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Treatment Sequencing: Making the most of what you have

                 There are times during clinical treatment, when you have to go with your experience and empirical evidence either because there is not a strong, researched based study to back what you do.  Or your clinical results stand for themselves.  Relying solely on research, or not being able to connect the dots, can leave you in a bind and drudging along with patient care.  One such topic that presents itself often when mentoring students, fellows, or colleagues is sequencing during treatments.

Sequencing of treatments:

                  In the presence of inflammation of a capsular tissue, the ability of that tissue to move dynamically from one direction in a straight-planed axis toward another is impaired if that tissue has been placed under a sustained load. This phenomenon is referred to as rebound pain.

Understanding the concept of rebound pain and thrust your clinical outcomes to a new level by reducing patient pain, improving the patients understanding of their condition, and proper outlining of their Home Exercise Program.

We have all seen it and been there.  Patients with the same condition, at the same timeframe, performing the same exercises, and one is on schedule with rehabilitation while the other one struggles to improve.  At times, it is easy to dismiss these differences as chalked up to compliance with the home exercise program or pathophysiological changes.  But what about considerations for what sequence those exercises are performed in?

Consider applying the rebound pain principle during your treatment.  One of the easiest examples is for rehabilitation of a Total Knee Arthroplasty.  Regarding tissue histology, full maturation of scar can occur anywhere from 5 weeks through 12 weeks.  However, in the presence of continued stress on maturing collagen fibers, this process can become delayed and present in the form of inflammation around the stressed tissue.  Sequencing can make a large difference in the amount of progress that you can make both intra-session and between sessions.  A basic outline of phases of sequencing treatments to address rebound pain can be defined in Initiation of Stretch (IS), Transitional Activities (TA), and Opposing Tissue Expansion (OTE). If the patient presents with altered gait and lacks ROM into extension, selecting a sequence of stationary biking, QS, squatting, step ups, prone hangs, SLR’s and heel slides might yield less than ideal results and more pain for the patient compared to a program selected sequence of prone hangs, QS, SLR’s, stationary biking (TA), heel slides, step ups, and squatting. This program begins with initiation of stretching tissues that may be limiting extension at the knee. A compliment of both manual therapy for low-load-long duration stretching and/or modality treatments may be used to prep the tissue for beginning the IS phase. Next, the stationary biking acts as a TA in an attempt to desensitize the tissues for working the opposite direction into flexion.  After the TA activity is complete, you can enter the OTE. After completing the OTE, the anti-inflammtory treatments can commence. If you find that the patient is unable to tolerate a straight knee for cryotherapy after this type of sequencing, then reversing this treatment program and finishing with achieving extension may be necessary to alleviate increased pain during the anti-inflammatory phase.

Sequencing should be considered for all tissues and joints that are showing signs of acute or sub-acute inflammation. I hope this information gets you thinking about how you can use sequencing your treatment programs and clinic and help you achieve improved results.


Eric M. Dinkins, PT, MS, OCS, Cert. MT, MCTA