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 are many goals when it comes to working with orthopedic disorders, but these are the objective health parameters I aim to achieve: full range of motion, full strength, full nerve extensibility, and good mechanics. Mechanics, loosely defined as how you move, is more subjective than the others, but there are norms with quality of movement too.
Full, pain-free function, or being able to do what the patient wants to do, is the most important, but functional ability typically relies on these four domains. In the event we cannot achieve full range of motion or full strength etc. - which can happen for various reasons - our goal simply becomes to achieve the maximum possible. (Other goals with care: efficiency, risk minimization, fostering patient independence, and teaching prevention strategies.) -- Laura
Let’s say I am helping someone fix her shoulder derangement. If I have the correct diagnosis, I expect significant improvement quickly with an exercise in a specific direction - and eventual 100% return to normal. Let’s say we figure out that direction (often it’s extension or functional internal rotation). By finding that positive response to that direction of movement, we confirm our diagnosis and therefore establish a reasonable prognosis.
Now, here are other factors that could affect the ability to get the problem 100% resolved: patient’s shoulder position at work, at play, while sleeping; patient’s compliance with the home program; patient’s performance of the exercise; stress level; diet; lifestyle factors (eg smoking); other health issues; environment; genetics; patient’s belief system/expectations; how the problem affects the patient’s life; and other people’s input/opinions.
For this reason, I often use the words “should,” “likely,” and “in most cases.” Yes, there are many problems that, in my head, I think are 100% fixable; but I know that, until something is 100% fixed, it’s not a given. There are numerous factors when it comes to addressing problems with the human body and mind. As a clinician, I set expectations based on interpreting all the available data. -- Laura
There are many theories about what is happening when someone’s body malfunctions (mechanisms), many theories about how best to remedy the problem (treatment), and, to my chagrin, also many theories about what successful outcomes entail. I enjoy educated debate about the first two, but don’t fully understand why there is so much disagreement over the final piece, optimal outcomes. (Yes, financial gain is a contributing factor in the American medical system.) The interesting point is that if all clinicians align with regard to best outcomes, the first two should more easily fall into place. Optimal orthopedic patient outcomes entail:
1. Meeting the patient's goals. If they are not realistic, input from the clinician is appropriate.2. Fostering patient independence at every turn. Patients need to be educated in regard to every facet of their care and be given control over their recovery.
3. Efficiency regarding time, cost, and risk mitigation. (Experienced MDT clinicians average around 6 visits with patients.)
4. Ensuring full/maximal musculoskeletal system health (eg range of motion, nerve extensibility, strength, etc.).
5. Teaching prevention strategies. Patients must understand how to keep their problem from returning and how to self-monitor for recurrence to minimize reliance on the medical community.
If we get these things right - no easy task - then I don’t care if you got there because you believe the joint moved and therefore uninhibited a muscle or because you stretched a muscle and subsequently the joint improved (mechanism). I don’t care if you had the patient do 20 calf raises 6 times a day or 100 calf raises 2 times a day (treatment approach). But if one outcome takes longer, costs more, relies more heavily on clinician assistance, or doesn’t achieve full range of motion, then that is a suboptimal outcome - and a better approach is necessary. -- Laura
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