It's Either End Range or It's Not... Period.... | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

It's Either End Range or It's Not... Period....

This is turning out to be a #MDT review week! A common comment on any continent I am teaching on is, "I have never moved someone as far as you have!"

One very nice Eclectic Approach participant once told me, "The difference between experienced clinicians and novice ones is that the experienced ones are more aggressive." When I begged to differ, she stated she meant not from a force perspective, but experience told them how far they could push someone, both literally in terms of ROM, and figuratively.

What is end range? It is the end of the physiologic range of motion.... period, that's it... When a patient or even clinician looks at me taking a cervical spine in retraction to end range extension or sidebending to the left for example... they get anxious. As a clinician, if you cannot take a patient to end range, how on earth do you expect your patient to do so?

In watching MDT Diplomats mentoring in the clinic for OMPT Fellowship, it was a real eye opener to see them take any area of the body to end range in repeated loading strategies and making rapid changes. That's what changed the game for me several years back. Passive end range loading is one of the best and only ways for a patient to replicate what your mobilization or thrust manipulation is doing neurophysiologically. Doing several sets of P/A mobs is not very intrinsically valid for the patient, if it improves their complaints, great! "Now how do I do that to myself?"

You can avoid this by starting out with repeated loading strategies, showing the possibility of making rapid changes in pain, ROM, strength, and/or function with a simple osteokinematic (not arthrokinematic) movement that anyone can do. It is not an 8 step exercise, it's 2-3 steps at most. Even those with poor body awareness can perform most MDT exercises correctly.

Where I differ in my approach with strict MDT is I initially move the patient in the loaded position or I have them perform it actively and I perform the overpressure, gradually working toward end range. Showing them exactly where the physiologic limit is gives them kinematic awareness. This is also quite the shortcut, it may take a patient 2-3 times/long to get to the end range as you will out of fear/anxiety. This reduces threat by demonstrating the movement helps if they go far enough. In addition, performing the same movement 50-60 times in a course of 5-15 minutes clearly shows them several reps is NOT going to temporarily irritate their condition.

Only after this do I start with manual therapy and other adjuncts to make the movement more comfortable. If repeated loading strategies are not tolerated in WB, I go immediately to NWB, perform IASTM, etc... then retest in WB. After several short IASTM treatments along a few patterns, the previously not tolerated loading strategy is now easily tolerated, and they still have easy homework to do.

More points on end range
  • someone with limited range (true capsular/issues in the tissues) will be a slow responder for motion, because their is no technique or method that rapidly deforms and remodels tissues 
  • however, because of their limited range, it is still very possible to modulate their pain rapidly because their end range is obtained earlier in the motion
  • bottom line, slow responder ROM may still be rapid responder for pain
  • conversely, lax individuals are difficult to get to end range, which is where many clinicians fail at MDT, if end range is where the magic happens, you have to push someone to THEIR end range, not yours, or what the you learned in your goniometry text (where did the AAOS get these norms from anyway?)
In the end, moving a patient to end range is just getting them to their natural limit, not some paraphysiologic limit, hypermobility promoting nonsense. If you want rapid changes that can be maintained after the patient leaves your clinic, try repeated end range loading in the directional preference. 

Keeping it Eclectic....

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