The large majority of patients I see have problems that can be resolved with physical therapy. However, when evaluating a patient - or over several visits - it sometimes becomes clear that a different intervention is needed. For example, oral medication, injection, surgery, cognitive therapy, and so on. My first question to myself as a clinician is always, “Is this person in the right place?”
Physical therapy is a great place to start for most people complaining of orthopedic problems, though, given it is indeed where most people need to be and given it’s non-invasive and carries little to no risk. I say that at least 80% of people I see benefit from what we can do together. That is partly due to the fact that I briefly speak with patients first before seeing them. But I still see patients that do not respond and therefore make an appropriate referral/recommendation. No intervention treats everything. The objective is to get a quality diagnosis and choose the best intervention based on the diagnosis. I diagnose based on repeatedly moving the body, which I find to be most effective.
Can we at least agree that a muscle spasm creates a shortening of the muscle as it performs its action? When you have a true calf cramp your foot starts to plantar flex (point down). When your hamstring spasms, your knee bends. When your toe flexors cramp, your toes curl. And so on. (There can be many causes of these muscle spasms including musculoskeletal, nutritional, and others.)
So, if your low back muscles were in true spasm, they (primarily extensors which extend - or backward bend - your low back) should pull you into backward bend. Why don’t they? Because while you feel muscular symptoms, it’s rarely (I want to say never) a true muscle spasm. Instead, it’s pain referred from the nearby low back joints. These muscular symptoms can be horrendous, but they are driven by the joint; and once you start to get the joint moving correctly again, the muscular symptoms calm down.
Many patients with low back problems actually lean forward or are stuck forward due to the joint derangement, which further disproves the common theory that muscle spasm is the problem and is what needs to be treated. -- Laura
Inflammation is rarely the main cause of complaints. And before any symptoms are addressed with pharmaceutical anti-inflammatories or injections, a quality clinical exam must be performed. Typically a mechanical problem will be found - which is treated with targeted movement. While inflammation may indeed be present, it almost always resolves once the real mechanical cause is resolved. Inflammation is usually therefore a symptom (not a cause).
If a patient does not respond to mechanical care, chemical (anti-inflammatory) care may be indicated. I have suggested anti-inflammatory measures in just 4-5 patients in the past couple years. So if your knee keeps swelling, for example, the question is why. A joint disturbance (derangement) can easily cause consistent inflammation. So can any number of problems.
I clearly remember one patient years ago who had years of knee pain with episodes of swelling that got so bad she had it drained many times. An avid runner, she was sidelined. The issue was coming from her low back and after 5 visits of different movements, her knee was good to go. Once her muscles had their electricity restored in the spine they could control to the knee so it didn’t reactively hurt and swell. -- Laura
Regularly sitting for prolonged periods, especially slouched, can lead to orthopedic problems. But the problems arise almost always from joints, not muscles. I continually hear people (health professionals, notably) declare that sitting’s “shortened” position of the hip flexors can cause painful, tight hip flexors. Granted this doesn’t affect all sitters (nothing does), but if large amounts of time in shortened states can lead to painfully tight muscles, then where is the observable pattern? Why aren’t more biceps affected secondary to prolonged elbow bending? Where’s the complaint of painful anterior neck muscles as our heads are so often forward?
Though I make my case verbally, people won’t budge. It’s likely the only way to prove my point would be to demonstrate an evaluation and treatment of someone with this given “diagnosis.” In the absence of that, I put forth that, one, we have ways of clinically determining if this is occurring, which, importantly, involves ruling out joints and nerves. Two, if we consider joint mechanics, deranged upper-mid lumbar segments and hip joints can send referred/radicular pain to the hip flexor area. Deranged elbows usually refer pain to the medial, lateral, or posterior elbow. And neck derangements typically send pain posteriorly and laterally – rarely anteriorly. The deranged joint pattern is observable. --Laura
Here’s a list of exercises I may prescribe for a person who complains of shoulder pain. I’m sure I’m missing a few, but my point is to illustrate that “shoulder pain” is a symptom, not a diagnosis. There's no universal fix for pain in the shoulder just like there's no universal fix for head pain or chest pain. I evaluate the person, make a diagnosis, and find the specific exercise a patient needs. Patients almost always get just one exercise at a time.
-seated cervical retraction
-seated cervical retraction-extension
-seated cervical retraction-extension-rotation
-seated cervical extension
-seated cervical flexion
-seated cervical protrusion
-seated cervical lateral flexion toward
-seated cervical lateral flexion away
-seated cervical rotation toward
-seated cervical rotation away
[all of the above also in supine]
[all of the above also sustained]
-seated thoracic extension
-seated thoracic lateral flexion toward
-seated thoracic lateral flexion away
-seated thoracic rotation toward
-seated thoracic rotation away
-seated thoracic flexion
-prone cervical retraction
-prone cervical extension
-prone thoracic extension
-supine thoracic extension over a fulcrum
[all of the above also sustained]
-shoulder functional internal rotation
-shoulder internal rotation
-shoulder extension with internal rotation
-shoulder horizontal abduction
-shoulder horizontal adduction
-shoulder functional external rotation
-shoulder external rotation
-shoulder internal rotation in flexion or abduction
-shoulder external rotation in flexion or abduction
[shoulder exercises also with resistance]
-shoulder caudal glides
[all movements may also be performed as clinician mobilization]
If you are not well-versed in ruling out the spine as the source of an extremity symptom, you are missing roughly half of the sources of patients’ problems. This issue can be mitigated if the patient has been referred from someone whom you trust has already effectively clinically cleared the spine. Often, however, people with knee pain go directly to a “knee doctor” or those with numb hands visit a “hand doctor” who, in my experience, only examine that specific body part.
A system, an algorithm, is needed to ensure success in any paradigm. In my practice, experience and pattern recognition factor in, but a structured process directs my evaluation and treatment. Most importantly, a patient’s spine is investigated before moving on to an extremity. I’ll say we need to ensure the problem is not coming from a faulty fuse box (since so often it is). How long I spend on this inquiry can be minutes, it can be days - it depends on the individual case.
There is certainly a role for these professionals, but our current utilization methods need revamping. Let’s use extremity specialists only when it’s clear-cut that that intervention would be most effective for helping patients. --Laura
Try to know the source of your orthopedic information the best you can. There is a huge amount of incorrect information out there and, as this phenomenon illustrates, people who know very little yet think they know a lot. I am happy to share my education and my experience with people and can easily admit when I don't know something. (This definition and graph courtesy of Wikipedia.)-- Laura
I recently spoke with Jason Ward, host of the podcast Mechanical Care Forum, about my trajectory in the field of physical therapy and what drove me to start my own practice. Episodes #243 and #244 are linked below but can also be found via the Mechanical Care Forum Podcast on iPhones. --Laura
This is a lateral shift. A lateral shift of the low back (lumbar spine) joints. It's not a hip, pelvis, SI, or IT band issue. They're not always as obvious as this, so orthopedic clinicians must remove the patient's shirt to see it. It is not observable in lying; the patient must be standing. It is corrected (often painfully) by moving the low back joints in the opposite direction first. Usually that entails side glides against the wall or in free standing, and sometimes I need to assist as the clinician. Once the patient has free movement in both directions side to side, we restore extension and flexion of the low back. These are not that common, but I will typically see a few patients a month with a lateral shift.
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