There are 3 ways to modify derangement reduction exercises or positions.
0) End Range
Any regular reader will know my affinity for MDT and how well it works for reduction of symptoms, centralization, and prevention. We won't rehash what I preach regularly.
Here are some strategies for reaching end range cervical motion
Have the patient hike the opposite scapula during cervical retraction with SB to slack scapular elevators enabling further end range. I have some patients do this actively, or they can lean on an arm rest to lift the scapula for passive slacking.
Self SNAGs to the CT junction, or around the painful area often help with cervical retraction with extension exercises.
1) Duration
For centralization of UE or persistent unilateral complaints, try having a patient lie in supine and lie in the directional preference position progressively getting to end range SB for 20-30 minutes. They can try it over heat if it makes the position more tolerable. Occasionally, it is not the frequency or the end range, but duration that causes the break through in relief.
For acute or severe HA that are not responding, you may try holding end range cervical retraction in supine. This is very easy for patients to perform at the onset of a HA.
2) Frequency
Everyone will have a "magic" frequency or dosage of prescription. It may be my standard 10 times/hour or 10 times every 5-10 minutes. I know for myself, if I have what feels like an acutely locked facet with a capsular pattern in the cervical spine, I can have it feeling 100% by the next day if I perform cervical retraction with SB toward the painful/blocked side more times than I can count hourly for the first day. I barely feel it by the end of the day and it progressively becomes easier.
Frequency is something to get on your patient's back about if they leave and they are better, but come back and any improvements in ROM, pain frequency/intensity/duration are not kept between follow ups.
For very acute/painful derangements, the MDT Diplomats told me they did an internal study on why outcomes seemed to be better during seminars vs the actual clinic. They found that the daily follow ups for 3-4 days really improved their outcomes. Despite having a high copay, patients in acute pain normally do not mind coming in 2-3 days consecutively, if it only means the next visits are 1 week apart just to see how they are doing. Patients who are seen on a Friday and wait til Monday or Tuesday and are not performing their exercises correctly, or as often as they should often think "PT" is not working. Frequency applies to visits for education and reinforcement as well as HEP.
3) Direction
If the patient is hammering away at end range, and you are using your best manual techniques to make sure they are able to achieve end range, but they are not improving or have reached a plateau, you may not have chosen the right direction. In the basic MDT courses and Cert preparation, they tell you to try sagittal plane first, however, the DIPs and more experienced clinicians try the frontal plane to centralize peripheral complaints or abolish unilateral symptoms. If frontal seems to be the way to go, but the patient is in too much pain, you can use a bit of flexion to open up the facets before loading them in neutral.
4) Getting Fancy
I recently used cervical retraction with SB toward the left on a patient who it helped with centralization of her radial neurodynamic dysfunction in the left forearm. It only reduced it to a 3-4/10, I had already treated her entire neural container with IASTM, JM and neurodynamic tensioners. I then tried placing her in neural load for the radial nerve, then had her perform the retraction with SB toward the left. While it initially peripherlized and intensified her complaints, they rapidly abolished. At last follow up, Sx finally reached 1-2/10 after being stuck at 3-4/10 for 2 weeks. Necessity breeds invention!
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