Thursday Thoughts: How Big is Your Leash? | Modern Manual Therapy Blog

Thursday Thoughts: How Big is Your Leash?

How many visits do you go without improvement before you throw in the towel?

MDT identified very early on, that finding a directional preference plus centralization, or any major changes on the first visit lead to good outcomes in general. Chad Cook further studied patients who came back with those improvements maintained on the second visit also predicted positive outcomes. Essentially, making big changes on visits 1-2 let you know you're onto something and that you are leading the patient in the right direction literally and figuratively.

Over the years, my visit average has gone from 20-30 in the early years, to 4-6 currently. Most likely, according to some research on outcomes plateaus, I will not improve on this. Since I've been "stuck" here for several years, I'd be inclined to agree. I continue to further my education to learn how to help more people fit into the rapid responder category that I could not before, or to help the slow responders... but the no responders (unofficial third category), that's what this is about.

A MDT Diplomat I mentored, Frank Ward, told me a MDT based study from waaaaay back in the 80s basically found if you had not made a breakthrough in 6 visits, you were in for a very tough case. After hearing that, I tended to agree, and this does not count conditions I place in the slow responder category...

  • frozen shoulder
  • recovery from major surgery/trauma
  • any true persistent pain/central sensitization patient
I'm talking about cases that according to the history and presentation, seem like you should be able to help them, yet they either come back with zero changes or get worse despite your best efforts and their compliance. 

My current leash is
  • 2 visits for OOW worker's comp, or no-fault cases with open litigation, that show no change or worse
  • 3 visits for noncompliance
  • 4 visits for everyone else (compliant, tried a few variations, still zero changes, and or worse)
I just know after 16 years of practice, that the first 2, I do not feel like dealing with anymore. In my area of Williamsville, NY, I did not have very many of these cases a year, maybe 2-3. However, I tell all patients on the eval, that we should see some change within 4 visits otherwise I'll refer them to another specialist I trust. 

And NO the above scenario does not happen often enough to lower my visit average, smart alecks! So two questions for you:
  • How long is your leash?
  • When was the last time you made an enormous breakthrough on visit 10 or more? (i.e. don't beat a dead horse)

Keeping it Eclectic...


  1. When practicing as an athletic trainer in the collegiate setting you never get to change the length of you leash...However, you do get to share the handle with others that you work with. You can also refer to others (MD, DC, PT) but even then you are still part of that leash holding.

  2. Interesting. Most of the time when I give someone else the leash, I don't hear from the patient again, but other times I was right, surgery needed etc, or it was gluten intolerance causing headache...

  3. ER, I thought you were a MDT guy and if so you're telling us with a true dysfunction patient you're thowing in the towel after 4 visits or two weeks? As you are aware I'm sure, a dysfunction patient requires 4-6 weeks to remodel tissue or are you doing something else with these patient's.

  4. No, I said discounting those who I call slow responders (dysfunctions), those who I think should absolutely be responding, but are not or are getting worse. I even list frozen shoulders as an example.

  5. Thanks for the clarification, I missed that i guess.

  6. Np, we all have a lot to read and absorb these days. Reading up, retention down, I'm guilty as well on many sites!