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Repeated Motions Exam and Treatment: Why You Should Be Using It

7/21/2014

6 Comments

 
The last month or so I have been using repeated motions consistently in my evaluations and treatments. Like many other PT's, I was taught McKenzie in school basically was lumbar extensions and only applied to a select few patients. The misunderstanding of how repeated motions work and should apply to our patients is probably one of the most significant disservices we are doing to our patients. Since incorporating them into my care (thanks to The Manual Therapist), I have noted significantly greater improvements in less time. Now I do not have a full understanding of the system based on MDT, but this post will link to several posts by The Manual Therapist so you can learn to apply it tomorrow.

Let's start of with why you should be using repeated motions in your exam. With about 90% of our patients being rapid responders, we should be getting immediate improvements on the day of our examination. Repeated motions are easy, reliable, have built in testing, lead you to treatment and give you your HEP. You will notice with application of these principles, for the appropriate patient you will be amazed at how much better your patients get faster.

Now what exactly is that about MDT and repeated motions that makes it so effective.
Let's start with some of the misconceptions about MDT. MDT does benefit from some manual techniques. While I like repeated motions because it makes the patient more independent and gives them their HEP, sometimes they are unable to get the patient 100% of the way there. A manual technique may get that extra bit or may even accelerate improvements in another area. The MDT theory is not based on disc model like what is taught in school. With modern pain science showing how much force is required to deform tissues and how much normal degeneration solidifies different tissues, we must realize that we are not actually affecting the disc. These "disc" injuries are often associated with McKenzie extension exercises, leading to the stereotype that MDT is extension. This couldn't be further from the truth as repeated motions can be applied to any direction and any joint (the link there has a video that shows various resets for repeated motions at different joints). So how are the changes acquired with MDT? One of the prime components of why MDT works (per one hypothesis) is because the repeated loading of the joints engages mechanoreceptors enhancing proprioception. This may alter the patient's perception of their ability to go into what was a painful motion.
Picture
What is necessary for repeated motions to actually work is to actually get to end range. We all have seen mobilizations and manipulations have improvements with our patients. There are different theories as to how these changes actually occur, but one of the necessary components is that end-range is required. Repeated motions have the benefit of making the patient independent with their care and allows a patient to maintain any gains acquired from PT. We may not improve ROM in all patients due to degeneration, but pain or other symptoms can still improve. It is often difficult for patients to get to this end-range out, because more often than not the direction that is prescribed is the painful one. With each motion in the correct direction, the patient will realize that it is okay to move into that direction and lower their fear avoidance.

How do we choose which direction to proceed? The treatment choice is based on the directional preference. The directional preference is the direction that a joint needs to be repeatedly loaded to have effects potentially on ROM, pain, DTR's, strength, and function. The direction is more often than not the direction the patient tends to avoid. When trying to find the directional preference for sure or when distributing a repeated motion as part of an HEP, it is essential that you remember the stoplight system. The stoplight system allows you and the patient to monitor the progress of symptoms ensuring the correct exercise was given. A green light is when the symptoms centralize and remain better. It is still a green light if the pain centralizes but increases centrally, because it is still centralizing! A yellow light is when a patient's pain or symptoms increases but they can "walk it off." What we must realize with yellow lights is that maybe a patient's pain will increase, but in doing so they have greater motion or greater motion before the pain occurs. It is easy to become hesitant with yellow light responses, but we must remember that we need to get to end-range to have the desired effect. A red light is when a patient's pain or symptoms worsen but cannot be "walked off."

Hopefully this helps to summarize some of the concepts of repeated motions and MDT. I encourage you to look at each one of the links for further information and better understanding of repeated motions. For more information, check back on Dr. E's blog regularly in order to enhance your understanding in the area. He often has posts like this that may show you how to incorporate MDT into your clinical reasoning. In doing so, you likely will notice rapid improvements with many of your patients.

-Chris
6 Comments
Robbie Horstman
7/21/2014 06:50:40 am

Dr. Fox -

Swish!

RH

Reply
Erson Religioso III link
7/21/2014 09:06:29 pm

Doc, thanks for sharing all those links. Glad you're getting the ease of repeated motions exam and HEP.

Reply
Chris Fox link
7/22/2014 02:24:51 pm

Thank you Dr. E! Keep up the great work!

Reply
David Adelman
2/14/2019 05:18:31 am

How do you typically approach repeated movements with true facet pain, if facet pain is usually exacerbated by extension due to increased loading on the joint from disc degeneration?

Reply
Chris
2/14/2019 07:41:28 am

I don't let the pathoanatomical diagnosis dictate my treatment. I assess my asterisk sign, then trial repeated motions in a direction and reassess my asterisk sign. The patient response is the guiding factor. Hope that helps!

Reply
Victoria Addington link
10/19/2022 05:51:25 am

I liked it the most when you shared that repeated motions allow a patient to keep any gains obtained from PT. My friend told me that he needs an independent orthopedic evaluation. I should advise him to see an experienced orthopedist to ensure reliable results.

Reply



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  • Home
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  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
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    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test