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
You’re assessing, assessing, assessing to arrive at a diagnosis. And then even when you think you have the diagnosis, you’re assessing, assessing, assessing to make sure you’re on the right track.
I want a plan that helps; that goes without saying. But when you’re figuring things out, you want to know about any and all effects - helpful, harmful, or indifferent. In order to get to the helpful plan, we need to understand what’s going on, which importantly includes knowing what tests and/or treatment strategies have no effect or which ones make you worse.
If a repeated movement has no effect, that might make me think there’s more likely a tissue problem instead of a joint problem. Or that we have a joint problem that needs more force, or a different direction. If repeated movement in a particular direction makes things worse, then it is more likely you have a joint derangement, and now we have information about which direction would be helpful. Knowing that something we test has a negative impact (on pain, movement, etc.) is just as powerful as knowing something has a helpful impact.
All of these pieces - all of these effects of repeated movement tests combined with the verbal history and physical baselines (as well as any other necessary diagnostic tests) - help us understand what’s going on. There are dozens of these puzzle pieces, by the way! And the faster we know what’s going on, the faster we can hone in on the treatment you need. -- Laura
I contributed to a piece the McKenzie Institute USA did on the myths surrounding the McKenzie method. Check it out here! -- 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
People clearly have differing ideas, but, even when presented with the same information, people can interpret it differently based on their currently-held worldview. Here is the most classic example I can come up with in terms orthopedic thinking: shoulder impingement. The predominant worldview (in the US at least) is that muscles, joints, tendons, and neural patterns around the shoulder are functioning improperly as a unit and therefore during overhead movements the subacromial space is impinged causing pain. My view is that in over 90% of cases one specific thing is not working correctly.
The prevailing treatment for the common worldview is simultaneously stretching or releasing one or more muscles, loading certain tendons, strengthening many muscles, and moving certain joints. I remember I used to give patients at least seven things to do at one time when I had that belief system, which I was taught.
My current view is that most patients need to move just one particular joint or tendon. That particular movement is often, but not always, included in the array of movements listed above, which is interesting but not surprising since the normal treatment includes so many things! So if people get better with the standard approach, people believe it’s correct.
My understanding now, however, is that the reason they got better is because they included the one thing they needed - and the rest was superfluous and, at worst, a waste of time and resources. My patients with shoulder pain with overhead movements almost always get just one exercise to do at a time, which may or may not change over time. (For me, what other clinicians diagnose as shoulder impingement, I diagnose as several different things: cervical derangement, thoracic derangement, shoulder derangement, and shoulder contractile dysfunction.)
It’s interesting to think about how our belief systems can inform how we understand the evidence. Clearly those who believe the predominant worldview and those who believe the MDT-leaning view interpret the fact that people get better with standard shoulder impingement treatment very differently. As I wrote recently: I am interested in what works, but I’m more interested in what works best. - -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
A stress test on a treadmill, hooked up to monitors, indicates how your heart functions when challenged. Repeated movement testing, which I perform and prescribe, indicates how your joints, muscles, and nerves function when challenged. Pictures tell us how things are at rest but not how they behave. And orthopedic special tests (OST) tell us how things are with a static test or with one movement. Barring a major structural problem, most problems are functional - and require dynamic testing (repeated movement testing) to arrive at a diagnosis. Repeated movement testing is one of the hallmarks of the McKenzie method.
Repeated movement testing is exactly what it sounds like. After I get a verbal history and note physical baselines such as range of motion, strength, and nerve tension, I choose a movement to be performed repeatedly and then assess the effect on symptoms and the baselines from the physical exam. The repeated movement I choose to test is based on several factors. An example of a repeated movement would be performing 10 shoulder internal rotations or 10 lumbar extensions.
The McKenzie Method is first and foremost an assessment approach to determine what the patient needs. It is not just a set of techniques or exercises, although the McKenzie Method does also include a treatment approach for those who are found to need therapy. (Most orthopedic disorders can be addressed with therapy vs invasive care.) The assessment (also known as an evaluation) may tell me a patient needs an injection, needs rest, needs surgery, or needs any number of exercise or manual interventions.
I learned skills in DPT school, at various continuing education courses, from other clinicians, etc. I continue to learn various techniques such as Mulligan techniques in order to have more tools to help patients, though I usually find the McKenzie Method treatment approach works best. You can have a zillion skills, exercises, and techniques in your repertoire, but the key is knowing when to use each one - and I find I can best make that determination based on a McKenzie Method assessment. -- Laura
When clinicians think of joint mobilizations, they think of clinicians moving joints at the level of the joint with their hands, which is true. This applies to the spine as well as the extremities. However, joints can be less-precisely mobilized - or moved - without that specific technique. In fact, if my goal for a movement is to move a joint versus, say, stretch something or strengthen something, I call it a joint mobilization. More loosely, we can just call it a movement or an exercise, but the intent is what matters - and the intent is to move the joint in a specific direction (its directional preference).
Sometimes the technique or the force applied by a clinician via mobilization or manipulation is necessary temporarily. But in the large majority of cases diagnosed as joint derangement, patients can learn how to mobilize themselves. In the trickier cases, we might have to figure out how to get assistance from some equipment at their home or from another person. When mobilizations (with or without a lot of force) are necessary as treatment, the results will be better the more often you do them. That said, in order to get those reps, it’s imperative we teach patients how to self-mobilize the best we can. The McKenzie method is predicated on teaching people how to self-treat in order to improve outcomes. My hands aren’t magic and I’m here to teach. -- Laura
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