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I get asked a lot about various types of manual treatments, sequencing, and in general how I go about working with "insert patient body area here."
One of the first things I ask, when treatment seems to be taking overly long, or not working is, "What's the home program and education?" The next, and more relevant to this post is, "What treatments are you using?" The misconception in general is the more the better, throwing the kitchen sink at them has got to work, right? Well, it works when it works, but a more simple approach is usually better.
Here are 5 Signs You May Be Overtreating
1) You are treating more than 2 areas per treatment on the first visit
- for the sake of this point, let's assume for a condition, like neck and arm pain, that treating the entire neural container is one area, as long as it's light IASTM or tissue work
- the on the first visit is important
- on the first visit, I like to set the stage, take a thorough history, and start with repeated motions as first treatment
- only after repeated motions are attempted, do I add IASTM, compression wrapping with EDGE Mobility Bands, or other "fancy" treatments
- I do not want the patient to think treatments they cannot perform at home are absolutely needed for them to recover
- a shoulder pain patient first visit may look like
- cervical retraction with SB and OP to the involved side
- repeated shoulder extension
- possibly light IASTM to cervical and lateral upper arm patterns
- education on cervical retraction or shoulder extension for HEP along with dosing
- even though the eval is an hour, treatment may be only 5-10 minutes, versus the interaction, education is usually at least 30-40 minutes, with the remaining time left over for questions and going over the homework
- contrast this with a question from a former mentee, he has a coworker who routinely does needling, IASTM, cupping, and joint mobilizations to the same area on each patient - he asked, is this too much treatment?
2) Too much time spent in one area
- I've been teaching manual therapy courses for 16 years, and for over a decade, used to teach 5-10 minutes per treatment, per area - ouch!
- due to accommodation, the more you do a treatment, the less likely it is to be a novel stimulus
- plus, they're more likely to be sore or over stimulated, that is not something you want to do - over stimulate a sensitized nervous system
- in general, I do like IASTM, functional mobilizations, or EDGE Band treatments for 30 seconds to 2 minutes, depending on the size of the area
- if you get rapid improvement after 30 seconds, maybe just sprinkle in a few hold relaxes at end range and then some overpressure to make sure end range is threat free
3) You actually forget to address the patient's complaints
- I'm looking at you SFMA clinicians!
- we all like to treat distal DNs, especially if there are large, seemingly relatable asymmetries
- if your patients regularly ask you, "When are you actually going to treat the area that hurts?" - from a patient buy in/satisfaction perspective, give it some love
4) Their homework reads like a book
- the treatment does not stop in the clinic right?
- keeping it simple, whether it's motor control, repeated motions, general strengthening, you should teach the patient 2 great strategies tops, at least for the first visit
- this gives you a reference to see how reactive they may be, for better or worse
- less = more when it comes to treatment, and patient HEP follows the same general guidelines
5) Most of your a patients are sore after your treatments
- ok TDN clinicians, your patients are probably going to be sore (same goes for strengthening and conditioning)
- for everyone else, whether your input of choice is mobilizations, manipulation, IASTM, neurodynamics, repeated motions, your patients should NOT be sore
- as a review, check out Myths of Manual Therapy: Soft Tissue Work
- a patient is either going to rapidly respond or not, but if you do not get a significant change in pain free range, general mobility and/or function after a few of your favorite treatments, they may need regular dosing throughout the day for a few days before that happens
- I put these patients into their own sub category of Stubborn Rapid Responders, it's like their nervous system needs a bit of convincing to give a green light
- after learning to be light, and trying to reduce threat (not BE the threat), I have not had to say, "You will be sore," in years
- if you say this regularly, you're overtreating, or using too much force
I've made most of these mistakes over the years, and have gone from a 5-10 minute history with 50 minutes of manual therapy to almost the opposite. If I can change after be so heavy handed and over treating for over a decade, so can you. Thoughts? Chime in below or on the facebook page!
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
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