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
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
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
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
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
I recently saw a social media post entitled “Prone Exercise Progression for Low Back Pain.” If only it were that simple! There is no "prone exercise progression" for low back pain. Prone exercises are used for certain diagnoses with certain patients. Pain, after all, is not a diagnosis. We don’t treat heart pain or lung pain - we treat the underlying diagnosis. Will I allow that there are rare cases in which we can’t establish a true cause? Sure. But in those cases you get there by ruling out a multitude of possibilities.
Not only can we do better than treating the symptom of pain, but we can be specific about what each individual needs. A prone exercise progression will help some people with some diagnoses. It will also do nothing for some people and will make some people worse. You can try whatever you find on the internet if you want. We all do it from time to time. But success is more likely when you have an individual diagnosis and plan. -- Laura
As I've written before: most orthopedic answers lie in moving people in directions they don’t usually move into. Top of that list? Yes: extension. How often do you bend your low back all the way back? Your neck? Your shoulder? Your hip?
But that doesn’t mean all problems are fixed with extension exercises. (Taking a step back, not all orthopedic problems are fixed with movement. Over 90% are, but that leaves room for conditions that require different interventions.) A person who responds to exercise, may need repeated rotation, side glide, side bend, flexion, or any combination of movements. I look for the exercise that positively affects a person’s symptoms, movement, and function. It really can be put that simply. While most need some form of extension, there are dozens of potentially therapeutic exercises.
Robin McKenzie did not invent the exercise of extension, but, as far as I know, he was the first to regularly explore if repeated extension (in its various forms) could be therapeutic. It’s really a shame that students (and others) have the notion that there are Williams flexion exercises and McKenzie extension exercises. It is not only an oversimplification - it is wrong. I am having one patient now perform lumbar flexion for her home program - and applying the McKenzie method to her problem is what got me there. -- Laura
I remember thinking years ago how odd it seemed that people’s joint pain (often occurring for no known reason) would be addressed by simultaneously stretching muscles, moving joints, strengthening other muscles, and changing posture (plus ice, heat, US, etc). It didn’t seem logical that all of those pieces fell perfectly into disarray, leading to pain.
Does it make more sense that joint immobility and muscle tightness and weakness led to the impingement, or that the impingement led to those findings? What I find more rational is that a joint impingement, a joint derangement, or, simply put, a joint that’s a bit stuck occurs because, well, joints are mobile things and these things happen. The most obvious example is you unknowingly sleep in a certain position and you wake up with stuck neck joints. Or your shoulder joint gets impinged because you repeatedly move in a new way starting tennis again. Or your low back gets deranged because you sit in the exact same position in your office chair for hours a day. These factors and others can easily lead to minor (fixable!) joint disruptions. In fact, most of these examples, especially the neck scenario, will resolve with daily movement (and possibly a little rest) on their own - no doctors or other help needed.
I deduce in the clinic if a joint is impinged/not moving optimally by repeatedly moving joints and gauging the effect. I don’t rely on “impingement tests.” I secondly don’t believe in the value of imaging except for a small minority of cases. It’s much more likely that the bony configuration of your joint (eg shoulder acromion or hip acetabulum) has been that way, if not your entire life, then most of your life, and therefore this new pain is due to new factors.
To address it, in contrast to the stretching, strengthening, and movement I alluded to above, we look for the specific joint movement that unpinches the joint. It’s typically one that is not regularly performed in the person’s daily life. The theory as to why these things occur is that it’s normal for joints to get a bit stuck if you don’t move them in a variety of directions or if you spend the majority of your time in one uninterrupted direction. They’re so common that most self resolve, but I see the stubborn ones. -- Laura
It’s easy to be misguided by immediate results from an intervention, whether the intervention is movement or something else like heat. For example, if we do 20 knee extensions in semi-loaded and you gain significant range in your obstructed knee flexion, that could be due to a few factors. One, I am just “warming up” the knee joint (or whatever structure(s)) so now we get more mobility. Meaning, if we do anything that moves the knee a lot, we’ll get more flexion. Or, two, extension in semi-loaded is truly the specific, necessary exercise for this knee to unlock flexion.
There are ways to answer this inquiry. For one, if we then wait several minutes with the knee resting, we can re-test flexion. After resting, if the gains remain, it’s less likely the factor was simply being “warmed up.” Similarly, if the person does that extension exercise over a few days at home, we should see improved flexion out of the gate (when “cold”) on the next visit. And, if we do a separate knee exercise 20 times and flexion does not improve or worsens, then we know there is something special about semi-loaded knee extension for this particular knee.
It’s not uncommon to see great changes in the clinic that don’t hold up over several days of repetition. That’s fine. It was prescribed as a home program to see the effect, not as a cure. That response tells us a lot of information regarding diagnosis and what to do next. But don’t persist if you see any type of positive change that, over time, just doesn’t stick. Sometimes that simply means the positive change that initially occurred was due to a general “warming up” phenomenon. Now look for the intervention that can create lasting positive change. --Laura
Once we find the direction a joint needs (its directional preference), we must establish the protocol. A rule of thumb is 10 repetitions every 2 hours, but it needs to be tailored to people’s specific situations. There are many parameters when it comes to the home protocol, mainly total volume, repetitions per set, sets per day, frequency, cadence, and time.
For me, frequency is the most significant - how regularly the exercise is performed throughout the day. Of course the other dimensions matter, but if I had to choose between 100 repetitions at 9:00am, 25 reps in the morning plus 25 reps in the evening, or 5 reps performed frequently (say every 3 hours), I would choose the final option. The reason is simply that in the intervening time people move their bodies, their joints, in all different directions. Doing the exercise regularly in effect “resets” the joint to the desired position. So if 6 hours or 3 days passes, when the exercise is revisited it’s more likely there’s more “resetting” to do. It’s as if the boulder rolled farther down from the top of the mountain and now there’s more to overcome. With high frequency, we want to keep the boulder from rolling down too far and eventually keep it set where it should be at the top of the mountain. This is not my exact mindset when I approach muscle, tendon, nerve, capsule, or other problems; however, for those I diagnose with joint derangements, frequency is almost always the number one priority for improvement. -- Laura
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