If you have surgery to repair a broken foot and then it hurts or rebreaks after you decide to go jogging prematurely, does that mean the surgery was ineffective? If you have a wound cleaned out and you decide, against orders, to go for a swim and it gets infected again, does that mean the debridement wasn’t effective? The intervention is the surgery, but it’s also the instructions that come with it. The intervention is the wound debridement, but it’s also the accompanying directions.
With physical therapy interventions I tend to give patients 1-2 things to do as well as 1-2 things to modify or avoid. Could I give more things to do and more things to avoid? Yes. But people don’t tend to follow a longer list of instructions, so keeping things simple is key. Say, though, to fix your elbow pain you seem to need repeated elbow extension and you wake up one day and symptoms are worse. We need to be critical thinkers. Is it possible the intervention of elbow extension is wrong? Yes. But if you were good before bed and you woke up worse, it’s more likely that sleeping interfered with your intervention rather than the intervention is wrong. When sleeping, we adopt postures unconsciously. It’s quite likely your elbow was simply in a position that made it worse. We need to figure these kind of things out.
There are plenty of examples of things that can interfere. It’s hard to foresee and prevent ALL things that may impede an intervention from working. But when they arise, we need to recognize them for what they are and not simply disregard an intervention that has the potential to work if given the right circumstances. -- Laura
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
If neck, mid, back, or shoulder blade symptoms are worse with driving or after driving, it’s worth considering your car posture. The same applies to symptoms anywhere in the head, face, shoulder or arm, all the way to your fingers. (The lower portion and bottom seat can play a role in low back and leg problems.) Most cars put the mid back in flexion and the neck in flexion and/or protrusion. In other words, the mid back joints are rounded and the joints of the neck are either bent forward or pushed forward.
If a posture has no effect on symptoms while you’re in the position nor after, and if your movement ability is not negatively affected, then there’s no problem. For a lot of patients with upper body complaints, though, posture in the car does warrant discussion. Many patients note driving is exacerbating and many patients spend a fair amount of time in their cars. The good news? With all of the patients’ cars I’ve assessed, adjusting the ergonomics of the car is easy and inexpensive. The theme is usually (if not always) to get the upper body straight, not flexed. The hardest part is for patients to get used to it - but that beats symptoms! -- Laura
My thoughts on posture's relevance to specific patients and the general public. Its importance doesn’t have to be a guessing game. We can test it. Every clinician should. (9 minutes) -- 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
I do not preach sitting 100% upright 100% of the time, but I believe that the majority of sitting time should be in the upright position. A chair like this in which the back slopes backward makes it difficult to attain upright posture since there is no upper mid back support in the upright position. Without that support or tactile feedback you are (much) less likely to sit upright - nothing is cueing, reminding, or helping you to do so. (It’s not as though we commonly lean back and therefore need this slope anyhow.)
A good work chair does not have to be expensive. In general, I prefer a straight back that comes up to the shoulder blades, a comfortable bottom portion, depth that fits your femur, arm rests that allow you to navigate your desk, and a lumbar roll that can be added and removed. --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
I recommend checking the spine first in nearly all patients, but if your symptoms are not improving (even symptoms like sinus congestion!) with whatever treatment, repeated movements are worth a try. The McKenzie method typically uses repeated movements to address patients' symptoms as movement is frequently the best medicine - and carries little to no risk as we use the least force necessary. While my role is to investigate exactly how you need to move, it's true that most therapeutic movements are those opposite our normal joint position. In this patient's case, that means neck retraction (moving the neck back). --Laura
Learn more about Robin McKenzie and the method he developed for treating patients. Dr. Yoav Suprun, DPT, Dip. MDT talks to Robin regarding posture, MRI use, exercise versus passive care, and more. Enjoy! --Laura
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