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
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
So sit-ups flex your spine? So what? We flex our spine thousands of times a day and sit flexed an awful lot as well. As long as you (1) know how to discern if an activity (such as sit-ups) is harming you and (2) know how to correct it if it is, you are good to go. The best way to know if an activity is harming you outside of symptoms is ascertaining if it decreases your motion. (If we’re talking about the low back, that means flexion, extension, left sideglide, and right sideglide.)
I incorporate sit-ups into my workouts as well as other spinal flexion exercises. I like sit-ups with my legs straight and ones with my legs bent. But, what do I also do? I spend 10 seconds every day checking if I have my normal low back motion and also perform prophylactic movements. (I’m lying on my stomach propped on my elbows right now.) If I were just starting sit-ups, I would check right after to make sure they didn’t cause me to lose motion (they never did).
Are there certain things certain people can’t do? Of course. Sit-ups could hurt your back just like brushing your teeth could or a long car ride could; they’re not extra scary. By understanding the concepts of how to keep joints healthy, we don’t have to avoid nor fear specific exercises. I’m here to teach. -- Laura
If someone complains of foot symptoms - pain, numbness, and/or tingling - it can obviously be due to several causes. When investigating to find the source (that is, diagnosing), I collect many pieces of information. First, there’s a good verbal history during which I ask pointed questions. Second, is the physical exam. With the physical exam I look at various things; nerve tension is one of them. If you put the lumbosacral nerves on tension (there are a few ways to test this), and a patient’s symptom appears or increases in the foot, we need to investigate spinal nerve irritation as the potential source. To be clear, a negative tension test does not rule out the spine, but a positive test more strongly rules it in as a possibility. It is common that irritated nerves in the spine create pain, numbness, or tingling in the areas of the body they're responsible for, and the nerves specifically in the low back are responsible for sensation in the feet. -- Laura
A spondylolisthesis can be present and not be related to your symptoms - just like imaging can show non-painful degenerative changes, tears, etc. It sounds scary, but in the absence of recent trauma, there's a strong chance you have a spondylolisthesis that doesn't matter.
Competent clinical reasoning and testing can differentiate if a spondylolisthesis is or is not the generator of symptoms. I find repeated movement testing to be the most valuable method. Physical therapy will not fix a spondylolisthesis, which is a bony structural problem, but can help. However, physical therapy can usually fix other spinal problems, which may be producing your symptoms. An image shows you what’s there, but it doesn’t usually tell you what’s causing symptoms. That’s why you always need competent clinical reasoning and movement testing. -- Laura
The glutues maximus, gluteus medius, and gluteus minimus are innervated (powered) by the nerve roots L4, L5, S1, and S2, which exit the spinal cord in the low back. A muscle can only achieve optimal strength and efficiency if it’s getting an undisturbed supply of electricity. I hear loads and loads of people talk and talk about problematic weak glute muscles. I usually don’t find weakness. Instead, I find that it’s almost always inhibition - a fuse box (spine) problem. Most low back problems are at the levels L4, L5, S1. Is it any surprise then that the nerves to the glutes may be compromised? There does not have to be back pain for a nerve irritation to be present.
If we prove that your nerves are indeed working well (which we do by clinically moving your low back, and sometimes hip, repeatedly - not by looking at an image), and your glutes are still problematically weak, then we can begin all those glute exercises such as squats, lunges, donkey kicks, clamshells, crab walks, sidelying leg lifts, lateral step downs, bridges, and so on. If a professional wants to diagnose “weakness,” then he/she better have first at least ruled out inhibition. Not only does that save months of work, but it gets at the real diagnosis. When a muscle doesn't demonstrate the strength it should, I check the fuse box. -- Laura
I recently saw a social media post entitled “Prone Exercise Progression for Low Back Pain.” If only it were that simple! There is no "prone exercise progression" for low back pain. Prone exercises are used for certain diagnoses with certain patients. Pain, after all, is not a diagnosis. We don’t treat heart pain or lung pain - we treat the underlying diagnosis. Will I allow that there are rare cases in which we can’t establish a true cause? Sure. But in those cases you get there by ruling out a multitude of possibilities.
Not only can we do better than treating the symptom of pain, but we can be specific about what each individual needs. A prone exercise progression will help some people with some diagnoses. It will also do nothing for some people and will make some people worse. You can try whatever you find on the internet if you want. We all do it from time to time. But success is more likely when you have an individual diagnosis and plan. -- Laura
Part of effective diagnosing is understanding the basics of how joints, muscles, and nerves work. People with low back pain commonly think they “pulled” a muscle. They may have. I will allow that it is possible. However, in ten years of work, not once have I diagnosed someone with a pulled or strained muscle (or tendon) in his low back. (It’s almost always a joint-driven problem - and joints can refer pain to muscles.)
A symptomatic pulled (also known as strained or torn) muscle - anywhere in the body - will hurt when contracted. Each personal case is different, but at some angle and with some type of resistance, when that disrupted muscle is asked to contract, it will provoke pain. The second finding with pulled muscles is that they often hurt when put on tension (stretch). This may or may not create a minimal range of motion loss in the plane in which the muscle is on tension. Third, when the affected muscle is on slack (at rest) and not contracting, nothing should happen and range of motion should be full.
An extensor muscle performs extension. If it is pulled you’ll usually find painful resisted extension, pain at end range of flexion with minimal to no motion loss, and full pain-free passive extension. This applies to extensor muscles everywhere, including in the low back. Therefore, if passive low back extension (prone, using the arms or a machine) is limited or painful, I’m not likely dealing with a muscle problem. If standing extension is pain-free but limited, I’m also likely not dealing with a muscle problem.
Again, knowing the foundations of biomechanics is essential. Just that simple piece of information can allow me to rule out a muscle. Unfortunately, many people (including clinicians) don’t apply these fundamental rules to diagnosing problems. Muscles can hurt due to referred pain, so just because pain is felt in a muscle doesn’t mean the muscle is the problem. A competent diagnostic process will provide the answer. -- Laura
Nerves becoming trapped outside of the spine are much less common than people think. Commonly talked about examples include entrapment in the ankle (tarsal tunnel), wrist (carpal tunnel), elbow (cubital tunnel), buttock (piriformis) and forearm (pronator teres). If there is trauma to an area, it certainly makes sense that the nerves in the area can be injured and/or the healing process can lead to tissue “entrapping” the nerve. But, without significant trauma, it’s quite rare to see this phenomenon.
While many patients tell me they indeed have carpal tunnel (or whichever), they usually describe symptoms inconsistent with that diagnosis (ie they say it affects the whole hand). Furthermore, they report that no clinician has investigated movements of the neck and mid back as part of the diagnostic process.
The nerves that end up in your periphery are commonly irritated as they exit your spine. If someone has symptoms in both hands or in both ankles, the likelihood that the spine (or something systemic) is the source increases dramatically. So while I agree that peripheral nerve entrapments can exist, I can’t remember the last time I found this to be a patient’s true diagnosis. Getting the correct diagnosis is the most important step in getting better after all. -- Laura
If you fix a medical problem by eating well for a month, it's silly to expect the improvement to stick if you return to eating crap. The same applies to mechanical, or orthopedic, problems. Consider movement (and sustained positions) your “diet” when it comes to mechanical problems. There are certainly some mechanical problems that never have to pay attention to diet again. But for most, it matters. There’s no hard and fast rule; each patient’s case is unique, and is understood during the treatment process.
If nothing in a person’s life changed except she bought a new sports car, used it a lot, noticed lumbar stiffness getting out of the car she never had before, and a week later she had an L5 radiculopathy to her big toe, there’s a great chance that position is a factor. Let’s say that point is confirmed during treatment. Meaning, sitting in the sports car now exacerbates leg symptoms and/or obstructs low back movement. After resolving the patient’s low back derangement, does that mean she can never use that car again? Probably not. But it’s likely she’ll do much better long-term if she adjusts the car’s seat, or does her corrective exercise before and after car rides over 30 minutes, or makes sure to check her low back motion after being in the car. In this scenario, resuming her old “diet” of just hopping in her sports car - and adopting that specific mechanical seated position - without thinking twice will likely lead to recurrence. -- Laura
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