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
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
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.
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
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