If you fix a medical problem by eating well for a month, it's silly to expect the improvement to stick if you return to eating crap. The same applies to mechanical, or orthopedic, problems. Consider movement (and sustained positions) your “diet” when it comes to mechanical problems. There are certainly some mechanical problems that never have to pay attention to diet again. But for most, it matters. There’s no hard and fast rule; each patient’s case is unique, and is understood during the treatment process.
If nothing in a person’s life changed except she bought a new sports car, used it a lot, noticed lumbar stiffness getting out of the car she never had before, and a week later she had an L5 radiculopathy to her big toe, there’s a great chance that position is a factor. Let’s say that point is confirmed during treatment. Meaning, sitting in the sports car now exacerbates leg symptoms and/or obstructs low back movement. After resolving the patient’s low back derangement, does that mean she can never use that car again? Probably not. But it’s likely she’ll do much better long-term if she adjusts the car’s seat, or does her corrective exercise before and after car rides over 30 minutes, or makes sure to check her low back motion after being in the car. In this scenario, resuming her old “diet” of just hopping in her sports car - and adopting that specific mechanical seated position - without thinking twice will likely lead to recurrence. -- Laura
The perfect position is the position that reduces, abolishes, or prevents symptoms. And if a lumbar roll doesn’t reduce, abolish, or prevent symptoms, then it is not indicated. A roll may make symptoms worse initially, but, as therapy progresses, it becomes helpful. Or it may only be tolerated for 20 mins but eventually is useful for long stretches. Its use should always be assessed, not recommended without reasoning.
When it comes to prevention, often that looks like a person who doesn’t have symptoms in sitting but has trouble rising, especially with straightening his low back. Or it may look like a person who has no pain all day sitting at work but then pain in the evenings at the gym. If using a lumbar roll all day prevents pain later at the gym, then it is indicated.
Lumbar rolls can be extremely effective as can any decent lumbar support built into a chair. The point is usually to reduce prolonged spinal flexion or enhance extension. Lumbar rolls can be easily added, adjusted, and removed. They can come in the form of a rolled up sweatshirt, household pillow, or something purchased. I’ve had patients support their low backs with water bottles and purses. I myself used my wallet while driving once. Their low cost and ease of use make them potent tools for helping those with musculoskeletal complaints. -- Laura
For the Lower Body, The Most Significant Aspect of Sitting All Day is Lumbar Flexion, Not Hip Flexion
I know this because I test it versus make assumptions. The hips and lumbar spine are physically close to each other, but tests can easily differentiate the two. We can move the lumbar spine without moving the hip and vice versa.
As I’ve written before, I strongly disagree with the popular idea that prolonged sitting (which puts the hips in flexion) leads to tight hip flexors which leads to pain in the hip flexors. That theory falls apart on so many levels. For starters, since when do tissues (especially “tight” tissues) hurt when put on slack? What is actually happening in the majority of patients who experience anterior pelvic and hip pain in sitting (the “hip flexor area”) is they are experiencing referred pain from the lumbar spine, which is also almost always in flexion when seated. In a smaller number of cases, the pain is referred from the hip joint(s).
If you have pain, you can’t just assume it’s from the muscle in that area. Often it’s coming from somewhere else, which I usually address with specific movement. You’ll get better faster - and stay better longer - if you treat the actual problem. -- Laura
If it's accepted that arm and leg pain can originate from the spine, it should be understood that joint pain can as well. I screen the spine with extremity limb and joint complaints. Forearms, thighs, arms, legs, hands, and feet are not entirely different from wrists, hips, elbows, shoulders, knees, and ankles. Limb (between joints) pain is more often coming from the spine than isolated joint pain, but it still happens frequently. Clinicians need to look for this referred and radicular pain. I use repeated movements of the spine to investigate if extremity joint pain is indeed spinal in origin, which could take anywhere from a few minutes to a few visits. -- Laura
Yes, injured structures can be fragile, but your spine is not inherently fragile. It is no more fragile than your ear, knee, or foot. The spine is well designed, just like the rest of your body, to withstand considerable demand. And it is just as resilient as the rest of you to bounce back from injury.
Things go wrong. Things happen. We get ear infections. We twist our knee. We break our foot. We injure our spines too. And when things go wrong anywhere in our body, they are almost always fixable. Stop telling people spines are fragile. And stop listening to people who tell you they are.
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
Regularly sitting for prolonged periods, especially slouched, can lead to orthopedic problems. But the problems arise almost always from joints, not muscles. I continually hear people (health professionals, notably) declare that sitting’s “shortened” position of the hip flexors can cause painful, tight hip flexors. Granted this doesn’t affect all sitters (nothing does), but if large amounts of time in shortened states can lead to painfully tight muscles, then where is the observable pattern? Why aren’t more biceps affected secondary to prolonged elbow bending? Where’s the complaint of painful anterior neck muscles as our heads are so often forward?
Though I make my case verbally, people won’t budge. It’s likely the only way to prove my point would be to demonstrate an evaluation and treatment of someone with this given “diagnosis.” In the absence of that, I put forth that, one, we have ways of clinically determining if this is occurring, which, importantly, involves ruling out joints and nerves. Two, if we consider joint mechanics, deranged upper-mid lumbar segments and hip joints can send referred/radicular pain to the hip flexor area. Deranged elbows usually refer pain to the medial, lateral, or posterior elbow. And neck derangements typically send pain posteriorly and laterally – rarely anteriorly. The deranged joint pattern is observable. --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.
Many, many bodily joints and tissues need to function well to be able to fully bend forward. Poor hamstrings, though … they always get blamed!
To regain forward bending ability, I hardly ever loosen patients’ hamstrings. However, say a patient did simply need looser hamstrings - then clinical care is hardly needed. (Stretching is not rocket science!) With consistent home stretching, hamstring length better consistently improve.
In almost all cases, forward bending is limited because lumbar structures are moving improperly. Usually it’s that the joints themselves are misaligned. In other cases, compressed/adhered/trapped nerves create nerve tension that limits this movement (with or without contemporary joint malalignment).
Forward bending (lumbar flexion) is usually restored once we get the patients’ lumbar structures moving properly again. Importantly, using forward bending to achieve this is beneficial in only a small group of patients. More commonly I utilize lumbar extension or sidegliding.
So why do people say they “feel it” in their hamstrings? It’s either that they’re actually feeling the sciatic nerve(s) pull or that, in attempting to bend further, their body eeeks out more motion in the only structures it can – muscles and tendons – so they “feel it” there. Expert mechanical clinicians know better. --Laura
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