Last time I wrote about The Rules for the Reset was back in 2013, and some of my views and terminology have changed since then. That post can be found here.
Here are my updated rules for patient self resets, very important for maintenance of improvement between visits.
1) It has to be novel
- things tend to happen with a lack of variability in your ADLs, training, or movements and positions
- many with "tight" hamstrings, or piriformis continue to "stretch" them, for months or even years
- however, moving in the direction of slack, usually to end range repeatedly, or holding for a sustained period often reduces pain, tone, and improves motion rapidly
2) End Range
- same rules apply here as always
- many times, the patient will have a loss of mobility in one direction/plane more than others, loading in this direction to end range often "resets" the CNS and improves pain and movement thresholds
- think of the glial cells in the brain doing their job and continously scanning the body for problems
- once pain alters motor control, and threat is associated with a movement, the nervous system limits motion in a particular plane
- during the CNS scan, it picks up a loss of motion and threat is reinforced
- stretching "against" high tone does not seem to work, at least rapidly, yet this is what many patients and clinicians do
- graded exposure to end range reduces threat associated with movement, also bombards the CNS with novel and non threatening proprioceptive information
- this opens the window of improvement for....
- "how often do I have to do these exercises?"
- the answer is really, "As often as you need to in order to stay better."
- remember, the nervous system is easily tricked, but not easiliy convinced, most of your inputs that end up in a rapid response need to be reinforced
4) No Pain, No Pain
- if a repeated loading strategy in the directional preference is painful, or causes peripherlization, it is less likely to work
- this may be only because the level of threat is still there, and the patient is less compliant, or too anxious to reinforce the clinic treatment
- Use the input which you feel most comfortable with, have the best psychomotor skill and "magic words" of explanation with to mitigate the associated threat
- then retest the loading up the directional preference to end range
- as much as possible, it should not peripheralize or be painful upon leaving your clinic, it may still work, but not as rapidly (in my experience) as resets that are only limited by motion and not pain
- education is empowerment
- make sure the patient understands threat perception, how perceived threat is caused by many things from movement, associations, stress levels, breathing pattern disorders, lack of variability in their ADLs/training, etc
- they should also have a clear understanding that you are their to facilitate their recovery, not passively "fix" them with some magic hands technique
- after I tell them how most manual therapies improvements are transient, and explain the window of improvement, I ask them, "So if you leave here feeling better, and I give you a simple strategy to keep at least some of the improvements, whose fault is it if you come back not improved at all?"
- most rationale people say, "Mine."
- note: This does not work with quick fix patients, but I am very transparent with them, any "quick fix" I may do is just that, quick as in short term improvement.
So the list is not that different from that in 2013, but the wording is different and I added Pain Free. Hopefully this helps your conceptualize your HEP. Keep on your patients to make them responsible for themselves, and help them achieve their goals.
Keeping it Eclectic...