Thursday Thoughts: Everything But The Kitchen Sink | Modern Manual Therapy Blog

Thursday Thoughts: Everything But The Kitchen Sink

A common question I get, sometimes daily reads like this, "Hi, I need help with x case, I have tried IASTM, TDN, MET, Joint Mobs, etc...."

My response invariably is, "What is the HEP?" Better yet, what does the patient move like, is there are directional preference to their condition, and have you used any pain science education?

Pain and motor control are outputs, any end range loading strategy, mobilization/manipulation, tissue technique, and/or corrective exercise are inputs. The right input often changes the output. This varies from patient to patient which is why the evaluation is so important.

It's not simply a matter of identifying a painful/tight calf in a marathoner and then going to town on that area. Sometimes that works, but when it does not, you are not doing enough to change the output. Here are better ways than just a bunch of passive treatments

  • education
    • on the transient effect of any passive treatments they may receive
    • on what pain is and is not (Why Do I Hurt, the best, least expensive option for patient's to read)
  • movement assessment - look for
    • directional preference
    • asymmetry
      • big differences in active and passive (pain and or ROM) means motor control issues that most likely need corrective exercise or means of self reset, NOT more manual therapy
      • consistency in active and passive motion (limitations in the same direction or little differences in AROM/PROM) most likely need manual therapy
    • look at least one joint up and down the chain for asymmetries, whether or not on the involved side
  • closely examine the patient's habits
    • intermittent pain is being reproduced, often mechanically/directionally and may therefore be alleviated as well
    • they are often doing something they are not aware of that is negating the reset
  • HEP - all of my sessions, and especially the initial session is have education as bookends
    • any time the patient walks out feeling and moving better, but that improvement does not remain between visits may be because of
      • you did not give the appropriate HEP to keep the nervous system reset
      • you did not instruct the patient on the importance of compliance so they remain better
      • the patient was not compliant
In the end, you're better off entirely switching gears or reducing the amount of treatments if something is not working rather than adding more. Remember to screen the lumbar spine and cervical spine using simple repeated motion exams first prior to examining and treating the periphery. Here are a few recent forum cases as an example: shoulder case, thoracic case

Take home points:
  1. Education and the HEP is what keeps the rapid changes going. 
  2. Make the patient aware it's up to them. 
  3. Keep the HEP and in clinic treatments simple
Keeping it Eclectic...


  1. On the pain science, here's a helpful video I have passed along to many a patient.

  2. Yes that's one of my favorites, very well done