Why You Should Be Using End Range Loading | Modern Manual Therapy Blog

Why You Should Be Using End Range Loading

A while back, someone started an MDT vs spinal manipulation argument with me on twitter out of nowhere. The ironic thing was, I was teaching a manipulation class that weekend and cite some of that individual's research to support manipulation.

The argument died down pretty quickly once said individual realized I wasn't arguing against manipulation. It's just that I'm lucky if I do more than 2-4 thrust manipulations/month, not counting teaching courses regularly.

However, let's get something straight, repeated end range loading has the same neurophysiologic effects that mobilization/manipulation do. They're all just movements on the same continuum.

This study shows that a majority of those that met the thrust manipulation CPR also fit into the MDT derangement category. That's not surprising, as individuals fitting into that CPR are healthy individuals with acute pain, low fear avoidance, etc. They should be Rapid Responders.

This study shows that lumbar spine mobilization improves SLR compared to static stretching and control groups. A similar study was done as a capstone at a local DPT school in Buffalo NY showing prone pressups having the same effect, significant improvement in SLR. You know why? Prone pressups have the same effect as lumbar mobilization. The patient just has to use a little elbow grease as opposed to lying there and letting you do all the work.

In the end both thrust manipulation and joint mobilization through arthrokinematic movements, or rapid thrust fire joint mechanoreceptors that bombard the CNS with proprioceptive information. Repeated end range loading does the same thing, but with osteokinematic (large, gross movements), but the difference is... the patient can perform them without you. - Give it up, you don't have magic hands!

Eval and Treatment of Rapid Responders is easy!
After history and education, The Eclectic Approach looks for patterns of directional preference in the proximal site of complaint. I then look for asymmetries using the SFMA. The area is then repeatedly loaded to end range, providing the patient can tolerate the treatment and their is a rapid response within 20-30 reps. Then, retest the asymmetries. In the best case scenario, the patient then says, "Wow, I am feeling and moving a lot better, thank you! Now what can I do to maintain this improvement?" Since you're using simple end range loading in gross movements, you can just reply "The same exact thing I just did." That's empowering!

And by "You" I mean the patient, not your passive treaments
You can't do that with mobilization, manipulation, IASTM, etc. Obviously I still use and promote those treatments, but I've said it many times, OMPT is just a cheat to get the patient to move and feel better, so they'll be compliant with the HEP which crystallizes the improvments. Any time I resort to using my EDGE Tool, Bands, spinal manipulation, etc, I am sure to tell the patient the effects are literally a "quick fix" and they need to keep up with their homework if they want to stay better.

A rapid response should occur in a majority of your patients, especially within the first visit. It's up to the patient, and your appropriate instruction for HEP to keep part of that improvement for the second visit. If you meet both of those variables, chances are the patient will have successful outcome sooner than later.

Keeping it Eclectic...

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  1. my question is...how can you guarantee a global movement will get a hypomobile segment to end range when there are other segments that may be adapting to the global movement by becoming hypermobile instead? In his text, Phillip Greenman, D.O. makes an interesting argument about the necessity of treating the hypomobility because too often the hypermobility is treated, because it is symptomatic, while the hypomobility lies silently to one side (pg 74-75). He also advocates being as specific as possible with our mobilizations/manipulations. I know the research is saying that a spinal manipulation induces motion at multiple levels (true obviously), but I would think that the less specific we become, the greater the possibility of not moving the hypomobility because the hypermobile segments are all too glad to move instead. Just my thoughts.

  2. Rich, that's a frequently asked question to those not exposed to formal MDT courses or not using repeated motions to teach their patients to self treat. The answer is, it doesn't matter. Not only can you not isolate a hypomobile segment, but what you're feeling via PIVM is groups of segments of at least 6 levels. While I still teach specificity because it's more comfortable and most likely better/safer technique for cervical thrust and mobilization, looking for hypo/hypermobile segments is more like training yourself to believe in something you should eventually feel. Trust me, I did it for at least a decade, but assessing for directional preference and asymmetry in movement patterns is not only more reliable, it's easy. Who doesn't like easy?

  3. Good food for thought, thanks!

  4. Let me know if you decide to stop the hope and poke or press and guess, seriously it's liberating!