I am totally hyped to finally meet and learn from one of the gurus of manual physical therapy, Dr. Erson Religioso III, DPT, MSPT, FAAOMPT. I have been one of the many followers of his works, blogs, videos, and practice.
Dr. E, as he is widely known is the developer and owner of The Eclectic Approach to Upper and Lower Quadrant. His approach to manual therapy includes assessment of movements, manual therapy, and home exercise program. Assessment is mostly SFMA [Selective Functional Movement Assessment], while treatment and HEP’s are MDT based, with combination of other treatment techniques like tissue works with IASTM, Mulligan’s Mobilization of Movement [MWM], and PNF [Proprioceptive Neuromuscular Facilitation].
The Eclectic Approach uses mainly evidenced-based approach, meaning assessments and treatments that are backed up by research and studies. The approach follows the ARC sequence of Assessment, Reset, and Crystallization [or locking in the progress attained].
The Eclectic Approach utilizes SFMA and FMS for movement screening. But since FMS is primarily used with athletes, only SFMA is introduced. Only pertinent movements consisting of seven parts are introduced, just enough to cover the whole kinetic chain from cervical to the ankle and foot. Repeated motions and overpressure are then performed for which is mainly part of MDT.
These are the seven SFMA movements used in The Eclectic Approach screening:
1. Cervical flexion/extension, side bending, rotation with retraction, and chin to shoulder
2. Shoulder external and internal rotations
3. Multisegmental rotation
4. Side gliding
5. Multisegmental flexion/extension
6. Unilateral standing
– Peripheral nerves like joints and muscles need to move freely and unrestricted. Neurodynamics is used to assess the mobility of the peripheral nerve.
– Dr. Erson said that he uses neurodynamics now as part of evaluation [and reevaluation] but not as treatment as he uses tissue work for treatment.
Other considerations during assessments are as follows:
– Movements are done both actively and passively. Overpressure is applied where limited motion is noted.
– Asymmetry in movements is also noted. If asymmetry is only present in active movement, motor control is most likely the problem. If the asymmetry is noted in both passive and active movement, the problem is within the joint and/or tissues.
– Movement is either pass or fail. Pass is when there is no pain, no limitation, and no asymmetry.
– The directional preference is determined. More often than not, the DP is toward the pain. This DP will be the basis of further treatment.
– Palpations as taught in PT school and done by so many therapists, osteopaths, and chiropractors are not recommended. Palpation is unreliable as there are many variations of the skeletal make up in each individual. This is something that I read a lot on twitter and I’m so glad to hear Dr E validate it.
Here is another thing that I appreciate with the Eclectic Approach. The treatment is simplistic, evidence based and no magical or mystical. For rapid responders, which is like 80% of patients we see in the clinic, you can see immediate progress in just few visits.
Here is the sequence of treatment as I understood it. In clinical setting I’m sure there are going to be some variations and overlaps.
- REPEATED MOTIONS AT END RANGE
While repeated motions to end range is a part of the assessment initially, they can be done periodically to see if the pain diminishes, centralizes, don’t change, or peripheralizes.
Here are what The Ecelctic Approach utilizes to get to the end range:
– Dr. E’s use of spinal manipulation is very simple. He follows non-specific spinal level principle which I have also read in another’s work before, as backed up by research. Biomechanically, if one level of spine is manipulated or mobilized at least 6 levels above and below it also moves thus specificity in manip is not really important.
– Spinal mobilization and trust manipulation have the same effect according to research. Manipulation is simply quicker and less painful.
– Instrument assisted soft tissue mobilization with the use of The Edge tool which is designed by Dr. Erson himself is an effective way to diminish muscle tone and relieve pain by activating the mechanoreceptors in the skin.
– Unlike similar techniques like AYSTM and Graston which uses aggressive forces, IASTM is very gentle. Fascia and scar tissue are very strong and need at least 100 lbs load to deform it. Or might as well use a scalpel to break it down.
3. MWM [Mobilization With Movement]
– Brian Mulligan’s concept of Mobilization with Motion on the extremities and Sustained Natural Apophyseal Glides [SNAGS] in the spine where the joint is taken to its pain-free end range and mobilized.
– Glad to hear Dr. E say that PNF is not only for neuro rehab, meaning patients with stroke, SCI, etc. But the again, orthopedic patients are also neuro patients in that pain is mediated by neural pathway.
– MET which is an osteopath technique is actually similar to PNF in that resistance is applied to while muscle is contracting. The difference is the very light force used. That’s why Dr. E fondly calls MET a fancy PNF.
– I was at another seminar and a clinician next to me hears of MET for the first time. When the techniques is demonstrated he whispered to me “Just like PNF!”
5. Diaphragmatic Breathing
– Diaphragmatic breathing is used simultaneously with resets. You’d be surprised how movement improves when diaphragmatic breathing is executed properly while doing repeated motions.
– Diaphragmatic breathing activates the pelvic floor. The PF when inhibited recruits surrounding muscles like the piriformis, glutes, and hamstrings thus causing limited hip motions.
– Resets are exercises performed to get a joint to end range, improve ROM, improve function and improve motor control.
– Resets include the following parameters: repetitions, end range, and holding the position for some time, say a minute or two.
– His you tube channels are full of sample videos of resets of various muscles and joints.
- The HEP [Home Exercise Program]
– HEP prescriptions are also very simple. Mostly repeated motions at end range using the DP.
– HEP is only limited to 1-2 exercises to make the patient compliant and to easily assess which exercises is not working.
– Exercises are done initially 10 reps every hour. If pain limits motion, 3-5 times every 30 minutes or so is recommended.
– Patients are educated to do their HEP as prescribed to lock in the progress attained during treatment sessions.
This is just summary of what I’ve learned from the course. There are so many things to say but would be long and difficult to put them into writing. Suffice to say that the assessment and treatment approach to orthopedic manual therapy by Dr. Erson’s The Eclectic Approach is simplistic, doable and evidenced based. There are many clinicians that I follow on facebook, twitter and the blogsphere who like to complicate the physical therapy practice I have often wondered if I can be even just half as good as them. It’s refreshing to hear somebody introduce something simplistic yet highly effective.
As already a follower of his works through his blog and forum, I have more or less used a couple of his technique in treatment [but not assessment since I haven’t really had training in movement-based assessment before]. As I hear him teach face to face, with lots of interactions with him, I have finally come to understand the things that I could hardly understand just by reading his blog and watching his short videos.
I’m also so glad that somebody has yet validated the fact that palpation as an assessment is unreliable. I’ve been studying movement as primary means of orthopedic assessment, and I hope to write a blog about it.
After this course, I know what succeeding courses, workshops and seminars to focus on. I’ve always wanted to take an in-depth courses in MDT and SFMA but it’s almost impossible to find one in Asia. I just have to pray harder…
And since it’s called an eclectic approach, one can still incorporate other treatment techniques that we are already accustomed with. Treatments that we have already been using and found to be effective.