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
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
Imaging can show plenty of things that are not related to people’s complaints. You need to move people to understand their problem. I am not against imaging when used under the appropriate circumstances. But imaging people’s spines (who have no red flags) before moving them to arrive at a diagnosis is plain wrong. Stenosis is quite normal with aging and is present on images of people with zero pain. Therefore, we know stenosis is not an automatic pain generator. If you have complaints and imaging shows stenosis, it holds that something else could be causing your pain. We don’t know until we move you. In my experience, the large majority of patients who have come to me saying another clinician diagnosed them with stenosis have done very well with therapy. In most of those cases, therefore, something else was causing their symptoms and their initial diagnosis was incorrect.
Scenario one. Your image shows stenosis. We move your spine and, despite the bony stenosis your image shows, you respond well to movement(s) and your symptoms resolve. [majority of cases in my experience]
Scenario two. Your image shows stenosis and, after we move you for several visits, it becomes clear that the stenosis is related to your symptoms. We discuss how we need just a couple weeks of specific movement to see if we can change any correlated soft tissue stenosis and impact your symptoms. We know that there is bony stenosis on the image but we still don’t know if bone or soft tissue is the real issue. Soft tissue we can usually change with movement, bones we cannot. After a few weeks your symptoms decrease or resolve so that no further intervention is desired/needed. [fewer cases]
Scenario three. Same as number two except, after the couple weeks of specific movement, your symptoms are unchanged. At this point we can integrate different strategies in therapy with goals of minimal to moderate overall improvement of symptoms - or you can have a surgical consult with the goal of more significant improvement. [fewer cases]
The point is we don't know which scenario applies to you until we move you. -- 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.
Centralization is a very important concept, and is well-documented in many research studies. Problems in the spine often cause pain/numbness/tingling in the extremities (legs, feet, arms, hands) as affected nerves carry symptoms along the distribution of the nerve. Centralization is when symptoms move toward the spine. This is a GOOD thing - even if the spine pain is temporarily more intense (before it goes away for good). By the same token, peripheralization is not a good thing. We don't want pain that is moving farther away from the spine into the periphery (extremities). Keep in mind that centralization also applies when left or right low back pain or left or right neck pain moves to the center of the low back or neck.
Not all patients will experience centralization. Some extremity pain just goes away without moving to the spine first. If you are receiving treatment or are just monitoring or treating yourself, remember to avoid things that peripheralize your symptoms and to perform the activities or movements that centralize your symptoms. When I treat patients with spine or extremity symptoms, I use specific movements to elicit centralization - and prevent peripheralization. If you experience centralization, you know you're on the right track!
When we bend forwards, the front of the vertebrae come together, moving disc material backwards. When we move backwards, the opposite occurs: the back of the vertebrae move together, pushing disc material forwards. Movement of the nucleus (the inside of the disc) within the annulus (the outer part of the disc) is normal - to an extent. Unfortunately, it is quite common for the nucleus to be pushed outside its normal limits, resulting in injury. This is typically referred to as a disc protrusion, a disc herniation, or a bulging disc. When discs move out of place, in most cases they bulge backwards or backwards and to the side. In rarer instances, the disc will move to the side, forwards, or forwards and to the side.
Why do discs bulge? The imbalance of forces on our discs throughout our lives is largely to blame. Did you know we bend forwards about 4,000 times per day? And about how many times do we bend backwards? I would say rarely, if ever. Considering that sitting in a slouched posture is also bending the spine forwards, we tend to spend a great deal of time with our spines bent forwards. This not only creates a severe imbalance of forces on the disc, it also overstretches all the supports that are designed to keep this from happening. Is it any surprise then that one day the disc will move far enough to hit something it shouldn't and cause symptoms, signaling to the person that there is an injury? This is why many patients do not report a traumatic event that created their back or leg pain. (Or, in the neck, their neck or arm pain.) Generally, the injury was years in the making, and then one day the disc went farther than usual and hit pain-sensitive structures, such as a nerve.
Keeping this anatomy and biomechanics in mind, it follows that to fix an injured disc, patients will RARELY need to perform exercises that bend their spines forwards. (Examples include touching your toes, child's pose, downward dog, crunches, single or double knee to chest, or the figure four stretch.) INSTEAD, most patients need exercises that bend their spines backward, such as standing back bends or lying extension exercises such as cobras or upward dog. Ultimately it is my job to diagnose the patient's injury and then choose the SPECIFIC exercise for that patient that allows him/her to get back on track. -- Laura
I realize I sound like a broken record, but I can't stress this enough: just because something is identified on an x-ray, MRI, or CT scan, does not mean it is causing a problem! Because so many people WITHOUT symptoms have abnormalities, it's clear we can't use imaging to diagnose orthopedic pathology. Instead, patients need a clinical exam in which the structures of the body are stressed in order to determine what the root of the pain/numbness/tingling/etc. is. This chart has some great statistics! Say you're over 40, for example: there's a 68% chance some of your disks are degenerated, a 45% chance some disks have shrunk in height, a 50% chance some disks are bulging, and a 33% chance some disks are protruded. These spinal changes are therefore quite normal as we age and are not necessarily correlated with symptoms. -- Laura
Ever wonder why so many people have their discs move out of place? There's almost double the amount of pressure going through the discs in the low back with slouched sitting compared to standing - not to mention really slouched sitting. And with the amount of sitting most Americans do, all that force can be a recipe for disaster. -- Laura
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