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
If I had to pick the one most important thing for preserving musculoskeletal health it would be maintaining full lumbar (low back) mobility. Of course it’s optimal to have normal mobility in every joint (including the mid back and neck joints) as well as normal strength, normal nerve length, and normal movement patterns throughout your body. But if I take into consideration prevalence of pain, amount of potential disability, and level of contribution to other disorders, then - if I had to prioritize one thing to focus on - maintaining low back mobility rises to the top.
Pain in the low back is one of the most common complaints among people, typically recurs, and often creates significant disability. Significantly, if a low back is not moving well then it can cause or contribute to any number of disorders from the low back down. A low back that is not moving well makes it hard for the lower extremities to move well (not to mention the rest of your spine) and can also cause the nerves exiting the low back to become irritated/pinched/compressed. Since these nerves control the lower extremities, if they are irritated there can be referred pain, numbness, or tingling into the lower extremities as well as weakness and poor balance. (Nerves control it all!)
So if you have full mobility of your low back (flexion, extension, left side glide, and right side glide), maintain it. Maintenance looks like different things for different people, but if you spend 10 seconds every day to at least check, you should have your full range of motion. If you don’t have your full mobility then we need to figure out what specifically you need to do in order to achieve it. (And if you don’t know if you have your full mobility, there are tests we can do to figure it out.) -- 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
Remember when your hip ached for no apparent reason and then it just went away a few weeks later? Or when you woke up with a stiff neck and after a day of moving around it got significantly better? I find most orthopedic aches and pains stem from joints not moving well. It’s easy for joints to get disturbed (especially given we tend to move them predominantly only in a few ways), but these problems often cause only minor complaints which do self resolve. Just continuing to move, possibly with a little rest, usually allows the joint tweak to work itself out.
In contrast to what most orthopedic clinicians believe, I don’t think that neuromuscular reeducation, strengthening, or passive modalities like laser are usually required. If they were so essential, I don’t think we’d see so many aches and pains resolve without them.
People that seek medical care, people that I treat, typically have these joint issues, too - they just haven’t gotten better on their own. What I find is that while most of these people do need movement, certain movements are better than others. Often we have to minimize the movement that seems to be perpetuating the issue as well. I typically have patients do just one movement at a time. Of course I do find some people have tendon, muscle, or nerve problems - and they get treated differently. However, I find around 80% of patients’ complaints stem from joints. In the McKenzie method we call them joint derangements. Mulligan calls them positional faults of the joint. -- Laura
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
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
Of course I am a proponent of general movement and general exercise, but a spectrum of attention to detail does exist. If you want to be smart about your mobility and/or exercise workouts, focus more on the movements that you get less in your day-to-day life, whatever that entails.
If, for instance, you sit all day, like many people do, then biking hunched over in the seated position might not be the best way to get exercise unless you’re smart about it and also move in the opposite direction. Likewise, if you sit most of the day, your hip is usually in neutral rotation or external rotation. If you have that knowledge coupled with an interest in above-average health or desire for athletic performance, you likely want to bias hip internal rotation movements in your exercise routine. (So much hip stuff I see on the Internet focuses heavily on moving hips into external rotation compared to internal rotation, which doesn't make much sense!)
This level of knowledge and personalization is certainly rarely taken into account with general classes (yoga, Pilates, Barre, etc.) - and it’s not expected to be. But if you want to be at the end of the spectrum designating excellent health, this information should be taken into consideration. The first general goal is simply to move. But a second goal is to be purposeful about how you move and focus on balance (eg balance between joint flexion/extension, internal/external rotation, and abduction/adduction). Our joints move in lots of different directions, though our everday routine is usually comprised of only some of them. Therefore, use the time you focus on exercise intentionally to help close any gaps. -- 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
Biking and spinning usually involve a lot of spinal flexion. That's not bad, per se. But part of having healthy joints is understanding what makes them healthy. Joint mobility is a big part of joint health.
Except for the lower neck, which is extended to look up, the mid back and low back are usually flexed forward with these activities. Sitting upright is of course an option on a bike, but when people are going for speed or effort, they tend to adopt a hunched forward posture. As I say over and over, maintaining full mobility in your joints is paramount to health. If your joints are consistently in one direction or one position - and rarely if ever get moved in the opposite direction - you are much more likely to lose range of motion. Be smart about your activities and your joint mobility and significant injuries can largely be mitigated. -- Laura
How do I increase a person's ankle dorsiflexion range of motion? There is no one way to fix a sign/symptom. I can name ten possible things I would do to increase a person's dorsiflexion depending on the source of the deficit. A sign or symptom is not a diagnosis. You diagnose the problem that causes the sign/symptom and provide the appropriate treatment for that diagnosis. It’s the same as with other medical problems. There’s not one way to relieve head pain nor one way to increase low blood pressure. You figure out the reason (the diagnosis) and address that.
I know I sound like a broken record, but people want to oversimplify orthopedics when it actually takes solid diagnostic skills to achieve effective care. If a patient of mine has decreased dorsiflexion, that is just one piece of data in isolation. Combined with the other data I obtain (verbally and physically) and combined with the response to repeated dynamic testing, that piece becomes more intelligible. If you think you simply need to stretch your Achilles to gain more dorsiflexion, by all means, go ahead. It will help sometimes, but it’s not high on my list of treatments I use to gain dorsiflexion. There are many treatments I use more commonly than simple muscle/tendon stetching. So the answer to how I increase dorsiflexion is: “It depends.” -- Laura
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