When clinicians think of joint mobilizations, they think of clinicians moving joints at the level of the joint with their hands, which is true. This applies to the spine as well as the extremities. However, joints can be less-precisely mobilized - or moved - without that specific technique. In fact, if my goal for a movement is to move a joint versus, say, stretch something or strengthen something, I call it a joint mobilization. More loosely, we can just call it a movement or an exercise, but the intent is what matters - and the intent is to move the joint in a specific direction (its directional preference).
Sometimes the technique or the force applied by a clinician via mobilization or manipulation is necessary temporarily. But in the large majority of cases diagnosed as joint derangement, patients can learn how to mobilize themselves. In the trickier cases, we might have to figure out how to get assistance from some equipment at their home or from another person. When mobilizations (with or without a lot of force) are necessary as treatment, the results will be better the more often you do them. That said, in order to get those reps, it’s imperative we teach patients how to self-mobilize the best we can. The McKenzie method is predicated on teaching people how to self-treat in order to improve outcomes. My hands aren’t magic and I’m here to teach. -- Laura
If the diagnosis is a structural problem, then the location of pain is almost always where the structural lesion is. Structural lesions with bones, muscles, tendons, ligaments, discs, cartilage, and menisci create local symptoms. The main exception is when structural lesions occur with nerves, in which case symptoms can travel along the nerve. So if what you suppose is a problem in a structure changes location, it’s more likely that instead of there being a problem with the structure, there’s a problem with how things are functioning - which is the majority of problems. With functional problems (that is, something is not working well instead of a structure actually being broken), it's common for pain to change location. Muscle strain, tear, pull pain doesn't move. It's where the strain, tear, pull is. -- Laura
Perhaps if people consider common “medical” problems, they can better understand musculoskeletal problems. While a cough may feel like it’s coming from the throat, plenty of things can cause a cough. It can be due to a problem in the stomach, lungs, sinuses, nose, mouth, or throat. A quality verbal history and evaluation will steer the clinician’s investigation into the cause (diagnosis).
While your knee may hurt, plenty of things other than your knee can cause your knee pain. While your hands may be tingling, plenty of problems other than hand problems can cause that tingly sensation. While your shoulder may not rotate, there may be a cause other than your shoulder. While your calf muscle may be weak, there could be a cause other than your calf muscle.
Signs and symptoms such as a cough, pain, paresthesia, decreased mobility, and weakness are pieces of data which help us understand the problem. The location of signs and symptoms is not necessarily the location of the diagnosis. -- Laura
If you have surgery to repair a broken foot and then it hurts or rebreaks after you decide to go jogging prematurely, does that mean the surgery was ineffective? If you have a wound cleaned out and you decide, against orders, to go for a swim and it gets infected again, does that mean the debridement wasn’t effective? The intervention is the surgery, but it’s also the instructions that come with it. The intervention is the wound debridement, but it’s also the accompanying directions.
With physical therapy interventions I tend to give patients 1-2 things to do as well as 1-2 things to modify or avoid. Could I give more things to do and more things to avoid? Yes. But people don’t tend to follow a longer list of instructions, so keeping things simple is key. Say, though, to fix your elbow pain you seem to need repeated elbow extension and you wake up one day and symptoms are worse. We need to be critical thinkers. Is it possible the intervention of elbow extension is wrong? Yes. But if you were good before bed and you woke up worse, it’s more likely that sleeping interfered with your intervention rather than the intervention is wrong. When sleeping, we adopt postures unconsciously. It’s quite likely your elbow was simply in a position that made it worse. We need to figure these kind of things out.
There are plenty of examples of things that can interfere. It’s hard to foresee and prevent ALL things that may impede an intervention from working. But when they arise, we need to recognize them for what they are and not simply disregard an intervention that has the potential to work if given the right circumstances. -- Laura
There are diverse opinions when it comes to orthopedics. And you should feel free to explore the myriad thought processes, approaches, opinions, techniques, etc. But when your goal is to fix something, you need to focus on one approach. Let one chef take over, even if just for the time being. Not only does that allow you to focus all your time and energy on the game plan in front of you, but it, most significantly, gives it the greatest odds of success.
If I want someone to repeatedly flex his spine, but another clinician wants him to repeatedly extend it - well, those are obvious contradictions. Doing both at the same time in this example would make zero sense and would preclude either approach from working. Outside of obvious examples, though, there are more subtle ways that things get derailed. For instance, if I tell someone she has a terrific prognosis if we follow these four steps, but her primary care physician keeps telling her therapy won’t help because the x-ray looks bad, then things often stall.
Research all the different options first if you really want to, but give just one approach, just one clinician, the title of head chef at a time. If it’s concluded that another perspective is needed, then you can move on. As the saying goes: we can't have too many cooks in the kitchen. -- Laura
It’s not uncommon that sleeping makes problems worse. That is, symptoms become exacerbated and/or movement becomes limited. Morning stiffness to a small extent is allowable when it comes to spinal flexion, but, otherwise, after being up and about for a few minutes, you should have the same amount of mobility you went to bed with.
During sleep, we often spend considerable time in one position without moving - whether we want to or not. It is my opinion that most orthopedic problems are related to movements and postures, so it makes sense that, just like with sitting or walking, sleeping postures can easily make people worse (or better).
If the thought process is that people need muscular strength to “hold” or “stabilize” joints in the right position, then there must be profound weakness if the simple act of sleeping causes joints to destabilize. Similarly, sleeping should not be aggressive enough to strain/pull muscles.
My thought process is this: I agree healthy joints should be able to withstand prolonged positions while sleeping, but I don’t think the answer is muscle-driven stability. And I don’t think muscles get pulled in our sleep. Benign positions like sitting or lying can indeed move joints - regardless of how much muscle is nearby. And these subtle changes can commonly cause symptoms. On the whole, strength is wonderful, but I believe we need to get the joint better first by moving the joint itself.
It’s true that spinal discs enlarge when we lie down to sleep, and that may be the sole factor why someone has more pain and/or less motion upon waking (vs related to any certain position). But even if that is the causative factor, then, again, I want to primarily address the disc (part of the joint) versus address the musculature around it. It’s also true that not all orthopedic problems are joint problems. Sleeping on a painful tendon can worsen symptoms, too. But most problems do have to do with joints - and addressing them effectively is important. -- Laura
Here are the top four reasons I can fix my orthopedic problems quickly. One, I address them as soon as they happen. Two, I know what to do. Three, I know what temporarily not to do. And, four, I have confidence in the methodology. I think the fourth reason is the most salient. I don’t get sidetracked by an uncle telling me to just get a shot. Or another clinician giving me his/her two cents. Or Google recommending medicines, oils, or any number of theories and movement programs. We all have aches and pains from time to time. By understanding orthopedics and how to approach problems methodically and effectively, even if I know my recovery will take some time, I know the prognosis, don’t have fear, and don’t waste time on unnecessary interventions. -- Laura
A lot of health measures take time, but we don’t often consider them nuisances. For one, because they’re normalized habits and, two, because we easily recognize their value. Many of these revolve around preventing infection. Our musculoskeletal system benefits from daily or at least regular attention as well. Is checking your motion or performing certain movements cumbersome? Well, it does take a few minutes. But if you value bathing and hand washing and devote time to those, you can also value the health of your joints, tissues, and nerves. The choice is yours - and, to be clear, it is a choice. (No equipment is required.) Like infections, musculoskeletal disorders cannot be 100% prevented, but “inconvenient” preventative measures (not just exercise) go a long way. -- Laura
If neck, mid, back, or shoulder blade symptoms are worse with driving or after driving, it’s worth considering your car posture. The same applies to symptoms anywhere in the head, face, shoulder or arm, all the way to your fingers. (The lower portion and bottom seat can play a role in low back and leg problems.) Most cars put the mid back in flexion and the neck in flexion and/or protrusion. In other words, the mid back joints are rounded and the joints of the neck are either bent forward or pushed forward.
If a posture has no effect on symptoms while you’re in the position nor after, and if your movement ability is not negatively affected, then there’s no problem. For a lot of patients with upper body complaints, though, posture in the car does warrant discussion. Many patients note driving is exacerbating and many patients spend a fair amount of time in their cars. The good news? With all of the patients’ cars I’ve assessed, adjusting the ergonomics of the car is easy and inexpensive. The theme is usually (if not always) to get the upper body straight, not flexed. The hardest part is for patients to get used to it - but that beats symptoms! -- Laura
Sometimes the neck isn’t just the neck. Movements affect joints of the neck in distinct ways. When you're at rest in sitting, for instance, the lower cervical is typically in flexion wheras the upper cervical spine is in extension. The designation into three separate sections (upper cervical, mid cervical, and lower cervical) is helpful. Retraction and extension target different parts differently, as do protrusion and flexion. Retraction-extension is not identical to pure extension. Lateral flexion in neutral is different than lateral flexion in retraction. And so on. As I believe most orthopedic disorders are fixed with specific movement, I am specific when it comes to finding that particular movement. -- Laura
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