I've seen a lot of changes in the way that practice is done and what is recommended in 16 years. I have gone through many transitions as well. Here are 5 things I have mostly given up and really streamlined my evaluation and treatments.
1) Passive intervertebral motion
- at best, the inter-rater reliability is fair-good, and that's only among practitioners who have been working together for a while
- most cannot even agree on a level, and it's also impossible to isolate and spinal motion segment
- what are you really trying to do? Test 6-7 levels at a time?
- stop the press and guess, move it and move on
2) Passive accessory motion
- same goes for any peripheral joint, since we're not deforming and stretching joint capsule with mobilizations or manipulations, why are you still assessing inferior, posterior, anterior glides?
- I am not sure this has been studied, but I am sure a "specific" set of treatments, glides etc, would have the same effect as a "non-specific" oscillation with mild distraction
- if you only follow the first two suggestions, I think I've saved you at least a decent amount of time
3) Special Tests
- special tests take time, are often provocative, and rarely, if ever dictate treatment
- don't be Tinel, who apparently went around tapping people right where they complained about, an area of peripheral sensitization, is that really surprising that it reproduces a complaint?
- many are grounded in pathoanatomy, and supposedly target a structure, but still do enhance your clinicial decision making
- SFMA and repeated motions tell you what to do with a patient
So now you're just looking at movement patterns and repeated motions, what next?
4) Treat Patterns
- a hallmark of The Eclectic Approach is treating patterns - with IASTM, functional mobilization, manipulation, neurodynamics, anything you can do to reset the pain/movement threshold
- treating larger areas, like scapular borders, cervical paraspinals, lateral upper arm, pec minor and subscapularis also stimulates a larger area of the homunculus compared to "joint" mobilizations
- by treating patterns related to the area of complaint, but avoiding the direct area of complaint (like inferior acromion and inferior shoulder glides) you are reducing threat and improving motion
- patterns work on most, which is convenient, and again almost feels like you're cheating because you avoided steps 1-3
5) Prescribing more than 2-3 things to do for homework
- nothing irritates me more than seeing a patient with a book of 10-15 exercises
- very few patients have a strength problem, if they haven't been immobilized or avoided movement/function for a prolonged period
- targeting the proximal complaint with a repeated motion based reset, or corrective exercise should be first tackled along with a healthy dose of pain science education
- the understanding of why they need to do 1-2 movements repeatedly throughout the day is just as important as their compliance
- even though I work in a gym, most of my patients are not getting traditional strengthening exercises (unless they train with me after "discharge")
In case you missed it, give up using pathoanatomical diagnoses as well and just focus on the "How" they get better, not the "What" they have.
Keeping it Eclectic...