“Opening” a joint is quite the buzzword! Each time you "open" a joint in one direction, however, you are simultaneously "closing" it in another direction. True opening, if you will, occurs when a joint is pulled apart via traction. Don’t get me wrong: I love moving joints fully in specific directions. But I suggest we need to comprehend what we’re actually doing. Using fancy terms is fine, but it can perpetuate or create the wrong idea.
The seated butterfly stretch/position, for instance, does not “open” your hip. It opens the anteromedial (front middle) aspect of your hip to an extent, but it also closes the posterolateral (back outside) aspect to an extent at the same time. Examples abound.
It’s worth considering, as well, that if you open in one direction and then do an opener in the opposite direction, the two may cancel each other out in certain circumstances. By no means does that apply to every case, but if you’re hoping to achieve something measurable, you need to see if this counteracting effect is occurring and thwarting your progress. -- Laura
A prescription for someone's hip pain may be: single leg stane on a BOSU with hip abduction, core stabilization on a physioball, soft tissue release of the psoas, Turkish get-ups, hip long axis traction, hip extensor strengthening, IT band foam rolling. My prescription for this patient may be: loaded hip extension. This is not an exaggeration. This is a representative example of what a patient might get for his complaint of hip pain with other clinicians and what I often give patients with a complaint of hip pain.
The logical question is why does this happen? The answer lies in the fact that I look at the neuromusculoskeletal system differently than other clinicians. Compared to 10 years ago, I evaluate differently and diagnose differently now. Ergo, I prescribe different treatment plans. I find that most orthopedic disorders are joints not moving well and therefore the treatment is specifically directed at getting them to move normally again.
Is there a scenario in which I would prescribe all those things in the first example? Maybe, but I can’t imagine that case. I know those things exist if I need them, though, because I used to employ them.
If I diagnose nerve compression or irritation, the treatment is removing the compression or irritation, whatever that is. Once that is removed, the nerve should move normally again. If I diagnose nerve restriction (or tightness), the treatment will include things such as nerve flossing, gliding, or mobilization to get the nerve moving normally again.
I make the diagnosis by repeatedly moving someone and assessing the effect on the nerve. (Compression either can or cannot change rapidly; tightness will not change rapidly.) They are very different phenomena, and of all the nerve-related problems I’ve seen, the large, large majority are compression/irritation problems.
A main problem I see in orthopedics is that clinicians diagnose nerves as tight when in fact they’re compressed. The analogy I always give is that you don’t want to pull on a hose when someone’s foot is on the hose. You want to get the foot off the hose. Effective care starts with correct diagnosing.
When treating the diagnosis of joint derangement, full resolution necessitates moving a joint to its end range. While there are of course norms for how far joints move in each direction, individual differences exist. An easy way to conclude if you’re at end range or not is to ask: Can I go any farther? And: Am I getting the desired result? In some cases we need external force to get a joint to its end range such as self overpressure, mobilization, using a wall, belt overpressure, etc. (Picture using your hands to pull your knee to your chest to achieve end range hip flexion in the unloaded position.)
Getting to end range is not a hallmark feature in the treatment of other diagnoses, but it’s usually a component. It’s a component simply because you want to ensure that with any orthopedic disorder joint mobility is not compromised. Considering joint derangements are roughly 80% of orthopedic disorders, repetitive movement to end range plays a big role in what I do.
Preventatively, I advocate for moving joints to end range all the time in order to ensure that the available motion is maintained. It’s important that your knee can get all the way straight! And that your neck can rotate all the way! Additionally, if you regularly move your joints all the way to end range, you’ll be able to pick up on any deficits soon after they develop – which you can address yourself if you have the skills or you can get help before it becomes a bigger problem. -- Laura
Five repetitions of a certain movement can make things worse, better, or have no effect. Same with fifty reps. Same with five hundred reps. That's the point of repeated movement testing: you don’t know if all someone needs for his orthopedic disorder is movement in one direction until you thoroughly investigate. Unless things are getting worse, you typically don’t have your definitive answer in just fifty reps. Too often people get these convoluted treatments for their orthopedic, movement-based disorders, when they just need someone who can figure out which movement they need based on how their symptoms and movement change with various movements. If a patient needs a specific movement to fix his problem, we say he has a directional preference.
Here are some examples of repeated directional preference movements I use for both testing and for treatment: loaded elbow flexion, unloaded knee extension, cervical right lateral flexion with overpressure, ankle dorsiflexion mobilization, lumbar sustained left side glide, shoulder internal rotation with belt overpressure, wrist extension with radial deviation, loaded hip external rotation. There are dozens of other ones. I use an algorithm based on the verbal history and physical exam to decide which movement to test, how long to test it for, and which movement to change to if needed. If clinicians and patients abandon a movement because there is no obvious positive change with fifty reps, they may be abandoning the movement prematurely - repeated means repeated.-- Laura
You’re assessing, assessing, assessing to arrive at a diagnosis. And then even when you think you have the diagnosis, you’re assessing, assessing, assessing to make sure you’re on the right track.
I want a plan that helps; that goes without saying. But when you’re figuring things out, you want to know about any and all effects - helpful, harmful, or indifferent. In order to get to the helpful plan, we need to understand what’s going on, which importantly includes knowing what tests and/or treatment strategies have no effect or which ones make you worse.
If a repeated movement has no effect, that might make me think there’s more likely a tissue problem instead of a joint problem. Or that we have a joint problem that needs more force, or a different direction. If repeated movement in a particular direction makes things worse, then it is more likely you have a joint derangement, and now we have information about which direction would be helpful. Knowing that something we test has a negative impact (on pain, movement, etc.) is just as powerful as knowing something has a helpful impact.
All of these pieces - all of these effects of repeated movement tests combined with the verbal history and physical baselines (as well as any other necessary diagnostic tests) - help us understand what’s going on. There are dozens of these puzzle pieces, by the way! And the faster we know what’s going on, the faster we can hone in on the treatment you need. -- Laura
I contributed to a piece the McKenzie Institute USA did on the myths surrounding the McKenzie method. Check it out here! -- Laura
The Main Point Isn't That Most Mechanical Disorders Can Be Fixed With Movement. It's That Most Orthopedic Disorders Are Mechanical.
Diagnosing a problem is always the most important step. Then you match the treatment to the diagnosis. When we diagnose orthopedic disorders we can think of 3 main categories: mechanical (or functional) problems, structural problems, and inflammatory problems. A huge problem I see in medicine is problems being diagnosed as structural or inflammatory when in fact they’re mechanical.
What do I mean by mechanical? Problems that are affected by movement, usually fixed with movement, and, significantly, not structural or inflammatory. My skill set is in treating these problems, which are >90% of problems. (My skill set is also in diagnosing which problem you have to begin with. If it’s structural or inflammatory, I refer you to a clinician who treats those.)
A structural problem is like a fracture, tear, stenosis, or dislocation. They cannot be fixed with movement; they need a separate treatment approach. I’ll say this again: very often people’s tears, etc. are diagnosed as structural and recommended a structural-problem solution like surgery when in fact the tear is not structurally unsound. Instead, the tear is causing or is related to a mechanical problem, which can be fixed with movement. People move and function just fine with “structural” problems “diagnosed” by imaging all the time!
Inflammation won’t be fixed with movement. In the acute stage inflammation can often be fixed with rest/time. In a sub-acute or chronic phase, other anti-inflammatory treatments may be necessitated.
Some may argue that central sensitization is its own category, which I'm fine with. But a central processing problem such as that may be better classified as a neurological versus an orthopedic disorder. There’s room for debate.
When I assess patients I’m asking: is this mechanical, structural, inflammatory, or other? By asking the right questions, listening, and expertly moving patients (when safe), we can figure it out. If someone has a structural or inflammatory problem, they won’t get better with movement. But they are the outliers, and you have to use repeated movement testing (when safe) to discern if someone’s tear, for instance, is truly a structural problem or a more easily fixable mechanical one. -- Laura
Here’s an example. If I have you bend your knee 30 times and then we assess and you have more knee bend, well, we’ve observed a change. But what if we’ve changed your knee straightening ability as well? Whenever I move a joint in one direction repeatedly a crucial thing for me to assess is if we change motion in the other directions of the joint. If you didn’t know what to assess you could incorrectly believe that since we assessed and observed a positive change (increase) in knee bend, performing the knee bend is beneficial - when it’s actually not.
Here’s another example. Say I move your low back into extension 30 times and I want to know if we’ve changed your three ankle baselines (findings). While it’d be great if all three signs changed with 30 extensions of the low back, I want to prioritize change in the “easier” signs first. That is, the baselines/findings I deem most likely to change first versus something more demanding that will likely take more reps over time. For instance, I’d expect range of motion or strength to change before I’d expect hopping ability to change. If we move your lumbar spine in order to assess the effect on your ankle, I also want to test the impact on your lumbar spine’s ability to move in other directions (as I explained in example one).
So, we can, and want to, observe change using cause-and-effect analysis for orthopedic disorders. But, more important than just observing change is observing change in things that matter the most at the time, the pieces that tell us the most information. That’s what expertise is. -- Laura
Most, if not all, people can recognize that the food you eat influences your health and that many health problems that arise can therefore be addressed with changing what you eat. If, however, diet seems too simple to be effective, then I understand why movement likewise seems too simple to be effective. After all, Americans have been conditioned to believe that fixing health problems necesitates solutions based on chemistry, technology, and devices.
I say leave all the fancy gadgets like laser, needling, and cupping for the small, small minority of people who need them for their orthopedic disorders. It’s worth pointing out that even with all the recent technological advances in the fields of medicine and orthopedic medicine, it’s a hard argument to make that overall outcomes are any better. Metabolic disorders and orthopedic disorders currently represent major problems in this country. Specific food is often the answer - and specific movement is too. -- Laura
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