I look for direct cause and effect. In most cases, the cause. the intervention, is movement. Movement is usually generated by the patient, but I can use manual techniques if needed. Here’s a simple, common example of how I implement this in the office.
A patient presents with isolated pain on the right shoulder, lateral aspect. History: intermittent pain, pain usually with reaching, no pain at rest, can’t throw, present for 3 months, staying the same, no trauma, notices loss of flexion which can vary. Physical exam: no pain at rest and no cervical or thoracic loss of ROM or pain. Shoulder flexion: moderate loss with pain at end range. Shoulder internal rotation: minimal loss with pain during movement. Concordant pain with resisted abduction and pain-free weakness in external rotation (3+/5). All other shoulder baselines are normal. I don’t regularly do special tests.
Now I want to investigate if there is a particular movement (directional preference exercise) that has a positive effect on those baselines. I test 10 reps of cervical retraction and extension with overpressure: no effect on baselines. I test 10 reps of right lateral cervical flexion with overpressure: no effect. I test 10 reps of thoracic extension with ball overpressure: no effect. I test 10 right shoulder internal rotations (hand behind back): shoulder external rotation improves to 4+/5 and flexion is less painful. We do 20 more internal rotations and flexion is now only minimal loss and there’s no more pain with resisted abduction. We have found a significant positive effect with the exercise repeated shoulder internal rotation.
That will become the patient’s home program until the next visit. It’s about demonstrable cause and effect, not theories or guessing. It’s about being specific and not giving someone who needs one movement a program of seven things to stretch, strengthen, and retrain when it’s not needed. -- Laura
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