How to Find Rapid Responders

How to Find Rapid Responders  
Often people like the manual therapist and others talk about finding rapid responder, which is a patient who can have a very noticeable improvement, if not full abolishment of their dysfunction in the matter of one or two visits.  And let me tell you there is nothing more exciting and rewarding than finding a rapid responder.  Now there’s several tools like MDT, SFMA, TDN,...add in your alphabet soup... that can find a ‘rapid responders’.  However, all these tools have something in common: they all rely on the ‘patient’s response model’.  My friend Harrison spoke on the Patient’s Response Model beforehand and its merit in finding consistent improvement, but in general it “simply utilizes the patient’s report of symptoms to assist you in classifying them into an intervention group”.  Today I want to break down a few specifics of the Patient’s response model that I utilize and in doing so assist the clinician in identifying the rapid responders. And just to add more letters I’m calling it the ‘S.T.A.R.S. Patient Response Assessment’. The STARS Assessment includes analyzing and synthesizing the following data from your patient to find the most appropriate intervention. STARS stands for:
Symptom Reproduction or Reduction
Tissue Tenderness
Asymmetry (significant) & Aberrant Motion
Resistance Testing
Special Tests and CPRs

 Now for a little more detail: 
S: Symptom Reproduction or Symptom Reduction.
Arguable the most important aspect of the patient response assessment. Here, you are trying to distinguish what movement(s)can alleviate/abolish/centralize/improve or worsen/reproduce/peripheralize.  The trick here is to look at a lot of motions and repeat the motion to see what happens.  Along with the acronym ‘STARS’, you can also perform your assessment in multiple planes like a star or asterisk (below). Using the eight pointed tape allows for more motions to be analyzed and expedites the overall assessment (ie it makes it easy to explain and for the patient to perform correctly).
Take for example the shoulder.  With the tape you can examine the change in symptoms during the crossover, diagonal forward reach, fwd flex, scaption, ABD, ER scratch, backwards diagonal reach (ie reaching back in car), pure extension, & IR scratch.  More movements=more data!  This can also be done for the hip and knee as well with movements like squat, lunge fwd and diagonals (to assess valgus), Y balance/reach backwards.  Another example for the back can include combining flexion with rot/SB couples towards forward diagonals or combining extension and rotation with one arm backward extensions.
Tissue tenderness (allodynia and hyperalgesia) & tone.  
Assessment of tissue quality may be done as well to examine for pain generating TrPs.  I personally try not to put my hands on the patient and start palpation until some movement assessment like above.  This way, I can see the multiple patterns that may be involved and think through what tissue would be involved in those motions functionally. This helps narrow down what tissue we want to focus on and where we will get the most bang for our buck with manual techniques.  It also allows us to know what direction  we want to work on ‘releasing’ soft tissue dysfunctions.
Asymmetry (significant) & Aberrant Motion
Along with measuring for change in symptoms during the STAR Assessment you can also test for the quantity (asymmetry) and quality (aberrant motion).  A few examples would include: the amount of perceived exertion compared to another motion, shifts and compensations during the motion, apprehension during movement, segmental hinging or lack of  a uniform arc, gower’s sign, and catching just to name a few.  This gives a wealth of knowledge towards motor control and muscle activation patterns. Improving these may give that quick response we are looking for.   
Resistance
Looking at AROM is very important but including the additional resistive ROM can add further insight:
  • Resistance can extenuate compensations noted with aberrant motion.
  • Resistive ROM compared to AROM can specify motor control issues.
  • Resistance at end range gives us information about joint integrity.  Further, resistance at mid range compared to end range will provide the clinician with a better understanding of how fundamental their motor control issues may be.
  • Additionally, resistance allows us to find out what patterns are involved and not assume overall strength is limited but just a consequence of guarding and protection in those specific patterns.
  • Resistance at end range, ie overpressure, can give information about joint end feel.  
Special Tests (and CPRs)
Special tests can be added throughout the assessment to assist with a musculoskeletal Dx vs Movement Dx.  Special Tests are often part of Clinical Prediction Rules which can add insight about possible interventions for us to consider.  
Not all Special Tests are pain provactors.  Tests like the ‘scap assistance test’ can direct us towards symptom reduction. So can something as simple as the cervical distraction test.

 I hope the STARS Assessment leads you towards finding more rapid responders!