There’s a reason why if I’m treating spinal pathology, or if I’m curious about the relationship of the spine to the patient’s extremity complaint, I a) only prescribe one movement at a time and b) assess the effect of the exercise on the patient’s baselines before allowing it. Even though you may think the spine is in neutral or is not moving when an extremity exercise is being performed, there’s a strong chance that the spine is influenced. Sidelying clams, biceps curls, squats, rows, leg lifts, as examples, can easily impact the spine.
It should go without saying that a strengthening exercise for a hip muscle influences the hip joint, a rhomboid exercise influences the shoulder, and a triceps dip influences the elbow. But we must not forget about the influence on other nearby joints, namely spinal joints. And we must be deliberate when assessing cause-and-effect to determine whether an exercise is warranted. It's not difficult to take spinal baselines, implement an extremity exercise, and then re-test to see if the spinal baselines have changed. Knowing to do that, and how to do that, is where the skill lies. -- 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
Nerves becoming trapped outside of the spine are much less common than people think. Commonly talked about examples include entrapment in the ankle (tarsal tunnel), wrist (carpal tunnel), elbow (cubital tunnel), buttock (piriformis) and forearm (pronator teres). If there is trauma to an area, it certainly makes sense that the nerves in the area can be injured and/or the healing process can lead to tissue “entrapping” the nerve. But, without significant trauma, it’s quite rare to see this phenomenon.
While many patients tell me they indeed have carpal tunnel (or whichever), they usually describe symptoms inconsistent with that diagnosis (ie they say it affects the whole hand). Furthermore, they report that no clinician has investigated movements of the neck and mid back as part of the diagnostic process.
The nerves that end up in your periphery are commonly irritated as they exit your spine. If someone has symptoms in both hands or in both ankles, the likelihood that the spine (or something systemic) is the source increases dramatically. So while I agree that peripheral nerve entrapments can exist, I can’t remember the last time I found this to be a patient’s true diagnosis. Getting the correct diagnosis is the most important step in getting better after all. -- 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
It is not uncommon to hear “My left leg is just not as stable as my right” or “I lack control placing my right foot on runs” or “My balance is much better on one side.” I haven’t encountered people voicing this about their arms, but it could certainly manifest in the upper body as well. I won’t say it’s always, but it seems like in all cases when patients have complaints about a lack of stability in one leg (not a specific joint, but the entire limb), it’s a spine issue.
Again, if we think of the spine as the fuse box, it makes sense that an irritated spine could create these somewhat vague complaints in the limb. While “instability” is usually a good, appropriate descriptor, it’s also often a lack of control, responsiveness, and/or balance. What I’ve seen people call “dead leg syndrome” on blogs is most likely an example of this too.
Don’t make the mistake I made. Years ago I noticed a marked difference in the stability between my right and left lower extremities. Leaning against the wall in the hospital one day with my legs about a foot from the wall, I could balance fine on my left leg when it was placed under my left hip socket, but failed miserably to do so on my right side. I spent close to a year doing relatively fruitless single leg strengthening and balance/coordination exercises. It got better, but not by much. Some time after that (having given up on making progress and having gotten into MDT), I remedied the issue with directional preference movements of my low back. -- Laura
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
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