Q&A Time: Repeated Motions Without Dropping D Bombs, Dry Needling, and Reset Explanations | Modern Manual Therapy Blog




A reader recently emailed me about giving a Pain Science Inservice at her workplace. She asked the following questions.

How do you explain lumbar flexion and extension without using the word "disc?"

Great question and one that has taken a while to get down! It certainly is easy to default back to the good ol' jelly donut theory, however that only works according to some lumbar studies, plus the annulus has to be intact. Instead of saying that, I talk about flexion/extension in terms of the nervous system needing variability.

  • too much flexion, sometimes the brain signals red light, and pain and movement thresholds lower
  • reset with a novel direction and the brain can make 1 of 2 decisions, safe or danger
  • if safe, pain and movement thresholds raise and they can "bank" more under the threshold (sit more, bend longer, move better)
  • too much of one direction, position, or movement, and not enough to balance it out
  • "flexion = +1, extension = -1" keep the equation balanced – this way you’re not dropping D bombs

How do you explain a "reset" to another clinician?

First, see this, previous Thursday Thoughts Post, Reset or Modulation for another take on Resets.

We have to look at any intervention, whether it's a technique, like IASTM, Manipulation/Mobilization, TDN as an input to the nervous system. The same holds true for short term movement and exercise. This is because very little to no mechanical effects are really happening in the short term, but we often see significant gains in pain reduction and/or mobility.

I explain reset as any novel stimulus that the brain makes an interpretation of safe. If the pain, or position that was previously associated with danger is now safe, you have a window in which to move threat free.

The threshold will lower again most likely in anywhere from minutes to hours, depending on how vigilant the CNS is. Thresholds were lowered when the brain interpretted danger, usually a combination of inputs (too much flexion, poor hip movement, excessive lumbar movement, prolonged sitting, belief of disc, thought viruses of exam/scan findings, poor word choices from medical professionals. The reset is temporary and must be reinforced with education and repetitive movement into end range. End range = green light (safe) by the CNS.

Where are you with dry needling? On one hand, it is very effective as a reset, but it can also be very uncomfortable.

Dry needling = very powerful due to it’s invasiveness, no one passes out or breaks into cold sweats typically from manipulation or IASTM (at least the way I perform them). The invasiveness is probably why it’s a stronger reset for some, however it’s a hard sell to patients - no one ever said "I love needles." The placebo of patient preference may not be there as much as other common interventions unless the patient has experienced positive effects from the same treatment in the past.

Lastly, how do you deal with skeptics?

Dealing with skeptics is what I do all day and every time I open my mouth. It’s important to be respectful of their old school, uninformed ways. Many of them are probably very charismatic clincians, have good outcomes, and run successful businesses. It's easy to feel that critiquing someone's clinical belief is a personal attack.

In The Eclectic Approach, I try to present modern manual therapy, assessment and pain science as food for thought, instead of "You’re all outdated dinosaurs." The goal is to make some of them think, and hopefully eventually change. You can’t win them all nor is integrating pain science into manual therapy assessment and treatment an overnight transition. It is an ongoing evolution of my approach and my explanations are being continously updated and refined with each patient encounter.

Keeping it Eclectic....



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