The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.

Here’s an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 38,000 times in 2013. If it were a concert at Sydney Opera House, it would take about 14 sold-out performances for that many people to see it.

Click here to see the complete report.

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Movement: it seems to me that this word has taken on a life of it’s on over the last few years. There was even a very popular book written by a prominent physical therapist with it as the title ‘Movement’.  In and of itself, the term is very ambiguous…what kind of movement are we talking about? There are so many types…off the top of my head:
– Passive range of motion
– Active range of motion
-Arthokinematic movement
– Osteokinemtaic movement
– Functional movement (whatever the hell that means…more on this later)
– Sport specific movement
– Single joint/double joint movement

This list is endless…

With so many avenues one could go with movement, how is one supposed to be a movement specialist? As a physical therapist I am supposed to be a movement specialist with the ability to assess and detect aberrant movement, which maybe causing a problem and then intervene with strategies to overcome these issues. Examples of this may include teaching someone how to walk again after a spinal cord injury, stretching a spastic muscle after a stroke, or teaching someone how to hip hinge so they can squat better. An old school chiropractor might say they are detecting subluxations which are causing a weak muscle thus limiting movement and then manipulate the spine. A Pilates teacher might try and isolate your transverse abdominus to help lumbar stabilization creating more optimal movement patterns. A personal trainer might teach you how to perform a proper pushup to facilitate better movement…again, this list goes on.

Here is the issue that I have with much of this ‘movement based therapy’ so many of us provide…I don’t think we know what the proper way to move is and really, is there even such a thing? Don’t get me wrong, I know that rounding your spine for a deadlift creates torque through the lower back and landing in knee valgus can cause ACL injuries. What I’m saying has more to do with screening of movement. I may use a combination of active range of motion via a selective functional movement screen to determine where I think a problem may exist while a massage therapist uses manual muscle testing to determine an inhibited vs facilitated muscle. We may come to very similar or dissimilar conclusions as to why someone has pain or “dysfunction” and our treatments maybe completely different for the same patient complaint…but we are both “movement specialist”…hmmmm

Imagine a patient with back pain… They can go to a physical therapist, chiropractor, and pilates instructor who all claim to be movement specialists. In my opinion, more times then not each professional will arrive at a VERY different diagnosis and treatment strategy. Who’s to say who’s right? Who’s wrong? And what is the standard we go by to make such determinations? The reality is there is not one standard of care in the movement based world of therapy. I know the FMS people are trying to make a movement checklist, which is good, but it has many loopholes. For instance, doing a movement screen of standardized movements will take two practitioners down very dissimilar roads of rehab. So in this case, the assessment maybe standardized, but the subsequent findings and treatment are most certainly not. I bet if a patient went to a 5 different dermatologist for acne the treatment would be pretty similar. When you see an orthopod for a torn ACL, the treatment is usually pretty standardized.  The same can not be said with the patient with back pain seeking conservative treatment. So are we truly specialized in the assessment of movement? Or are we all doing the best with what we know? (and there is NOTHING wrong with that)

So with so much ambiguity in the term movement, can anyone really be a movement specialist? A specialist by definition is someone who is highly skilled and has detailed knowledge in a specific area of study. As I mentioned earlier, there is no specific area of study in movement because it encapsulates so many different things.

So what is the point in all of this?

With so much differentiation in how we treat and assess based on our individual training and philosophies, we must still utilize a common panacea to help us understand what it is we do. And my friends, that common panacea is something I like to call research (uh oh, research is boring and so un-radical—this is what I hear a lot!) Research asks a question, uses different methods to try an answer that question and then determines which method works best based on various outcome measures. It does not rely on personal bias, monetary gain from taking a guru course, or personal anecdote. So, remember that patient with back pain who saw a chiro, phyio, and RMT? Well, if each of these professionals utilizes research to guide their practice to at least some extent my hope is that similar conclusions would be drawn based on the existing body of evidence detailing why we have back pain. Of course clinical experience and patient preference play a roll in therapy, but at the end of the day, I want to know if I refer to another physiotherapist they will treat them in a similar way that I would…and they would do that because they to know what research says works and does not work.

There will always be charlatans and snake oil salesmen promoting their methods as the best cure for…whatever. This will never change. It is then incumbent on the evidence informed professional to do what is best for the patient and provide care that we know works. In general this means active patient participation in the form of education of condition, minimizing psychological threats, hands on therapy (again, very ambiguous term), exercise and reassurance. Will this get everyone I see better? Nope. Can I rest assured knowing I’ve done everything my skill set allows be to do while utilizing research to guide me…you bet’cha

In conclusion, I don’t think anyone is truly a movement specialist. I think we need to understand anatomy, biomechanics, physiology, pain science, exercise science and bring it all together using research to treat our clients. This is the kind of specialist I would like to be…

Trigger points are a hot button issue in manual medicine. The research on their existence is sparse and there is considerable amount of subjectivity in the ability to find a Trigger point (TrP). Although their true nature is uncertain, the dominant theory is that a TrP is a small patch of tightly contracted muscle, an isolated spasm affecting just a small patch of muscle tissue (not a whole-muscle spasm like a “charlie horse” or cramp). That small patch of knotted muscle cuts off its own blood supply, which irritates it even more — a vicious cycle called “metabolic crisis.” And when we have a lot of these Trps in various muscles within the body, we call it myofascial pain syndrome…a diagnosis given a lot!

TrP’s are tricky in that they can be elusive to find. For example, did you know anterior wrist pain that is often diagnosed as carpal tunnel actually stems from a TrP in the subscapularis muscle! (a muscle located under your armpit). Therefore, carpal tunnel release surgery may do nothing to help with wrist pain if the TrP of the subscap isn’t released (how that is done is highly debatable and will be discussed a bit).

How do we find these TrP’s?

Pragmatically speaking, I find them by trial and error. For example, if someone comes in with radiating pain down the leg stemming from their butt and I press on one of the hip external rotators (specifically the inferior gemellus muscle….what? You don’t know how to isolate that muscle? Shame on you 😉 and it reproduces their leg pain I can be reasonably assure that they have  TrP causing their symptoms. How these tender points developed is also up for debate. But there are schools of thought that say that a TrP can be caused by being sedentary (sitting on your ass all day), over activity within a certain muscle (think over training), trauma to a muscle (think falling down or car accident) or nutrition deficits (such as lacking vitamin D). In all honesty, if someone comes in with pain of insidious onset (no known injury), I have to look for trigger points…It’s a must!

 Okay, so I think I have found a TrP in a muscle, how do I get rid of it? 

This is a hard question to answer as there is no good evidence that any one method is superior to another. In my experience, pinning a muscle at the site of the TrP and having the client actively move through a non to minimally painful range of potion while the TrP is under compression tends to help..similar to ART I would say (?). I also employ proprioceptive neuromuscular facilitation (PNF) stretching to help “trick” the nervous system into letting go of tight bands of muscle. This ‘contract-relax’ method works only after manual “release” of the TrP in question has been achieved (that is my opinion only, FYI). I also know some physiotherapists who use intramuscular stimulation (IMS) to destroy TrP’ whereby a muscle is stabbed at various angles using an acupuncture needle…sound fun, right? Again, the science behind IMS is hit or miss, but anecdotally I have heard great success stories with its use. I commonly hear “it hurt more than pregnancy but it really helped my pain!”

To end off this small introduction on TrP’s I wanted to share with you the top 5 Trigger Points I treat and have had great success with. The “X” on the muscle shows where the trigger point is and the red dots show you where the trigger point can refer pain into….pretty cool pics from http://www.triggerpoints.net

1) Subscapularis  (posterior shoulder, lateral arm and anterior wrist pain)

Subscapularis Trigger Point Diagram

2) Levator Scapulae (chronic neck pain/tightness), pain along the medial scpaular border
Levator Scapulae Trigger Point Diagram

3) Pec minor (anterior shoulder and medial arm pain..symtoms of TOS or numbness into fingers 4 and 5 can be helped with pec minor relase)
Pec Min Trigger Point Diagram

4) Gluteus Medius ( “Sacroiliac joint” pain…always check glute med first! It’s rarely the joint itself causing the pain)

Glut Med Trigger Point Diagram

5) Solues (Plantar facitis..check the solues)
Soleus Trigger Point Diagram

Next time you have a patient with pain without any one particular reason, look for TrP’s…It just might help!

SFMA course review

Posted: October 21, 2013 in Uncategorized

Hello all,

As many of you may know, last week I took the Selective Functional Movement Assessment (SFMA) course in Toronto.  This course explains and teaches how to identify faulty movement patterns that maybe contributing to someone’s pain.  This done through an assessment that is based on 7 top tier movements whereby each one is rated as functional, dysfunctional, painful and non painful (or any combo of the above). From there, we were taught breakouts, which are just ways to further assess why one of the 7 top tier movements maybe dysfunctional by isolating different areas of the body and possible culprits for the dysfunction.

The 7 Top Tier Tests

Why would I want to take such a course? Easy! It’s a pretty cool idea…who doesn’t want to try and tease out the “real” reason someone has chronic shoulder or low back pain? Who doesn’t want to know what specific exercise is best suited for each patient at our clinic? Who doesn’t want a system...and that’s they key for me. This course provides a fantastic check list to systematically assess the body in a movement based way. It gives the therapist a way to create outcome measures based on pre-determined categories that can be consistently followed within and between treatments… I bet some of you reading this are saying “but I already have this..it’s how I normally assess/treat”. And to that I would say you are probably kidding yourself. Many of us (and we all do this) jump into treatment based on what we feel like doing for that particular day. No real plan or thought…we look at a few movements, palpate a muscle or two and off we go…with very little thought for pre and post treatment measurements. I’m not saying we can’t get clients better this way…but what about the ones we don’t? Wouldn’t it better to have a system in place to check off issues that maybe causing pain? That’s what the SFMA provides.  It also provides great pre-and post treatment assessments that a patient can easily see improvement in. ..hello buy in!

I bet from reading all that you think I’m in love with the SFMA. Well, that is true…but with a few key exceptions.  Like I said on the video I’m going to post talking about the SFMA, I still was left wondering how a lumbar spine stability problem can end up with elbow pain (as what was said in the course). These sort of anecdotes were thrown around without very much real explanation, using evidenced based terms that the informed therapist could use to justify what was being said. This is why I left day 1 of the course sceptical. It is so easy to say amazing things and label things as dysfunctional (or whatever), but unless there is rational evidence or even sound logic to back it up I may not be so enthused by it.  I found myself having to really think “why” a lot on this course…and that’s good, but I wish my why’s were answered a bit more. It would be better because I could tell a client exactly why there lumbar spine stability issue is causing their elbow pain with confidence…instead I’m left having to fill in the gaps myself.

Oh, it also pisses me off that to learn the techniques employed to treat many of the problems the SFMA finds you have to take the advanced course…ca’mon man!

Overall I would encourage SOME people to take this course. I personally believe having a few years experience before diving in would be a good idea. You need to see real pathology and pain before understanding the significance of this course (in my opinion). And I want to caution anyone who uses it or wants to take the course to not jump all in. Medical assessment and differential diagnosis can not be forgotten for the sexier and more in vogue functional assessment. Sometimes back pain is just that…back pain! There may not be some crazy anatomical/fascial/kinetic chain link causing it. It may even be serious and that’s why as a medical profession this can’t be all we do.

Here is a video of my friend and colleague, the manual therapist himself, interviewing me about my thoughts about the SFMA course. It’s 22 minutes long  so feel free to fast forward if it gets full 🙂

Until next time!

What 3 years has taught me

Posted: September 21, 2013 in Uncategorized

Over a year ago I wrote a post about what 2 years as a physiotherapist has taught me and it was well received. Entering my 3rd year as a clinician I think it would be fun and educational for new PT’s to see what I’ve learned over the course of my 3rd year in practice. This has been a challenging year both personally and professionally. On a personal note, I have moved my home and ended a significant relationship and on a professional note I left my old clinic to start out at a new facility in the big city of Toronto. Thus far, moving clinics has been an absolutely amazing decision for me and it’s provided me with so many more opportunities that I didn’t even know existed. I have never been happier professionally than I am right now.
I accomplished a few nice things this year in the physio world that I am proud of. I was a member of the blog team that was selected to go to Quebec City to write about the IFOMPT conference. I got to work with a physiotherapist I respect and am proud to call a friend, The Manual Therapist himself Erson Religioso. He is truly an encyclopaedia and very eclectic in his approach to assessment and treatment. I got to meet and talk shop with Gray Cook, Diane and LJ Lee, Peter O’sullivan, and David Butler. Later on in the year I received my intermediate diploma of manual and manipulative therapy from the Canadian Physiotherapy Association, I became a Titelist Golf Fitness Professional, and I dabbled in teaching clinical labs at a local PT school in Ontario along with lecturing to teenagers about fitness at a fantastic gym in Toronto. Later on this year I will be taking the SFMA course and my level 4’s through the CPA…always more to do!

No such thing!

So without further adieu, here are a few select things I learned in my 3rd year as a physiotherapist:

1) No single method or philosophy will work on every patient that walks in my door. I left my old clinic in part because I felt pressured to adhere to a style of practice I didn’t agree with. It was a philosophy on how the body should be assessed and treated that stopped making sense to me once I got enough experience to question what I was being taught. Did that style of practice work on some patients? Sure it did! Would rubbing their painful back and telling them they will be just fine also have worked? Probably to some extent.

Someone with low back pain from getting hit playing a sport, a sedentary lifestyle, or 20 years of chronic pain should all be treated very differently. In other words, following such things as clinical prediction rules, the pain science biopsychosocial model, or straight biomehcanics will yield different treatments based on the TYPE of patient I am seeing.

This leads me to point #2…and it’s a good one!

2) NO ONE KNOWS IT ALL!! There, I said it. The internet is full of gurus spouting how their method is the missing link to abolishing the world’s pain. I’ll be honest, there have been times I have read testimonials from someone who claims to know how to fix whatever pain and I’ve felt like I must learn what they know…ironically enough, more often than not they were selling a course just so you could learn how to do what they do. How convenient! Look, this is not to say that people who sell courses are just out to make a buck. In fact, I know that is not the case. But I have learned that if you question their methods and their main reply ultimately leads back to them trying to sell you their course than I think they just may be full of it. Prove me wrong…please! I will make special mention of a friend, Dr. Andreo Spina of Funcationalanatomyseminars.com. I have probably asked him over 30 questions on his blog posts and methods and he has personally responded to each and every one of them. He has even private messaged me just to make sure I understood what he was talking about…and I have NEVER taken one of his courses nor has he even tried to sell me one. For that, I plan on doing a bunch of his stuff in the near future. Also because I love what he has to say in the field of sports medicine and functional anatomy…but I digress.

Moral of point #2: Do your own research and don’t believe everything you read. The best people to learn from are those who are willing to admit they don’t know it all but use evidence to back up what they do know. Someone who says “you won’t get it unless you take my course” is full of shit in my opinion…bring on the hate mail!

3) Interdisciplinary facilities are the way to go! I work in a clinic now that has Physio (kick ass ones), Chiro (an awesome one), Sports med docs, Physiatrists, Massage therapists, Chiropodist, Psychologist, Pilates instructors etc. I have been able to sit in with my physiatry boss as he teaches  residents advanced neuro and medical assessment skills…so fun! If you know me you know that I will never give up a chance to learn something and working with such a stellar team of professionals is such an advantage. For example, the physiatrists I work with can come into a treatment session with me and look at something that seems “weird” such as a potential red flag. They have a different and more specialized skill set than myself so having that access is so refreshing. If I worked in a clinic with just physio I would only get physio input, which is not bad at all. Just great to have so many people to bounce ideas off of as well.

My clinic (shameless plug)

4) We are not as specific as we think are being: As someone going through the syllabus system in Canada to become an FCAMPT I am hesitant to write this. On a side note, I have had FCAMPT PT’s get upset with me over some of the stuff I have written on my blog…so I hope this doesn’t piss anyone off. I have read study after study that stipulates in black and white that we really have no clue what segment we are on when we are mobilizing and manipulating the joints of the body. Even better, research now clearly shows that it doesn’t even matter! Just look at the manip used in the CPR guideline for low back pain. It’s a wind ‘em up and crack em approach and magically clients still get better. Can we really determine the exact level of instability with our stress tests? Can we even isolate the joint itself with our stress tests? Do PIVM assessments matter? This time last year I would probably have said YES, of course they do! But as my sceptical brain kept digging, I realized over the course of the year that maybe it’s not as important as we once thought it was… I will leave it at that for now. More hate mail coming my way for sure! Haha

Take a guess at what they found
“The immediate changes in pain intensity and pressure pain threshold after a single high-velocity manipulation do not differ by region-specific versus non-region-specific manipulation techniques in patients with chronic low back pain.”

5) It’s not my job to fix anyone: I no longer think I have magic hands or know exactly what button to press to make someone feel better. Do you know why? Because there ain’t one!! I used to pressure myself into getting everyone 100% better within a 30 minute visit and if they weren’t all better by then than I failed as a physio. This left me going home frustrated and upset many a night. I now know that clients HAVE to be active participants in their recovery. It can not be just me working on them. I said this last year in my 2 year post and I am repeating it again because I keep forgetting it…I don’t fix people, I provide the tools, education and assurance for the clients I see so they can fix themselves. Some may not like that but I don’t really care. Do the odd hands on techniques help someone’s pain? Absolutely they do! And if we’re lucky, that pain stays a way for a while. But if the patient assumes that it was my manip, mob, soft tissue technique (whatever) that cured their pain than I have done a bad job as their therapist. This breads dependency and that’s a one way road to failing. This is HARD guys…really hard! Who doesn’t want to think they have magic hands? Or that they can cure someone’s pain with just their amazing manual therapy skills. It feels amazing when a client hops off my table and thanks me for fixing them…it does! But I know that they will be sore in a matter of days if they go back to doing what ever it was that brought them to me in the first place.

6) It doesn’t have to be complicated: In my 2 year post I wrote about the regional interdependence model and how much I liked and believed in it. I still do! However, I have learned that neck pain can just be neck pain. And ankle pain can just be ankle pain. I don’t need a movement screen to help be tease out the non-painful dysfunction to help me figure out someone has loose ankles or suboccipital tightness due to forward head posture…You may disagree and that’s cool! But I have done quite well treating locally when I feel it is warranted and have had some good results too. Along the same lines as point #4, I don’t think I have ever diagnosed someone neck pain by saying their right C0-1 posterior glide is tight combined with left C2-3 facet hypermobility and a fixated C4-5 IMP glide on the left…yet I have heard other manual therapists make these type of diagnosis’s all the time. Maybe they are just better at me at detecting these things, but I for one don’t know how they can rest their hats on something their colleague next door would not likely find (inter-rater reliability sucks for that stuff). Again, I will concede that maybe there are truly therapists with better hands than me that can feel these tiny nuances and then make a corresponding diagnosis based off of them. I for one think it doesn’t really matter all that much.

There are probably hundreds of little facts I have learned this year as well that are too boring to write about on this blog. These are some of the more holistic ideas that I have adopted in my 3rd year of practice. I’m lucky to report that I love my job and continue to be passionate about it. I really couldn’t imagine doing anything else. I get to help people move and feel better all day…what could be better than that?! I hope in 3 years time I will have learned all new stuff andI will laugh at what I wrote in this blog post. This blog is like a career time capsule in that sense. I am documenting my journey for all to see and enjoy. Let the professional growth never stop!

Till next time!

Jesse

Patellofemoral Pain Syndrome (PFPS) is a common condition encountered in orthopaedic practice. PFPS most commonly presents with retro- or peri-patellar pain associated with positions of the knee that result in increased or misdirected mechanical forces between the kneecap and femur. Climbing stairs, running, kneeling, squatting and long-sitting are frequent pain aggravators. Clinicians have come to understand that the cause of PFPS is not always directly at the knee, realizing the importance of surrounding dysfunctions proximal or distal to the site of pain….we must understand that knee pain is not about the knees (most of the time), a holistic approach must be utilized in both assessment and treatment to figure out why one would present with knee pain.

Here is a list of 4 common reasons for knee pain and a subsequent diagnosis of PFPS (which is a crappy diagnosis)

1) Weak Hips

You’ve probably heard it before, but it’s worth repeating: Weak hip abductor and external rotator strength is a key reason for PFPS. It is believed that weak hips cause medial rotation, adduction and valgus collapse of the tibia and femur leading to excessive joint compression and patellar mal-tracking. This is especially true in women due to the larger Q-angle they present with (wider hips), which makes it all the more important to strengthen the hips as part of a comprehensive treatment approach

“Current research reveals that poor proximal neuromuscular control and/or weakness of the hip musculature may lead to limited control of transverse and frontal plane motions of the hip (especially during single-legged stance). Other evidence suggests such dysfunction can result in dynamic malalignment including components of femoral adduction and internal rotation, valgus collapse at the knee, tibial rotation and foot pronation. Findings of deficits in hip abduction, extension and external rotation strength has also been shown with patients with PFPS. Further, multiple studies by Willson and colleagues demonstrate that there is an increased hip adduction angle in PFPS patients compared to healthy controls”

Journal of Orthopaedic & Sports Physical Therapy 2012; 42(1): 22-29.
The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females with Patellofemoral Pain: A Randomized Controlled Trial

American Journal of Sports Medicine 2011; 39(1): 154-163A Proximal Strengthening Program Improves Pain, Function and Biomechanics in Women with Patellofemoral Pain Syndrome

See what I’m talking about?

2) Restricted Ankle Dorsiflexion

I wrote an entire blog post about this a few weeks back. Long story short: If you can’t get the 10-15 degrees of dorsiflexion in your ankle that is needed for proper gait or squatting you will ultimately compensate by falling in on your arches thus pronating through your subtalor joint. Just like with weak hips, if you excessively pronate you will tend to have tibial and femoral internal rotation thus placing the knee in an awkward position when doing such tasks as descending stairs. Muscle imbalances my result along with excessive joint compression at the knee causing PFPS symptoms.

I have not come across a lot of studies that specifically look at the effects of ankle dorsiflexion on knee pain but here is what I’ve read to date:

N Am J Sports Phys Ther. 2009 February; 4(1): 21–28
Treatment of Lateral Knee Pain by Addressing Tibiofibular Hypomobility in a Recreational Runner

J Sports Rehab 2012 May;21(2):144-50.
Effect of limiting ankle-dorsiflexion range of motion on lower extremity kinematics and muscle-activation patterns during a squat.

“Altering ankle-dorsiflexion starting position during a double-leg squat resulted in increased knee valgus and medial knee displacement as well as decreased quadriceps activation and increased soleus activation. These changes are similar to those seen in people with PFPS.”

Knee to wall test: How I assess ankle doriflexion

3) Lumbar spine pathology:
Conditions like spinal stenosis, arthritis or a disc herniation from L3-4 (most likely) can refer pain down to the knee. The nerves that exit the lumbar spine at certain levels travel down to the knee to provide motor input and sensory output. Thus, irritation of a nerve root in the lumbar spine can be a chief cause of lateral (L5), anterior (L4) or medial (L3) knee pain. Anecdotally, I have treated a few clients with no back or upper leg pain, but complained of tightness and burning at the knee. Once all knee-specific subjective and objective tests are ruled out, it became apparent via dural mobility testing that the knee pain was a function of a lumbar spine pathology.

Quick tip: If a client has unexplained knee pain and you think it maybe neurologically mediated (well, all pain is neurologically mediated…you get what I’m saying though) then test dural mobility and see if that recreates their knee pain. If so, you have a great outcome measure to see if you made a difference post treatment. If a slump test causes burning lateral knee pain, treat the lumbar spine and re-test the slump. Hopefully it’s better afterwards!

4) Hallux Valgus or 1st MTP restriction:
Just like at the ankle, if the 1st toe can’t extend or dorsiflex like it should the foot  will fall into more pronation through midstance to toe off (the big toe has to find a way to get to the ground and it does so by forcing the subtalor joint into pronation). This again leads to dynamic knee valgus and the possibility of PFPS…Knee pain? Check the big toe!

Good ROM

Summary:

  • Knee pain is often multifactorial and keeping in mind regional interdependence yields a more comprehensive assessment and treatment approach
  • Knee pain can have components of articular restriction, dural irritation, tendonopathy or a combination of many things (usually the case)
  • When someone comes in with insidious onset unilateral knee pain and the prescription from their G.P says “overuse injury, treat with ROM, strengthening and stretching of the knee” (what I had last week) you MUST explain to the patient that unilateral overuse with bilateral activity (running etc) is probably impossible.
  • Treat the joints above and below and even on the contralateral side if needed

Integrated Systems Model

Last week I had the opportunity to listen to Diane Lee, PT, CGIMS. FCAMPT give a 3 hour lecture on her and her associate L.J Lee’s (no relation) theories as it relates to the pelvis and her Integrated Systems Model (ISM). This has not been the first time I have heard them speak about this either…at IFOMPT in Quebec they put on a very similar lecture. Now, before I get into a brief summery of what was said, I want to point out that Diane Lee is a true visionary in our profession. She has written 4 books on the pelvis and in all honesty, she is the true founder of the regional interdependence model of care that Gray Cook and Mike Boyle are so popular for creating.  In summery, she has put in her time and knows a thing or two about this thing we call manual physical therapy.

Diane started off by explaining the idea that we should not start using interventions until there is sufficient evidence for them is essentially wrong. She stated that if we as PT’s waited until there was sufficient evidence for the things we do we would not be able to do a heck of a lot. While I agree with this, I think there are some loop holes. She demonstrated this point by talking to the room about the Stork or Gillet test and how the research around it is less that stellar for its reliability. Diane said that just because the literature tells us we can’t feel the pelvis move, we still can see how it moves with our hands and must be able to determine imbalances based on this test. This is key for her ISM of care…

“Being able to detect asymmetric motion of the pelvis between sides in this task is a key feature of the Integrated Systems Model (it’s a sign of failed load transfer if asymmetric) and requires that we can reliably feel the difference”

Thoracic rings

The ISM theory also talks quite extensively about how thoracic ring shifts (rib connected to spine, connected to sternum connected to adjacent rib and back to the spine=1 ring) can alter the kinetic chain up and down the body. They would call a ring shift a potential driver of an issue (the root cause). For example, they have attributed knee pain to a 4th thoracic ring shift and by correcting the ring shift by “stacking” the ribs into proper alignment, the joints below can function properly thus eliminating the knee pain.

There is much more to their theory than what I said out here. They have come up with a very cool concept that helps you organize your closet of tools to come to systematic approaches to dealing with problems. For someone like me who reads a lot of research and knows a bit about most things in our field, I can respect why this model would appeal to a lot of physiotherapists. It appealed to me! They really make it seem like their model is the missing link that brings all the “stuff” we know together to treat the patient holistically.

However (and it’s a big one), their model has one huge flaw (in my opinion). It relies on nitty gritty palpatory skills to “feel” where the driver is coming from. Essentially during the talk we got into partners and had to feel for subtle ring shifts, feeling posterior and anterior rib rolls with body rotation (based on THEORETICAL biomechanics). The issue is this…the ISM tells us we have to palpate to find imbalances (which research tells us we suck at AND that there is weak correlation to pain/dysfunction anyways) and that what we are supposed to palpate isn’t actually even proven to happen in the body in the first place. Then from those findings, we are supposed to hang our hat on what the cause (driver) of the patient’s complaint is. I for one just find that VERY hard to do faced with so much evidence to the contrary. It seems almost futile to argue over this model because of how well received its been with physiotherapists across the world. It makes me wonder if anyone really lets the research guide their practice. This model is hard to swallow because it relies on the ability to feel something that I’m not sure many therapists can actually feel. I’m sorry, but that’s just what I’ve determined by keeping up to date with current pain science literature.

At IFOMPT in front of 100’s of very smart physiotherapists and medical doctors they were applauded for their presentation on the ISM. However, many shared my concerns over this model that compartmentalizes bioemechanics into a package and sells it as a new way of looking at the body. I know I’m not the only one with these concerns. The over arching comment from both IFOMPT and the conference last week was that until a better model is proposed, we can’t argue with what is seemingly working for them in their practice. I mean, if it works, who cares? Right….?

Current pain science tells us that misalignments in the body rarely are the cause of chronic pain and may not even be relevant to pain at all (this I’m still not sure about). This is why I’m not sure I can endorse the IMS yet. I will surely learn more about it and keep you all posted on what comes up. I challenge you to read THIS article (it’s long) on why posture and alignment may not matter as much as we once thought. I warn you though..it will make most of you uncomfortable. It did to me the first time I read it.

To see a video of the Lee’s discussing their model you can view it here

Other interesting articles by the Lee’s click here

This will be another quick video blog explaining the thoracic spine manipulation roll down technique  Personally I really enjoy this technique because if done on the appropriate patient, almost immediate relief can be obtained. I will stop right now and say only those who have spinal manipulation within their scope of practice should be attempting this. You must also be very confident in knowing who to and more importantly, who NOT to do this technique with. Here are a list of some contraindications for spinal manipulation (reasons why it should not be done)

  • Recent spinal fracture (duh)
  • Bilatareal/Quadralateral numbness/tingling
  • Constant pain/night pain
  • Osteoporosis
  • Lack of consent (you would be surprised how many times I’v heard patient stories of a practitioner just manipulating away without even telling the patient what they are about to do)
  • Pain in the premanipulative hold
  • This is a personal contraindication…I do NOT manipulate children under 13 and adults over 65

Here are some reason why I would choose to do a Thoracic manip

  • Chronic loss of thoracic spine mobility…could be a stability issue though, so that should be rulled out too
  • Pain with inspiration
  • Chronic loss of shoulder mobility/ROM (please see JOSPT ‘The Effects of Thoracic Spine Manipulation in Subjects with Signs of Rotator Cuff Tendinopathy for more information
  • Cervical spine pain/headaches/Stiffness (please see The Journal of Manual & Manipulative Therapy, 2008: 16(2): 93-99. “The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial” for more information

Keep in mind that I am still new to the video blog entries and as such, I need to practice my camera angles/mic control. I know it’s pretty small but now I know to film horizontal with my iPhone and not vertically…I will get better, not to worry 🙂

Importance of thoracic spine extension in shoulder elevation

A great patient buy-in outcome measure I like to do pre and post manip is bilateral arm elevation. If the client is restricted with upper thoracic extension they will have difficulty getting those last few degrees of bilateral shoulder flexion because a lot of the end range shoulder flexion comes from the spine going into extension. Have the patient raise their arms over their head, note restriction and pain levels, do manip and then re-test. If this helps, the patient will notice right away and…bam, instant credibility

Explaining the technique on a spine model:

Demonstrating the technique on a real person (the film got turned off too fast and I was about to say that after the manip is done I always check patient response to see if they are feeling good.

Thank you for reading and if you have any pointers, questions or comments I’m always happy to answer

This is going to be a quick video blog demonstrating one manual therapy technique and one corresponding exercise to restore talocrural joint dorsiflexion. In my experience, many medial and anterior knee pain clients tend to have restricted ankle dorsiflexion. This limitation causes a compensation to occur at the subtalor joint creating “over-pronation” to create more range into dorsiflexion. The tibia will follow the ankle leading to tibial and then femoral internal rotation…which we all know is a factor in patellofemoral pain syndrome (PFPS).

More generally, clients complaining of a pinching sensation at the front of the ankle with such things as squats can also benefit from the mobilization and exercise I’m demonstrating in the videos. Post inversion ankle sprain clients often also become restricted with dorsiflexion and just treating the ligaments with ultrasound and stim just won’t cut it….ever! You need to get your hands on the ankle!

A great ‘buy-in’ test to see the pre and post treatment results is the knee to wall measurement. Clients are often amazed at how much more mobility they get with only a few sets of this mobilization. The effects maybe neurologically driven, mechanically driven or a combination of both…who knows. It just works and that’s what’s important to me (and my patients).

Not shown in the videos is the importance of stretching and mobilizaing both the gastroc and solues muscles to aid in any myofascial restrictions contributing to the dorsiflexion restriction. I hope these videos help your clinical outcomes!

Talocrural mobilization with movement:

Home exercise for dorsiflexion:

References:

The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains
Natalie CollinsPamela TeysBill Vicenzino\
Department of Physiotherapy, The University of Queensland, St. Lucia, Brisbane, QLD 4072, Australia
http://www.sciencedirect.com/science/article/pii/S1356689X03001012

The “D” Word

Posted: February 19, 2013 in Uncategorized

In some physio and chiro clinic settings there is an unspoken rule that discharging a client is a negative thing. Some might say that we should never discharge because it allows the client to maintain a relationship with their therapist on an ongoing basis. While I can see some validity to this for a SMALL minority of chronic pain patients, I refuse to believe we should not discharge our clients.

When I see a new patient for the first time they usually have a specific complaint (sore back, injured shoulder, tight neck etc). They come to me because I am an expert at assessing and treating their initial complaint. They don’t come to me for friendship or any other ongoing relationship outside of the physio-patient one that develops while in the processes of helping them with their issue. Don’t get me wrong, I like to get to know my clients and figure out what their meaningful tasks are. Once their meaningful tasks have been achieved, I will ask if they have any other complaints and if not, they are told to come back only if they feel the need to. A meaningful task is anything the client is coming to you to be able to do. For example, a meaningful task for a shoulder pain client may be to unhook her bra without pain. Once this task has been achieved, they are discharged. My job is done.

It is my belief that clients respect this and in turn will refer their friends and families to me because they know I won’t swindle them into months and months of care (which there is no evidence for anyway). One of the best predictors of success with therapy is either a within session (preferable) or at least a between session change of symptoms. If after 3-4 treatments the client feels no changes at all then either therapy is not for them or the course of action needs to be altered (that is assuming the client was compliant with their home program). If their initial complaint is getting better, then I see no need in making them come back for weeks and weeks to address postural faults, over pronation, etc. These biomechanical benchmarks have been shown to have zero correlation with pain and do not correlate with injury risk either. Where my rules on this bend is with exercise. If a client demonstrates interest in an exercise program after their initial injury or pain is better then I will keep them on as long as they would  like me to help motivate and teach them progressions for their exercises. If a client needs me to help them get in shape, I am more than happy to oblige.

Overall, I feel like clients are actually assured when they ask me “how many times will I have to come in?” and I say “I won’t keep you here for a single session more than you need”. They respect this and are refreshed by it…I would HATE to know my clients think I see them as dollar signs instead of real people with busy lives who have better things to do to come to physio so I can “fix” them. I always tell patients that my job is to get them independent with their condition so they won’t need to come into see me very much if at all. This might take 3 sessions or it might take 8 or 10. Anecdotally, I see very few clients over 10 times. Ten sessions with me costs $625…if I can’t get them doing their meaningful task after spending over $600 then I have not done right by my patient.

Do I have the odd patient that comes in for “maintenance” (I hate that word…we are not cars!). Sure I do, but it’s always their choice. I don’t try and scare them into coming back. If a marathon runner or assembly line worker feels like they need to get manipulated or stretched out to feel great again who am I to disagree? I also stress how important it is to get in SOONER rather than later after the onset of back pain because the sooner I can see them, the more immediate success we  have with them.

How do you feel about discharging patients? Do you do it? If so why? How do the economics of running a clinic factor in on your decision?