (Skin) Slack Goes a Long Way

For those of your familiar with mobilizations with movements, here is a variation that requires even less force and gets you or your patient to end range that much easier!

Cervical Retraction and Extension Clinical Pearl
  • this repeated loading strategy can feel uncomfortably or painfully blocked for several reps or even several sets before it gets easier
  • this depends on how much you have been unloading prior to using the repeated loading strategy to reset the area
  • the sensation of blocking is normally strongest around the lower cervical and upper thoracic area
  • try lightly pulling the skin superiorly to slack it (as light a touch as possible) and try the same cervical retraction with extension
  • it should feel much more comfortable with either little or no sensation of blockage
  • have the patient perform their HEP mode as normal, only now with no "threat" of discomfort

Remember the OMPT Channel is still on sale until tomorrow at midnight! $10 off the first year - so $39.99 now, and half off the first month $2.50 - time to sign up and see hours and hours of videos, case demonstrations, every technique I've ever taught and more!

Keeping it Eclectic...


  1. Is it a "blockage" if as I think you are suggesting nothing is blocked but the mere input of a skin stretch changes the underlying sensation?

  2. Hey Eric, great to hear from you! As you know, very few individuals we see have true mobility issues that require actual tissue deformation, like frozen shoulder or status post immobilization for prolonged periods resulting in contracture. As such, the blockage I'm referring to is just a perception due to CNS limitations, motor control issues etc.

  3. Hi Erson, thank you for sharing.
    Any evidence related to the efficacy of this “Clinical Pearl” ? Many things seem effective in the clinic, but how do we know that we are not just wasting the patient’s time doing this?
    Thank you for your time.

  4. Hi Evan, No evidence that I know of for this variation - guess you'll have to trust my expertise that I wouldn't instruct something that is a waste of time. It's a tried and MDT technique for cervical pain, headaches, radiating UE pain etc with a variation to make it more comfortable. Your outcomes may depend on how familiar you are with MDT and/or how assertive you are with the HEP mode instruction.

  5. Thank you Erson. I agree that I’d have to trust your opinion to accept this as a “clinical pearl”, but I’d have to say that I’m really bad at trusting clinicians, especially those who make claims that are not based on any literature. Manual therapy techniques often seem to “work” while our hands are on the patient, but their effects appear to be short lived. Of course placebo related processing may affect perception, memory, and learning, which may influence future seeking behaviors (chiropractors fully depend on this imo). In the meantime, the patient gets better (most of the time) and the clinician and patient think that it must had something to do with the manual technique or intervention. Then we have the other scenario, what if the variation you propose makes the patient worse or makes no difference to how the patient tolerates movement? I’ve seen this with patients using Mulligan techniques or a gentle variation with just stretching the superficial tissues w/movement. I’m not saying let’s don’t look for variations to traditional techniques to maximize comfort, but I’m saying that we should be careful not to generalize a variation by calling it a "clinical pearl" just because it works on some of our patients.
    Thank you for the opportunity to discuss this issues.


  6. Evan, you are clearly either a new reader or just visiting. If you regularly read my blog, you would know that I adhere to the MDT "stoplight rule" as in you NEVER do a treatment that makes a patient remain worse. Again, you're most likely not MDT trained, as it makes no sense to use a treatment just because someone recommended it if it 1) does not work 2) makes the patient worse. Is that not common sense? Also, a regular reader would know that I place the HEP and education above all else and make it the patient's responsibility for permanent change and treatment from day 1. All manual therapy and exercise benefits are transient, not just the ones that someone says works. My definition of a Clinical Pearl is one that is a variation or new twist on something we've all been doing for a while that may be useful, not a 100% certainty on all patients.

  7. Erson, you are right that I’m not a regular here, but I don’t see how that or adhering to any diagnostic-treatment model eases any of my concerns. I agree that it’s common sense for us to avoid making patients worse, and IMO there is no need to become MDT trained to figure that out either. The problem with relying on "expertise" for manual therapy (or any intervention) is that we don't really know if we are helping, having no significant effect (wasting the patient's time), or worst case scenario delaying the patient's recovery. I also agree with the rest of your points about HEP, MT, exercise, but I remain skeptical about “clinical pearls”. There are endless variations to traditional manual techniques and none of them IMO is superior to another. We have literature that suggests that when it comes to manual technique selection, clinical reasoning might not even be that important (in the context of effectiveness) as we once thought. An example is the Chiradejnant et al. study
    There conclusions are contrary to what traditional manual therapy models claim. Thank you for your time.

  8. I believe he is referring to a clinical pearl as an additive to an already sound technique and approach as in MDT. The fact that you aren't MDT trained is kind of a big deal in this situation. There is a plethora of evidence to support the MDT approach. We know we have to get the joint to end range to get the greatest amount of good for the patient. The fact that altering sensory input so the patient is able to tolerate end range loading is a clinical pearl. Someone is not going to do a technique at home on there own to abolish their symptoms unless they are noticing a change and/or they are able to do it without large amounts of discomfort.

  9. Carl, it's not worth it, already raised that obvious point, that's why I bowed out

  10. Hi Carl,
    I haven't even argued about the MDT model yet (don't get me
    started!). It sounds that you and Erson have missed the point. We can
    come up with many variations of "evidence based" techniques that "feel
    comfortable" and call them clinical pearls.

  11. Good pearl here Dr. E.,
    I haven't ever performed this manuever, so thanks for the advice! I'll definitely include it in my exercise routine. I find that even shrugging the shoulders or better yet retracting, will assist in changing the tissue elongation and lead to better compliance as it is less painful.

    For very irritable patients (which seem to be most of mine!), shrugging prior to say a chin tuck works very well.


  12. Thanks HV! Haven't tried shrugging as it's active, and those with high tone it may not help, but passive shrugging on arm rests works well for some