Yes, it matters if you had surgery last week. It may or may not matter if you had surgery years ago. It also matters if you fell last week, if you had the flu, if you have vertigo, if you have an inflammatory disorder, and so on. Your entire history can matter - and your surgical history is simply one piece of that history I consider when I determine the most appropriate questions to ask you as well as the appropriate ways in which to move you. Given how people often have lots of things going on health-wise, it takes expertise to know what is relevant and not get bogged down with extraneous minutiae (which can eat up your precious time with patients quite quickly).
The biggest overarching error I see with clinicians treating patients specifically for postsurgical rehab is that they assume the surgery indeed addressed the true problem. Resultingly, they fail to both ask questions and move patients in ways that are diagnostic in nature. I make my own diagnosis - which may be a straightforward diagnosis of “postsurgical” - and treat accordingly. There are a lot of postsurgical patients out there whose surgeries did not resolve their underlying issues, which makes this way of thinking imperative if you want a successful outcome. --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
It is not uncommon to hear “My left leg is just not as stable as my right” or “I lack control placing my right foot on runs” or “My balance is much better on one side.” I haven’t encountered people voicing this about their arms, but it could certainly manifest in the upper body as well. I won’t say it’s always, but it seems like in all cases when patients have complaints about a lack of stability in one leg (not a specific joint, but the entire limb), it’s a spine issue.
Again, if we think of the spine as the fuse box, it makes sense that an irritated spine could create these somewhat vague complaints in the limb. While “instability” is usually a good, appropriate descriptor, it’s also often a lack of control, responsiveness, and/or balance. What I’ve seen people call “dead leg syndrome” on blogs is most likely an example of this too.
Don’t make the mistake I made. Years ago I noticed a marked difference in the stability between my right and left lower extremities. Leaning against the wall in the hospital one day with my legs about a foot from the wall, I could balance fine on my left leg when it was placed under my left hip socket, but failed miserably to do so on my right side. I spent close to a year doing relatively fruitless single leg strengthening and balance/coordination exercises. It got better, but not by much. Some time after that (having given up on making progress and having gotten into MDT), I remedied the issue with directional preference movements of my low back. -- Laura
Given how often I see patients whose non-spinal pain is related to their spine, I make sure to investigate the spine as a possible contributor or cause. As I’ve said before, that investigation varies in time based on the case.
If I read a study on patients diagnosed with “patellofemoral pain syndrome” or “shoulder impingement” and there is no mention of clinically looking into the effect spinal movements have on the person’s complaints, I take that study with a grain of salt. I use the word “clinically” on purpose: you cannot rule in or out spinal involvement solely with an image. At least 25% of people’s shoulder and knee pain I see is actually a spine problem, addressed with moving the spine.
I also say “probably” in this post on purpose. If an orthopedic study looks at people who have traumatically fractured their tibias, that is a different ball game. Most orthopedic problems, however, aren’t obvious traumas. -- Laura
1. How long has it been this way?
2. What brought this about and what brings it about?
3. Is it limited actively?
4. Is it limited passively?
5. Is there pain with active ROM?
6. If so, when? If so, where?
7. Is there pain with passive ROM?
8. If so, when? If so, where?
9. How does the end of the ROM feel?
10. Is it consistently like this, or does it vary?
There are more concerns regarding the whole patient presentation and problem at hand, but these focus in on range of motion (the entire motion available to a joint). Presumably I’m only discussing ROM with a patient if it’s problematic. This may seem like a lot, but it really only takes a few minutes to get these verbal and physical answers. Knowing the questions to raise is step one, knowing how to physically test it (the easiest part) is step two, and knowing how to interpret the findings is step three.
The McKenzie method (MDT) is the system that determines what the patient needs so it is inaccurate to say someone isn’t a “McKenzie patient.” Most often the assessment reveals that the patient would benefit from a movement-based protocol. But assessments can reveal patients need anti-inflammatory intervention, surgery, rest, non-musculoskeletal care, etc. A feature that’s wonderful about MDT is you can recognize when the person doesn’t need to be in your office. Compared to my career before I started using MDT, I know much sooner when movement is inappropriate. -- Laura
There are many things that can go wrong with a joint. What I call joint derangement is when the joint isn’t sitting quite right - which I find to be the most common joint problem. Derangements vary widely in severity and can rapidly change. There could be structural changes in a joint due to arthritis or tears in ligaments or menisci. These (and many other examples) are addressed in their specific ways.
Joint capsule problems are less prevalent. The patients I’ve seen with capsular problems (manifested primarily as pain and tightness at the end range of a joint’s movement(s)) are mostly patients with frozen shoulder and patients who are older. There are distinct ways to address this problem as well. Capsular tissue problems tend to take considerably longer to fix than derangements. -- Laura
Yes, injured structures can be fragile, but your spine is not inherently fragile. It is no more fragile than your ear, knee, or foot. The spine is well designed, just like the rest of your body, to withstand considerable demand. And it is just as resilient as the rest of you to bounce back from injury.
Things go wrong. Things happen. We get ear infections. We twist our knee. We break our foot. We injure our spines too. And when things go wrong anywhere in our body, they are almost always fixable. Stop telling people spines are fragile. And stop listening to people who tell you they are.
Elbow pain with push-ups does not mean doing push-ups created the problem. Knee pain triggered by squatting does not automatically incriminate squats. While we usually have to avoid triggers temporarily in order to heal, that is not to say we avoid them because they caused the problem to begin with. Triggers, once the cause of the problem is correctly addressed, cease being triggers. Sometimes a trigger is the same thing as the cause, but in my experience that is not common.
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