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
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
Your abdominal muscles (in the front of your trunk, not in your back) do the real work when it comes to sit-ups. Many structures are of course still involved with this exercise, though, as with any movement. When someone tells me that sit-ups hurt his back my thought is that repeated joint activity (flexion) causes his back pain. With sit-ups, the spinal joints flex, or bend forward. If repeated muscle activity was the problem causing the pain, we’d expect the pain to be in the abdomen, where the muscles actually are.
Location of pain and provoking factors are just two pieces of the puzzle when it comes to diagnosing, but they do tell me two important things. One, in this scenario the person likely has the diagnosis of joint derangement (versus a muscle or other problem). And, two, it’s unlikely the person will need spinal flexion to get better, since it is clearly provocative. (Thus it’s more likely he’ll need another spinal direction to get his joints working properly again - and therefore be able to soon tolerate all the flexion in sit-ups.) -- Laura
People clearly have differing ideas, but, even when presented with the same information, people can interpret it differently based on their currently-held worldview. Here is the most classic example I can come up with in terms orthopedic thinking: shoulder impingement. The predominant worldview (in the US at least) is that muscles, joints, tendons, and neural patterns around the shoulder are functioning improperly as a unit and therefore during overhead movements the subacromial space is impinged causing pain. My view is that in over 90% of cases one specific thing is not working correctly.
The prevailing treatment for the common worldview is simultaneously stretching or releasing one or more muscles, loading certain tendons, strengthening many muscles, and moving certain joints. I remember I used to give patients at least seven things to do at one time when I had that belief system, which I was taught.
My current view is that most patients need to move just one particular joint or tendon. That particular movement is often, but not always, included in the array of movements listed above, which is interesting but not surprising since the normal treatment includes so many things! So if people get better with the standard approach, people believe it’s correct.
My understanding now, however, is that the reason they got better is because they included the one thing they needed - and the rest was superfluous and, at worst, a waste of time and resources. My patients with shoulder pain with overhead movements almost always get just one exercise to do at a time, which may or may not change over time. (For me, what other clinicians diagnose as shoulder impingement, I diagnose as several different things: cervical derangement, thoracic derangement, shoulder derangement, and shoulder contractile dysfunction.)
It’s interesting to think about how our belief systems can inform how we understand the evidence. Clearly those who believe the predominant worldview and those who believe the MDT-leaning view interpret the fact that people get better with standard shoulder impingement treatment very differently. As I wrote recently: I am interested in what works, but I’m more interested in what works best. - -Laura
When atraumatic problems occur it's usually because a problem someone knew he already had has worsened, a problem someone didn't know he had has worsened, or a problem he or science didn't know how to test for and/or define has worsened. It’s not unusual that symptoms don’t become apparent - or symptoms don’t reach the threshold of impacting your life - until they’ve been percolating (silently or noisily) for years.
Does aging give you lung cancer, or does smoking every day for 50 years give you lung cancer? Does aging give you low back pain, or does a life moving around lacking full low back mobility since you fell off a horse when you were 11 give you back pain? Does aging give you severe headaches, or does growing up inhaling toxic fumes nobody knew were toxic give you severe headaches? Figuring out what causes problems is not necessarily easy, but it’s overly simplistic to attribute the onset of symptoms to a body simply getting older. There are normal changes associated with aging (in essesnce these diffuse changes are aging), and then there are problems. -- Laura
People often remark they have a "tight" or "stiff" joint. Most times people have joints that are actually tight in only one or more directions but perfectly fine in other direcctions. The distinction matters.
Whether or not a joint is restricted in motion in one or more versus all planes of motion is extremely relevant to diagnosing. I know what people mean when they say their joint is tight, but a quality physical exam will easily reveal the specifics, including in which direction(s) motion is limited, how much is missing, and the quality of the movement and accompanying presence of symptoms. Joints have many planes of motion such as flexion, extension, side glide, external/internal rotation, abduction, adduction, and others. Missing motion, combined with a verbal history and other physical tests, helps me know whether the problem is related to a muscle/tendon, the joint itself, a nerve, an infammatory process, and so on. -- Laura
I wasn’t taught that lumbar spine range of motion (ROM) included left side glide and right side glide in physical therapy school. Now, however, I find it’s an indispensable part of my lumbar evaluation. In addition to lumbar flexion and extension, I evaluate side glides as a part of the simple range of motion tests. With any range of motion test for any joint in the body, both quantity and quality are assessed. And just like with any spinal or extremity joint, motion that is lacking or painful tells me a lot about the diagnosis and potential treatment options.
I often use repeated or sustained left or right side glides as part of treatment if I diagnose a lumbar derangement. Side glides are tested in free standing (feet under the shoulders, legs straight but relaxed) by pushing the pelvis to one side as far as possible. The lumbar spine therefore glides on the pelvis. This can also be tested on the wall. For treatment procedures, the wall variation is used most often, but I have also utilized side glides in free standing, in a doorway, and in sitting.
One of the several goals of orthopedic care is making sure a patient has full and pain-free motion in all planes of the joint. Maintaining full and pain-free motion is key to preventing recurrence of symptoms as well. If you're not testing this side-to-side motion of the lumbar spine, I think you're missing a lot of important information and treatment potential. -- Laura
If a muscle is actually physiologically tight (versus feeling tight), it can only restrict movement when it is put on stretch/tension. So, if your left upper trap muscle in your neck feels tight and you’re missing left side bend but have normal motion into right side bend, the left upper trap muscle is not actually tight. A muscle like this on the left is put on slack with movement to the left and put on tension with movement to the right. Therefore, something ELSE - not the muscle - is the cause of the tightness feeling. That is, something ELSE is causing both the loss of motion in left side bend as well as the feeling of tightness in the left neck.
In this scenario, it is most likely that a joint in the neck is not moving properly – and that is the issue, the cause, that needs to be addressed. Joints that are not moving well can cause loss of movement in one or more planes of movement and can cause local symptoms or referred symptoms in other areas. The term I use for this diagnosis is joint derangement. It is addressed primarily with movement in a specific direction.
Just to be clear, it is rare that a muscle is actually physically tight, especially for no apparent reason. It is common, however, for muscles to feel tight as the feeling is referred from nearby structures such as joints. We can determine if a muscle is actually tight vs feeling tight with a thorough evaluation; we don't have to guess. The most obvious example I can think of when a muscle is indeed actually tight is when there has been direct muscle injury. As it heals, the scar tissue will be tight, as is its nature. With appropriate progressive movement, the length will be regained. -- Laura
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