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
Here are the top four reasons I can fix my orthopedic problems quickly. One, I address them as soon as they happen. Two, I know what to do. Three, I know what temporarily not to do. And, four, I have confidence in the methodology. I think the fourth reason is the most salient. I don’t get sidetracked by an uncle telling me to just get a shot. Or another clinician giving me his/her two cents. Or Google recommending medicines, oils, or any number of theories and movement programs. We all have aches and pains from time to time. By understanding orthopedics and how to approach problems methodically and effectively, even if I know my recovery will take some time, I know the prognosis, don’t have fear, and don’t waste time on unnecessary interventions. -- Laura
A lot of health measures take time, but we don’t often consider them nuisances. For one, because they’re normalized habits and, two, because we easily recognize their value. Many of these revolve around preventing infection. Our musculoskeletal system benefits from daily or at least regular attention as well. Is checking your motion or performing certain movements cumbersome? Well, it does take a few minutes. But if you value bathing and hand washing and devote time to those, you can also value the health of your joints, tissues, and nerves. The choice is yours - and, to be clear, it is a choice. (No equipment is required.) Like infections, musculoskeletal disorders cannot be 100% prevented, but “inconvenient” preventative measures (not just exercise) go a long way. -- Laura
Yes, some patients have problems that cannot be fixed with movement. But how will you know unless you test movements and interpret the effect? In almost all orthopedic cases, diagnosing should involve repeated movement testing. Morton's neuroma is currently diagnosed by imaging and provocation testing, but, as Michael David Post and Joseph R. Maccio's paper "Mechanical diagnosis and therapy and Morton's neuroma: a case-series" demonstrates, a repeated movement exam is needed to assess if patients will benefit from repeated movements.
If you take people with no toe pain and put them in an MRI, many will have neuromas. So we know they can be present without causing pain. When patients do have pain, then, we can't assume their neuroma is the cause. We need to investigate if the spine is the cause or the toe joint is the cause. Additionally, assuming a neuroma is causing pain still doesn't mean the patient won't do well with repeated movement treatment (but you have to find the correct movement).
What percentage of patients who complain of toe pain receive a competent repeated movement exam? How many with toe complaints will have a clinician investigate their lumbar spine? And what percent will even be recommended to see a movement-based therapist if the image shows a neuroma? If these three patients hadn’t resolved their problems in just a few visits with repeated movement, what types of therapies, injections, surgeries might they have had? In this case series, three patients with medically-diagnosed diagnosed neuromas abolished their toe pain with repeated movements, with those results remaining at one year. One patient required repeated movements of the lumbar spine (low back) and two patients needed repeated movements of the affected toe.
When it comes to movement testing, I believe in end-range repeated movement testing that investigates the relevant spinal segments as well as the relevant affected joint(s). This is the core foundation of the McKenzie method. Movement testing is not the same as orthopedic special tests or palpation tests or provocation tests. It means repeatedly moving a person in the clinic and at home and evaluating the effects if has on the person’s symptoms and mechanics. Looking at a picture and seeing if something hurts when you press on it is rarely enough. -- Laura
When the public hears that all it takes is a quick MRI to know what their orthopedic problem is, it can be hard to educate regarding the importance of movement testing. Sometimes it only takes a few minutes, but movement testing may take more time. However, even if I have to test someone using movement for a couple weeks, we do save time in the long run. Repeated movement testing - combined with clinical reasoning of course - tells me which type of treatment is appropriate (physical therapy, injection, medicine, surgery, etc.) or if another form of testing (ie imaging) is needed. It also tells me, if physical therapy is indicated, what specific treatment is called for. We want to match treatment to the correct diagnosis. -- Laura
I appreciate having a method of approaching the body when it comes to musculoskeletal problems. With regards to any problem, I have an order of investigation: the spine, local joints, tissues, and other. When it comes to an extremity, I always look at the related spinal segments. With extremity joints, I always look at active motion, passive motion, strength, and function. With regard to movement testing, I look at the sagittal plane first and then the frontal or transverse planes (except in rare cases). I use the least amount of force first and add force incrementally only as needed. There are many other examples of how the McKenzie method embodies a systematic approach.
The point here is that diagnosing and treating can be simplified according to the core principles. Care is not based on a hodgepodge of tests. For instance, if you only learned how to treat shoulders using the McKenzie method, you should be able to apply that to hips - and vice versa. The more you use the method, the more efficient you become at implementing it. -- Laura
Just because something happened recently does not necessarily mean it needs to “settle down” or “take some time” to get better. We can do better than making assumptions that the time frame alone of an injury tells us the diagnosis and, therefore, the prognosis. Time frame is just one factor. Why assume the remedy is time when you can investigate to see if there is a more appropriate (and faster) solution?
In general terms, when I diagnose problems, there are three main categories: joint problems, tissue problems (capsules, tendons, and muscles), and other problems. Within the “other problems,” which encompasses many distinct issues, each a small overall percentage, is “acute trauma.”
For me to arrive at the diagnosis of "acute trauma,' I have to rule out other diagnoses. I don’t assume that since you hurt your hip playing soccer four days ago, that your pain and limitation is automatically a result of its acuteness. Most significantly, I need to rule out that you have a joint disturbance - especially given joint disturbances are the rapidly resolvable problems. There’s a good chance that your hip joint could respond favorably to directional preference exercise. In that case, you don’t need to just wait for time to run its course - you can fix it quickly, sometimes within a day or two. If a structural compromise (like a fracture or major tear) is suspected, that may also be further investigated at the appropriate time to rule in/out.
If I do actually diagnose a problem as “acute trauma,” which, importantly, means it’s not something else (or something else yet), then treatment is geared more toward non-provocative mid-range movements and general movements (like walking) that similarly do not exacerbate symptoms. Anti-inflammatory intervention may provide some help, but not always. The plan in this case is to give it a few more days (because acute trauma by definition does get better with time) and then reassess to try to determine a more specific diagnosis. -- Laura
We don't have to assume a muscle is tight or a muscle is weak. We don't have to assume a joint is obstructed or a joint capsule is restricted. We don't have to assume a muscle is inhibited. We don't have to assume a structure is inflamed. We don't have to assume a nerve is compressed or entrapped. There are tests for these things.
These problems are distinct and can be distinguished from one another through competent and thorough testing. Sometimes that testing takes five minutes in the office. Sometimes it takes movement testing at home for two weeks. If needed, in rare cases we also have imaging testing to rule in or out fractures, relevant structural compromises, and sinister pathology. The heart of the matter is we don’t have to assume. I’ve spent over a decade learning and perfecting this testing so I can find the problem fast and then instigate the correct treatment. Differential diagnosing ability is central to helping people. -- 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 don’t think I’ll ever forget when a patient said this to me - in a friendly way. It was visit 4 and it was time for discharge since we had met her goals: no more pain and back to exercising. She was ecstatic to have her old self back, but wanted to let me know how skeptical she had been. She said she hadn’t believed anything I had said but figured she would do what I had asked because 1. Her doctor had specifically recommended the McKenzie method 2. She had already tried a round of physical therapy and not improved 3. She was not a surgical candidate 4. She had nothing to lose, especially given the homework was so simple.
What was I saying that was so unbelievable? That it seemed she was in the large cohort of patients with her symptoms that would heal quickly with simple exercises, performed repeatedly. That often times joints stop moving well and we can find specific movements that return them to normal. She abolished her years-old low back and right thigh pain with lumbar extension procedures over several weeks. Between visits 3 and 4 we reintroduced lumbar flexion and yoga.
I of course realize that what I tell people is almost always contrary to what they’ve already been told. I do my best to get patients on board (to serve their own interest), but it doesn’t always work. Luckily, this patient came around - because she started to feel better. She also told me on that last visit that she would tell everyone about MDT. -- Laura
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