I’d love to hear your thoughts on ‘reset’ therapies and window in which we have to affect the baseline pattern (ie how long, and how much, and how much step back do we expect) and expected rate of recovery in the ‘normal’ case. Let’s say for shoulder impingement or shoulder instability.
Thanks for the great question! For anyone that is not familiar with the term “re-set”, what Eric is referring to is the idea that when we are working with some individuals (mainly those in pain) you are trying to look for some sort of way to “re-set” their brain in order to allow them to progress forward with their rehabilitation and get back to being active and moving pain free.
Let’s start there…
When I think about a “re-set” I think about you, as the clinician or therapist, doing something to the client. This may come in the form of joint mobilizations, massage/soft tissue therapies, dry needling, etc. My friend and colleague Charlie Weingroff wrote a great blog article on manual therapy methods as a “re-set” in his blog – Putting Manual Therapy Into Perspective.
It has always been my thought processes that manual therapy (in my case soft tissue therapy mainly) opens the window. You place your hands on an individual’s skin, interact with their brain, and in some way work to change their perception about what it is they are feeling or experiencing. Basically, in my mind, you are attempting to use touch (which can be very powerful) to modulate the threat response. Once the window is open you have an opportunity to wedge a few pieces of wood under there or maybe a few books and buy yourself sometime to change their perception even more – most likely with movement or more active therapies. If you simply open the window and then do nothing the window will just close eventually and the person will be back where they were before. This is where chiropractors who just crack their patient’s spine and then send them on their way leave a really bad taste in my mouth. The patient becomes reliant on the manipulation and has to come back frequently because they have not been taught how to build back their own confidence in their body when they window was open.
This is essentially the “re-set”. Open the window in some way, keeping in mind that not all therapies will work for all people (therapy is more “read and react” where you do something, see what the effect was, and then go from there), and then try and keep it open with some form of movement therapy to help put the patient/client in control of their own healing. This, I believe, is also where we can see some benefit from the Selective Functional Movement Assessment (SFMA) concept of first trying to work on the dysfunctional-nonpainful and/or functional-nonpainful patterns. A 2010 paper by Boudrea et al., actually discussed the concept of novel movement stimuli and its role in musculoskeletal pain disorders. One of the key points that stood out to me in the paper was that novel movement stimuli could be useful in enhancing neuroplastic changes in the brain as the patient feels that the new movement they are being taught is beneficial. In essence, the patient’s brain makes favorable changes with regard to perception of pain when movement that is new to them is emphasized. With the SFMA, when we exercises in patterns that are non-painful but dysfunctional we are basically choosing movements that don’t cause a threat response from the patient (because they aren’t movements they perceive to be painful) and because the pattern is considered to be “dysfunctional” any movement we choose in that pattern would challenge the patient as “novel stimuli”. Even with the functional-nonpainful patterns, I believe we can make large improvements in the client’s perception of pain because we can exercise in those patterns that are pain free and tell the brain “Hey, I am not that messed up! There are things I can actually do that don’t hurt!”
Just as I emphasized the power of touch above I will also emphasize that movement is just as powerful.
So, to re-cap, open the window, try and keep the window open by choosing appropriate movements, encourage the patient/client to take control of their own healing, and continually find movements that challenge the client’s brain to turn down the threat response. Those are my thoughts on the “re-set”.
How long, how much…Normal Cases?
It is hard to say anything about “normal” cases since each person is individual and each person adapts at their own rate. Additionally, this rate of adaptation is dependent on a number of variables such as their stress levels, which I wrote about in a previous blog article, and their general health. Let’s face it, people are becoming unhealthier and more unfit and not every problem that people have will be solved by some soft tissue work and exercise. People may need nutritional intervention, lifestyle intervention, better sleep, stress management, psychological intervention, etc. You can do all the great therapy you want but if the person is a walking inflammation soup on the inside it is either going to take really long to get the result you want or it is not going to happen at all. If you want really fast results you need to try and control as many variables as possible (which may not always be an option).
Being very general, I like to say that you should see some sort of result after one session and hopefully some more dramatic results after 3 sessions – people should know that you are the guy that can help them after that first session. Sometimes, depending on the individual and how proactive they are with the things I mentioned in the previous paragraph, I can make some really fast changes (like playing 3-days after having a muscle strain or making changes in a pain that someone has had for a very long time only a few sessions) but this is not always the case because people have a lot of things going on in their lives and, again, I can’t control all of those variables. My goal is always to attempt to restore the person back to normal function in the fastest time possible without compromising their health. That being said, there are three people I tend to see:
1. Those that I can help and seem to have the answers for.
2. Those that I can’t completely help but I can help manage their issue better than others might (meaning that they don’t want to take drugs or get a surgery but I can help “keep them out of the red”, so to speak).
3. Those that I can’t help because either I am not the guy for their particular problem, they have some other stuff going on that warrants medical attention, or they need to be in the care of a medical professional to help treat their problem.
So, again, being very general, if I can open the window and pick the right exercises I expect things to happen pretty quickly. I am very hard on myself in terms of how things progress with someone so if I am not seeing the changes that I want in the time that I expect to see them I am immediately thinking about what I am missing or what I need to consider further.
Hope that helps answer your questions!
Boudreau SA, Farina D, Fall D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy 2010; 15: 410-414.