I want to share with you a patient who I’ve seen 5 times over the past 7 weeks for right shoulder pain. He is an avid volleyball player and want’s to get back to his sport. I saw him earlier on in 2012 and diagnosed him with a SLAP tear. He was referred for an MRI which showed just what I suspected. Unfortunately conservative care could not fully abolish this patients pain and clicking in the joint. He had labral repair surgery 10 weeks ago and while in surgery, his surgeon noticed substantial anterior capsule laxity and decided to do a capsular resection and shift…meaning they cut into the anterior capsule to pull it tighter together preventing excessive humeral head anterior migration.

Initially treatment consisted of gentle PROM and scap setting stuff. He was told he could not go past 90 degrees abduction and over 10 degrees ER in neutral for the first 8 weeks (seems excessive to me). We have done lots of manual therapy work in the form of gentle PNF stretching, myofascial release (or whatever you want to call it), passive scapular mobilizations  and are now starting both anterior and posterior capsule stretching. I am also starting gentle proprioceptive drills with him in supine. His exercises to date have included:

  • Pendulums (codmans)
  • AAROM into flex, abduction, ER in neutral using a golf club
  • Proprioceptive drills leaning the arm into a rubber ball against a wall and making figure 8’s
  • Scapular rows
  • Prone glenohumeral joint centration exercises using a 10 pound weight… think “suck the ball back into the socket”I had him doing scaption with a band but stopped this exercise due to what I was seeing in the video you can see below. Can you guess why I decided I didn’t like it for him?

Based on the one video you are about to see of this gentleman doing bilateral shoulder abduction can you tell me what you see? Based on what you see can you give me some reasons for it and what you would do about it? I would be curious to get other perspective as I have my ideas and will share them in part 2 of this post but I always like knowing what other clinicians would do.

Shoulder video

Thanks!

This post will be one I will add to as the list gets longer. I want to write a short post about the people I learn from in this industry. The key to being great at what you do is to never stop learning and with the advent of social media and the internet, staying current has never been so accessible. In no particular order, these are the people and websites I refer to and trust to provide me with current, thought provoking information…enjoy!

Erson Religioso III:
Having met him in person and worked with him professionally on the IFOMPT blogging team last year I can safely say that Erson is a wealth of information. His website (the manualtherapist.com) is exceptional for providing high quality instructional videos on manual therapy techniques. His eclectic approach is great because he incorporates so many different schools of thought into his teachings. He uses Mckenzie methods, Mulligan mobilizations, functional screening, Instrument assisted soft tissue work, and so much more to provide the reader with holistic ideas on how to treat patients…just look up one of his 15-20 minute videos to see what I mean!

I have the EDGE tool he created and it’s really quite awesome. If you don’t have one at least go to his website to check it out. It’s a great tool to have. Lastly, his OMPT channel provides more in depth and clear video instruction on so many orthopaedic related topics…and it’s $5/month!

Mike Reinold:
I first got introduced to Mike Reinold after reading his Current Concepts in Shoulder Rehab article back in physio school. I immediately went on to research who he was because the article was great and still provides me with solid shoulder related exercise progressions to this day. Mike is the head therapist for the Boston Redsox and is a shoulder specialist. His website (Mikereinold.com) is packed full of great articles for literally every part of the body.

I’m also a member of in Inner Circle group, where he has live video lectures and discussions posted every month on topics related to physiotherapy and strength and conditioning. It’s been a great resource for me and allows me to ask him questions about his topics in real time. He certainly makes himself accessible to his followers. He’s read my blog which I think is truly awesome because I’m sure he has 100’s of people wanting him to endorse/read their stuff. All in all, I would say he is the best physiotherapy-related writer on the social media scene.

Gray Cook:
This guy needs no introduction as I’m sure most if not everyone reading this blog has heard of him. He’s certainly a revolutionary thinker in our field and has probably done more to change the way manual medicine providers practice than anyone else has in the past 10 years. He is a proponent of creating a universal language we can use to describe and analyse faulty movement patterns. He has created a system to categorize acceptable levels of movement competency via his FMS and SFMA screening tools. Is there controversy within his methods? Yup! But at least he is creating the dialogue and forcing us to think outside the box. His book “Movement” is a must read…no questions asked.

Me and Gray Cook

Dr. Stu McGill:
Dr. McGill is a professor of spinal biomechanics at the University of Waterloo. I first got introduced to him in  my first year of Physio school when I “borrowed” my first clinical instructors copy of Low Back Disorders…I guess I just forgot to give it back to him (ooops!). The book was right up my alley…all his theories on the how and why of low back pain were backed up by solid research. It’s not bullshit with Dr. McGill…he uses objective data to defend his views on back pain and proper methods to train the back….which is more than I can say for many social media gurus in our field. His second book (Ultimate Back Fitness and Performance) should be right next to ‘Movement’ as a must read title for anyone treating athletes with back pain. I am yet to hear him speak live, but it’s on the to do list for sure.

Dr. Andreo Spina:
Functional Anatomy Seminars is a great website to check out even if you haven’t taken any of his courses (like me). I want to do an FAP course but time and money allows for only so many things to get done. He is a CMCC graduate who founded Sports Performance Centres in Vaughn, Ontario and later went on to create and instruct in a series of courses based around specificity of palpation. He has a few different sub-sets of courses (FAP, FRR, and now FRC). He is also a research nut who writes very thought provoking blogs. Some call him arrogant or cocky, but being asked to teach your courses to professional baseball teams in the MLB would probably make me that way too 😉

Dr. Craig Liebenson:
Craig is the master of blending in theories of exercise and rehab to make a point. After taking one of his courses in Toronto last year I can safely say that I have never learned more applicable skills in one weekend than I have with his course. He is passionate about bridging the gap from rehab to performance and is a tireless advocate for active care instead of pure passive care in the treatment of painful conditions. He is an engaging speaker who makes you question the way you practice…and we all need that from time to time!

Honourable mentions:
Dr. Harrison Vaughn of InTouch Physical Therapy Blog – very good writer and I love his ability to critically analyse popular beliefs in therapy

Dr. Jeff Cubos of jeffcubos.com- Like Dr.Liebenson, Jeff is great at putting it all together and making it interesting. I read his stuff all the time and get a lot out it…and he’s Canadian! The exercise section of his website is super useful!

Dr. Greg Lehman of Thebodymechanic.ca- Craig is what I would like to call a skeptic and his ability to question everything with such great detail is truly a gift. He articulates my concerns with so many of the common myths within rehab/training in a way that most could never do. I have profound respect for his writing and critical thinking skills and read pretty much everything he writes. Want to question the way you practice? Read his blog!

Dr. Shawn Thistle of Shawnthitsle.com- Shawn has created a website called Research Review Services. It is an ingenious idea that allows busy clinicians the time to read small digestible summaries of current research in our field. He is a great Chiropractor and someone who really ‘gets it’. The chiro profession should be proud to have him as a colleague.

This last one is not really one person but more so a collection of people that I learn from. As many of you know, I am working towards getting my FCAMPT designation through the Orthopaedic Division of the CPA. I have done quite a few manual therapy courses and have learned a lot about differential diagnosis, joint biomechanics, and neuromusculskeletal pathology. Not everything they teach is useful nor evidenced based, but I can still say I have enjoyed the courses that the Orthoapedic Division has laid out. You really do have to take the good with the bad with these courses and they really are what you make of them.

There are so many people that I learn from, but these are some of my favourite. They are game changers in the field of manual medicine and athletic development that should be part if everyone’s reading list.

Who do you learn from? Who did I miss? I’d love to know!!

Just like a house, which requires a strong foundation to stay supported, so does the glenohumeral joint of the shoulder complex. Although a thorough anatomy review is beyond the scope of this blog, I feel a few key concepts need to be reviewed. The only thing connecting the shoulder complex to the rest of the body is the scapula via the acromioclavicular joint. Some argue that the scapulothoracic complex is a joint but I will argue that is it most definitely not! It’s just a bone (the scapula) sitting on top of the ribs…no joint there. Anyways…

Since the scapula is the only thing connecting the shoulder to the rest of the body, it only stands to reason that it is the foundation from which the shoulder can function optimally. Therefore, I see very little use in training the rotator cuff muscles without first addressing scapular stability AND mobility. Too many clinicians focus on just scapular strengthening exercises without addressing scapular mobility first when they have a client with shoulder pain. For example, if levator scapula is tight, what will it do? It will downwardly rotate the scapula placing it in a disadvantageous position for glenohumeral joint mobility. If pec minor is tight (and who’s isn’t?) what will it do? It will anteriorly tip the scapula lifting the inferior angle off the ribs creating issues for lower fibers of trapezius to aid in upward rotation. Therefore strengthening lower fibers of trap without FIRST addressing pec minor tightness is less than ideal. You will never be able to achieve strength goals until the scapula is sitting flat against the ribcage with the spine of the scapula at around 15 degrees of inclination.

Furthermore, thoracic spine position is critical to scapulohumeral rhythm. An article was just published in the latest JOSPT (December addition) that dealt with the beneficial affects of thoracic spine manipulation on rotator cuff tendinopathy/pain. It only stands to reason that if the upper back is moving better, the scapula can move better, therefore allowing the rotator cuff to act as a humeral head stabilizer instead of a prime mover…which it often has to do in the case of kyphotic postures. So, hypothetically if the thoracic spine is mobile and upright, the tendons of the rotator cuff can “relax” and thus decreasing the inflammatory response due to impingement or overuse.

The beautiful thing about this model is that is applies to so many “shoulder related’ conditions. Thoracic outlet syndrome (TOS) is a function of muscle imbalances and posture. Studies are showing that cervical radiulopathy is also a function of thoracic spine and scapular positioning. Even distal conditions like carpal tunnel syndrome and tennis elbow can be traced back to shoulder positioning (not all the time, but it’s always something a prudent clinician should check).

Conditions such as rotator cuff or long head of biceps tendonosis, upper limb nerve entrapments, and even labral tears can usually be traced back to scapular positioning. But what can we do about this? How do we train the scapula more optimally? Here is the key: STOP doing external rotation exercises for the rotator cuff to fix scapular positioning  I see it all the time and it drives me nuts.

Now I will outline a summery of what I feel needs to be done to addresses many shoulder- related issues:

We all know that we should balance our pushes and pulls, especially with regards to our bench pressing and rowing, right? But what if it’s not so simple a relationship?

In essence, what we’re looking at here is balancing our ability to protract and retract the scapulae. Bench pressing is a horizontal pushing movement that you’d think normally produces protraction (forward movement of the scapula around the ribcage) and trains the muscle that cause protraction, a.k.a. the serratus anterior. The logical opposing movement would be a row of some sort. Balanced, right? Wrong.

Question: What’s the most effective scapular position to maximize bench press performance?

Answer: Retraction and depression

Question: What scapular position is achieved in the contracted phase of a rowing movement?

Answer: Retraction and depression

Balanced? Nope.

Get it? What looks good on the outside, feeds an imbalance on the inside. Serratus anterior becomes ineffective as a protractor, stabilizer, and upward rotator. Then there’s an added bonus. But first a quick anatomy lesson.

Next time you’re cutting on a cadaver (What? Doesn’t everyone?), check out the serratus anterior and the rhomboid. What you’ll find is that because of the fascia that covers everything in the body, they’re essentially the same muscle with the scapula kinda stuck in the middle.

So if the serratus anterior isn’t fully effective at producing an upward rotation force and the rhomboid (a downward rotator) is getting trained with both pushes and pulls, then guess who wins the tug-o-war with the scapula.

Correct! The rhomboids and downward rotation. This means you’re more likely to experience shoulder impingement. (thank you Mike Roberson for that great example!)

It becomes clear that one of the best ways to train the shoulder is…the PUSH-UP!!! This classic exercise is fantastic at activating and strengthening the serratus anterior as an upward rotator of the scapula. It also acts to counteract  the forces of pec minor by flattening the scapula against the rib cage (fighting that anterior tilt a tight pec minor exerts on the scapula).


Lear and Gross determined that push-ups performed with the feet on an elevated surface significantly increased the activation of the serratus anterior compared to traditional push-up variations. If it’s been a while since you performed traditional push-ups, it would be a good idea to start with basic variations, but elevating the feet is a viable progression if your primary goal is improved serratus function.
(J Orthop Sports Phys Ther. 1998 Sep;28(3):146-57.)

Another clutch exercise for optimal shoulder health is the Face-Pull. This exercise works to strengthen the scapular retractors…but the beauty of this exercise is that is does so with the scapula pre-set in an upwardly rotated position.  We must be careful here..too much posterior deltoid activity is no good…we want pure scapular retraction occurring with minimal humeral head elevation.


Another not so popular exercise that is often forgotten for shoulder health in the Standing Straight-arm pulldown. I love this exercise because it is dead easy to preform and coaching for it is a breeze. Very little that can go wrong here. This exercise is fantastic because it teaches the latissmus dorsi muscle to work to depress the humeral head in the glenoid without activating the deltoid. This will prevent excessive humeral head elevation with overhead reaching…a common source of pain in shoulder pathology patients.


Besides exercise, I will ALWAYS employ manual therapy to help with scapular positioning. Here is what I do:

Pec Minor soft tissue release (I would say ART but I’m not allowed…it’s like $2500 for a weekend ART course…are they serious?!?!) I digress… I pin the muscle just at its origin on the coricoid processes and passively or actively flex the arm in the plain of the scapula to release this muscle. I then do manual stretching to aid in loosening it up.

Levator scapula/Upper trap stretching and soft tissue release

Passive side lying scapular mobs into elevation, depression, upward and downward rotation


Thoracic spine manipulation to aid in upper back mobility

(Not exactly how I do it, but you get the idea…you want more of a superior directed force as opposed to a straight anterior to posterior force)

So how do you make a rotator cuff happy?

1) Address upper back posture.

2) Maintain optimal balance of the muscles around the scapulae and the shoulder joint.

3) Then addresses rotator cuff muscle strength AND endurance (which is an entire post in itself!)

Happy new year!!

2012 in review

Posted: December 31, 2012 in Uncategorized

This year over 10, 000 new readers found my blog from over 80 different countries. To some this may seem like a small number, but to me it is an epic accomplishment   I’m so happy that people are enjoying the content and I look forward to being more active with my blogging in 2013. It’s something I love to do and will try to write more relevant content week after week. Thanks for all the support!

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 10,000 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 17 years to get that many views.

Click here to see the complete report.

 

I wanted to share a quick story about a new patient I had at my clinic a few weeks back. This 34 year old male came in as a new patient with a complaint of some “minor knee pain” after falling at work. He walked into my treatment room with what seemed like good control of his knee. I didn’t see a limp nor was his gait antalgic in the least. I figured it was a muscle strain or something of that nature. I get him on the bed to do stability testing and this is what I find:

 

At fist I thought it was an ACL tear but upon further investigation it was a PCL tear. I didn’t show it in the video, but his sag sign was very positive.

I then did another stability test and this is what I found:

 

 

This maybe a little harder to see but he also have extreme laxity of his MCL!!

So let’s review: This patients calmly walks into my clinic with very little pain after falling at work and hearing a pop. He looks stable in gait yet these orthopaedic tests tell us a very different picture…not sure I’m able to explain this clinically

I had him go back to his GP to get an MRI to confirm my diagnosis and it was in fact shown to be a full PCL and MCL tear. His surgeon does not want to do surgery as the PCL has a very poor recovery rate as her his words ( I didn’t know that at the time).

Any suggestions on how to treat this? Just curious to see what others might do?

Pretty interesting case, right?!

Thanks for readng

Me and Dr. Craig Liebenson

 

Over this past weekend I had the opportunity to see Dr. Craig Liebenson present a course at SPC in Toronto. In this blog I will write a review of the course with some interesting take home points.

For those that don’t know, Craig is a chiropractor from Los Angeles. He is what I would call a revolutionary chiropractor as he has taken concepts from so many discipline and formed his approaches based on the work of physicians  physiotherapists, strength coaches, etc. He is well known for his ability to make us look at the body as a unit and not as separate parts that need to be fixed in isolation. He is a master at corrective exercise prescription and he understands movement better than pretty much anyone else I have ever heard speak. He is a strong advocate for bridging the gap from rehab to fitness…meaning manual therapy and modalities are great, but we must also teach our clients to move right to empower them to be able to heal their own pain.  HERE is the link to his personal website  where he literally gives away tons of information and printable exercise  sheets for patients. It is refreshing to know that he doesn’t charge for everything, and he doesn’t seem like he is in it for the money at all.

Craig started the day on a rather interesting “rant”. He told us we are in the midst of a rehab renaissance and if we fall behind, we will be lost. He encouraged us to see Pr Stu McGill, Grey Cook, and take DNS, kettlebell FMS, and SFMA courses to make us complete practitioners. Personally, I found this strange at the onset as he never said “good work” for taking a weekend and spending hard earned money to take his course. Instead he almost made us feel bad for not taking other courses. Towards the end of the weekend he rectified  this by thanking us all and saying how much he appreciates us in Toronto for having him back for a third time.

After his initial rant he went on to discuss societies failure. We as a society have become super sedentary and it’s reeking havoc on our health. He brought up an interesting slide that looked like this:
Obesity, High BP, and sedentarism
GP’s- medication, imaging
Ortho Docs- Injections and surgery
Gold standard: Manual therapy and Exercise

Essentially, we has physiotherapists, chiropractors and personal trainers (minus the manual therapy) are well positioned to educate the world about how devastating inactivity is. Dr. Liebenson told us we must be at the front lines of batteling this. I agree with him 100%!

We talked about the postural conspiracy and how poor kyphotic postures are causing lower back, neck, shoulder pain along with headaches and so much more.

Back and neck pain..check!

Bruegger’s exercise

We reviewed the joint by joint approach and we talked about the importance of micro-breaks for our office worker patients. To break the code and get people moving better, we can’t have them go back to sitting in a hunched position for hours at a time. This defeats the goals of corrective exercise. HERE is an exercise sheet I give to ALL my desk worker clients, regardless of their initial complaint. Throughout the weekend Craig had us doing Cat-Camels, Reach the ceiling, and bruegger’s exercises to keep us limber…he is a man that definitely practices what he preaches.

 

We discussed the overhead athlete and how shoulder impingement might be due to a contralateral hip internal rotation deficit. If a pitcher can’t post on his lead leg when pitching due to a lack of hip IR, he will ultimately have to use more force through the throwing arm to get the acceleration he needs. This over time can lead to a tight capsule and impingement.  Moral of the story: we must look at each client as a whole and not just treat the site of pain.

Breathing was also big. Long story short: we must breath through our belly and not our accessory muscles of respirations (pec minor, scalenes, upper traps) as this can cause chronic neck pain/tension.

Dynamic knee valgus was also discussed as a leading cause of ACL injuries in women (nothing new there).

Exercises to mobilize the thoracic spine such as the T4-8 sphinx, foam roller extension, and child’s pose positions open books were all discussed as ways to self-correct the kyphotic postures our desk jobs put us in….I should probably do some sphinx exercises right about now! We talked about squat training and how to from a goblet squat to a sumo squat and then to a potato sack squat with a kettle bell to train for a weighted squat with a bar…this was an excellent progression as I am always looking for better ways to teach my motor moron patients better progressions to squats with.

There was so much talked about on this course that is it very hard to summarize everything. I will say that the biggest take home for me was HOW we get our patients to buy in to the corrective exercise framework of rehab. I asked this question on the course….I wanted to know how we convince a back pain client who wants to get passive care to buy into an exercise based approach. This is how we should integrate this into our practice:

1) Find out what hurts (movement, ROM, specific exercises, ADLs…whatever!)

2) Find out what movements the patient is bad at that do NOT hurt (non-painful dysfunction)

3) Pick an exercise that helps correct #2  , which should also help with #1. You can pick ANY exercise you want, as long as it helps with the patient’s initial complaint. If you know the principles of movement, the method doesn’t matter as much. Just get the patient feeling better and moving better and they should feel better. If by doing the chosen exercise for teh non-painful dysfunction helps with the clients initial complaint, they are MUCH more likely to buy in.

(With all that said, I still think it will be impossible to get some of my patients to exercise…they just have ZERO interest in active care which is both depressing and frustrating as they are essentially denying them self a pain free existence due to laziness)

NOTE: Being able to tease out the non-painful dysfunction and then figure out which exercise to give that will help that dysfunction and simultaneously decrease their pain is hard. It takes practice and is the art of what we as manual medicine providers do. We must learn as much as we can about why we hurt and how the kinetic chain can become compromised. Once we know that, it becomes easy (as Craig said).

We left the course with this amazing quote by Karel Lewitt:

I am always aware of how many things which I taught in my long past have since been proved wrong. The most important attitude is therefore to be constantly aware that what you are doing and teaching now you will have to modify and correct in view of new facts. Thus you must keep an open mind for new knowledge, even if it sometimes shows that what you believed and taught before was wrong

Here is a small clip just to see what it looked like at the course. Enjoy:

IFOMPT Day review

Posted: October 8, 2012 in Uncategorized

Thursday was my second day at the conference and it was my favourite of the 3 I was in attendance for. To start the morning off we had Gray Cook talk about how we look at movement screening, testing, and assessing movement patterns. I wrote a full blog post on his talk that can be seen HERE .

After a break with exhibitors, I attended a specialist master class  pertaining to complex cases presentations. The presenters all described a real case which served as a great clinical lecture with real take home messages for me. Dr Trudy Rebbeck from Sydney Australia talked about a very interesting case of 15 year old football player who suffered concussion like symptoms after being aggressively tackled in a game. Any movement of the neck produced numbness and weakness in the arms and legs (yikes!). He was sent for an MRI which was “negative”. After a course of therapy including DNF exercises, gradual return to play re-training and balance training he was cleared to go back to his sport. The one detail that astounded me was after the initial MRI was cleared, the Physiotherapist (Dr. Trudy Rebbeck) wanted to see it because his symptoms just didn’t make sense to her. After she reviewed it and asked another radiologist to look at it, they clearly found out that this young boy had incomplete fusion of the arch of the atlas and small tears in the alar ligament. The condition is called Spina Bifida Atlnato and was completely missed by the first radiologist.
Moral of the story: We must exercise clinical judgement and we can’t believe everything is fine with our patients even when they are cleared medically.

There were other case presentations that dealt with similar situations. The overall theme of this class was to think holistically at the body and always to think outside of the box when treating any one specific joint. I.E anterior shoulder pain might be an issue with the rotator cuff, LHB tendon, cervical spine, thoracic spine, serratus anterior or lower trap weakness…the list is long and we have to differentiate to get a a true clinical diagnosis.

After that class the conference gathered back in the main room to witness Robert Elvey get the Geoff Maitland award for clinical excellence throughout his 40+ year career as a physiotherapist. He has been dumbed the father of modern neurodynamic therapy and has taught 1000’s of clinicians the art and science of OMPT all over the world. He was not in attendance to receive the award due to health matters, but his acceptance speech read by a friend and colleague of his was excellent. Congratulations to Robert Elvey on this distinction.

The last presentation of the day was called ‘Manipulation in the Thoracic Ring’ by Dianne and Linda-Joy lee. Unfornately I arrived just as they started and was forced to stand for the 2+ hour lecture with about 30-40 other people in the back. I could not write any notes down as I had no space to do so. Even with that in mind, I still highly enjoyed their talk. If you’re a physio in Canada, chances are you have heard of the lee’s. Diane lee is synonymous with the pelvis and they have been vital in their work of the theoretical model of thorax biomechanics. In a very large summery of what they said, their 30+ years of clinical experience has lead them to believe that many common orthopaedic conditions can be traced back to the thorax. It is their contention that the ribs can shift to the right or left… envision the rib-vertebra-rib-sternum complex as one complete ring. Therefore we have 10 complete rings from rib 1 to rib 10 (last 2 ribs are floating and don’t constitutive a true ring). They believe that subtle shifts in these rings can alter our positioning, creating muscle imbalance, join compression, and really many different problems. They used videos to demonstrate their ring re-positioning techniques on their patients with what seemed like miraculous results. The lee’s really made this concept look like the missing link that integrates all forms of therapy into one conceptual model. They showed video of a rower with a long history of LBP with rowing and long periods of sitting. In their video they showed the rower long sitting (like a rower position) and we saw his lower lumbar spine shift sideways with each rowing movement. L.J Lee then placed her hands along the side of the thoracic wall (which 2 ribs i can’t recall) and ‘repositioned’ the rings and told the patient to do another rowing motion. After her force was applied, the rower had no more pain in his lower back. All in all I left this presentation with so many questions as I always am skeptical of techniques that are advertised as cure-all’s. I’m not saying they out right said their form of treatment can cure everything, but they did have an almost mystic-like tone to their presentation. To learn more about their very interesting model, click HERE

In summary: This day and really this whole conference has been about the connection between research and clinical experience. We must use research to guide our practice, but we can’t let it be everything. Like the Lee’s said: RCT’s will never encompass or be able to examine the therapeutic relationship we have with our patients…and this is a very valid point indeed. This conference has also really been about thinking about the regional inderdependence of the body and to view it in a holistic way. Surprisingly, I didn’t hear as much as a I thought about specific manual therapy treatment. I heard more about functional movement assessment, integrated systems model (Lee’s), and the biopsychosocial model of pain.

Thanks for reading,

Jesse Awenus

This is a case presentation that I knew I had to share with my readers as i’m sure you will be as shocked with the ‘results’ as I was.

A 23 year old girl presents to me with an acute onset of left groin/hip pain after sitting down in a car 3 days prior. She came to me after getting a massage from an RMT at my clinic and was in even worse pain. She reported that after the pain started she went to the ER where the attending physician diagnosed it as a hip flexor strain/spasm. There was no imaging done.

Her complaint was that of an anterior/medial groin pain that was worse with hip flexion but was in little to no pain at rest. Her flexion/adduction/internal rotation test was positive for re-producing her complaint. She also mentioned that she has a history of hip discomfort from time to time while skiing and biking. My mind immediately went into differential diagnosis mode…could it be femoroacetabular impingement, labral tear, hip flexor strain, ingunial nerve irritation, pelvic alignment issue…the list goes on.

I continued to assess her using palpation, movemnet screens and length tension tests for the adductors, hip flexors, glutes, and quads. I also noted a mild anterior innominate on that side (yes, I know the studies proving we can’t really tell blah blah blah). After reviewing in my head her MOI and her complaint of pain with hip flexion and how a massage made no changes in her pain, I gave her a preliminary diagnosis of FAI. I treated her with gentle mobilizations of the posterior hip capsule, thomas test hip flexor stretching  and soft tissue work to the adductors. She reported “feeling better” after the initial session.  Fast forward two weeks later…

She comes back to me two weeks later stating that she felt amazing for one week after my treatment, which obviously made me happy. BUT she had xrays in her hand that she wanted to show me. She went on to tell me that while at the gym doing squats one week later the same pain returned but even worse then before. She stated that she could barley move her leg without pain. She went back to the ER and this time they decided to do xrays….and you won’t believe what they found:

Sewing needle in her leg!!

Do you see the red circle? Well, that is a sewing needle that got logged into her adductor muscles right behind her pubic bone on the left side….SERIOUSLY?!?!

She told me that when she sat down in that car (when the pain first started) she felt an immediate bout of pain but had no idea why. She was moving apartments and apparently a needle was sticking up from the car seat and BAM…right in the leg. How there was no blood or sign of the needle for almost 3 weeks (from time of injury to time of xray) is astounding to me.  I also have no idea how my treatment abolished her pain for almost a full week…yes, she literally resumed her life pain free until squatting at the gym made her sore again.

Anatomically, let’s think of how lucky she was…aside from all the muscles she must had hit with that needle, she also has one more major anatomical structure she avoided…can you guess what it is?

The needle could have easily hit her femoral artery causing a whole host of other issues! Yikes!

Femoral artery anyone?

Although this is a freakish case, it does make me think about something quite important.  My mind was all about biomechanics, and finding the route cause of her pain and not simply treating  her symptoms.  This can possibly get us in trouble at times because if we are so caught up at finding what we believe is the “cause” of the problem, we might actually miss the real cause, which might be staring right in front of us. Now, I admit that I am VERY lucky my treatment didn’t make anything worse, but there was no way that from her history I would think she was impaled by a metal object! This case made me realize that anything can walk into our doors as physiotherapists and we have a duty to our patient to make sure their pain is actually within our scope of practice to treat instead of assuming it’s due to faulty movement patterns, motor controls issues or any other catch phrase term that is popular now.

Hope you found this as interesting as I did!

Oh yeah, the doctors took out the needle using local anesthetic and she was pain free 2 hours after the surgery…go figure!

 

Homunculus Man!

The following blog is going to be a review of a recent study I read and a topic that has really been on my mind for the last several months. Essentially, from my visits to SomaSimple.com and reading Jason Silvernail and Barrett Dorko’s expert writing on the topic of pain, I have started to question my motivation for practicing the way I do. In making this short and simple, I will only say that being a reflective practitioner has made me question the framework I have chosen to use to treat my patients. When a client comes to be with chronic back pain, I assess them biomechanically and start manual therapy, patient education and corrective exercise to either “hold” the manual work I have done on them or to strengthen areas I deem as being weak leading to a painful dysfunction. But am I doing all that I can to help? Am I really even scratching the surface in terms of finding the cause of their pain? What if pain is actually all in the brain? What if the representation of pain from their back is so pronounced on their brain that manual therapy and exercise alone just won’t be enough?

The article I read that discussed just this is called ‘A neuroscience approach to managing athletes with low back pain’.  It comes from the journal Physical Therapy in Sport and was published in 2011. Basically, the premise of the article stipulates that recent neuroscience research into the biology of pain suggests that clinicians (me) involved in the management of the athlete with LPB should embrace a biopsychosocial approach by engaging the brain and nervous system. What does that mean? How does one even do such a thing? These are the questions I had and this article did a decent job of explaining it.

As per the article, a true biopsychosocial model includes a greater understanding of how the nervous system processes injury, disease, pain, threat and emotion. These components work homogenously to create the sensation of pain. This model includes several categories, some of which we are very good at working in at and others we probably should be doing more of. The categories include our working understanding of functional anatomy, biomechanics, tissue pathology, pain mechanisms, representation, psychosocial issues, and fear avoidance.

For me, the most interesting of these categories is representation. Essentially, this model of pain takes on the brain and its processing of pain to treat a patient. New functional MRI (fMRI) scans have allowed scientist to show that when the brain processes information from tissues, many areas are activated to deal with the THREAT of an injury, disease, or situation. These areas, via connections in the brain, generate a “pain map”, which is commonly referred to as a Neuromatrix. The key point here is that the neuromatrix is NOT dependent on any specific tissue (disc, facet, nerve etc), but rather the impending THREAT of pain. “Emotional pain uses similar area to physical pain”. Therefore, if the sum result of the brains processing of information concludes that tissues are in danger (real or perceived), it is logical for the brain to produce pain as a means of protection. This means that anytime the brain perceives pain even from non painful stimuli such as bending forward, or back exercises, this map activates and pain is produced. The problem is when other “maps” form in the brain regarding beliefs, perceived knowledge about pain, and social issues are formed.

Maybe that patient with chronic pain that I was speaking about before has built in maps of pain that can’t be fixed by manual therapy. What if his original back pain started when bending over to pick up a pencil? What if he also had financial or relationship issues when the pain started? These issues all factor in to his current pain state and how it needs to be addressed. The article does a fantastic job of summarizing this by stating:

“Therapists treating athletes with LBP should realize that by addressing the tissue issues (e.g. joint strain, instability etc) with typical therapeutic interventions (e.g. spinal stabilization exercises, manipulation etc) they are only addressing one of the perhaps many issues associated with the development of LBP. The athlete may have such an innate fear of LPB that any activation of the amygdala may activate the LBP map, even though “the tissues have healed”. If medical care continues on the path of seeking the injured joint or tissue and results in more medical tests, more opinions, and more failed treatment then fear itself may increase and LBP may persist”

We have all had those patients that just never seem to get better…don’t lie, I know you all have! Maybe with these patients treating their tissue through whatever technique or exercise you like to utilize is just not going to work. They might require a biospsychosocial model to help them understand their pain and reorganize those maps in their brains to really make them believe that hurt does NOT equal harm and that they will be just fine. The article makes the case that we must educate our patients on pain biology and why they feel pain. With a firmer understanding of their pain and why they experience it via educational sessions, it has been shown to have immediate improvements in patient’s moods regarding pain, improved physical capacity, and a better outlook on their future.

The article concludes by saying we should not abandon our manual therapy techniques at all. We should do all that we are doing so well with our clients, but we need to incorporate pain education by addressing the psychosocial aspects of pain, especially fear, anxiety, and faulty knowledge regarding the cause of their pain. Some practical advise would be:

  • Do NOT tell clients they have degenerative disc DISEASE! All they will here is that they have a disease and the fear and anxiety will surely become elevated. Instead tell them they are experiencing a normal phenomenon with ageing and that pain is only temporary and they should continue with their ADLs as tolerated.
  • Do not show clients pictures of their herniated discs, osteophyets etc. This does nothing but make them think they have a physical deformity in their back that requires surgery or will never get better on their own. Instead, explain that thousands of people have the same imaging findings and have zero pain! There is very little correlation between MRI/Xray findings and pain.
  • Explain that hurt does not equal harm and that pain will go away with appropriate care. Explain that manual therapy serves to reduce pain by stimulating the nervous system…not by moving a bone back in place. This breeds a dependence on passive care that, in my opinion, is so unfulfilling to treat.
  • Include aerobic exercise into your treatment of chronic pain. Aerobic exercise has been shown to help clients who have a very widespread pain neuromatrix. It helps by increasing oxygen and blood to various tissues and has been shown to actually decrease nerve pain from sensitized nerves, help patients sleep better, improves mood and reduces depression.

This article talked about so many great ideas on why we feel pain but I think I gave to the gist of it. Empower your patients to be active in their recovery. Challenge them to not let their pain “win” and they are stronger than their pain.

For a phenomenal resource that can be easily used to teach pain concepts and why we experience it, I would urge you to check out the patient education book ‘The Pain Truth and Nothing But‘ By Dr. Bahram Jam of the Advanced Physical Therapy Education Institute. It is simple to read, funny at times, and highly entertaining.

For a great educational video you can easily show your patients, take a look the youtube video ‘Understanding Pain: What to do About it in less than 5 minutes:

 

Reference:
Puentedura, E., and A. Louw. “A Neuroscience Approach to Managing Athletes with Low Back Pain.” Physical Therapy in Sport 13 (2011): 123-33. Print.

Have you ever had someone tell you that before? I get asked questions like this all the time in my practice. People who crack their hands, spine, knees, feet etc ask me if they are causing damage to themselves by cracking their joints. I always ask them if there is any pain/numbness/tingling associated with the crack. If they say no, I tell them not to worry about it as there is no evidence that says cracking is bad for you or will give you arthritis. (Authors note: The studies I am referring to were only conducted on the hands and I don’t know of any literature that addresses this question for any other part of the body).

In short, there are a few reasons why joints “crack”. It could be because of a tendon snapping over a bone (snapping hip syndrome). Or it could be a bone moving over another bone (snapping scapula syndrome). A true joint crack occurs when joint surfaces of an encapsulated joint (say a facet joint in the spine) are separated. This in turn creates a reduction in pressure within the joint cavity. In this low-pressure environment, some of the gases that are dissolved in the synovial fluid (which are naturally found in all bodily fluids) leave the solution, making a bubble,,which rapidly collapses upon itself, resulting in a “clicking” sound. This process is known as a cavitation and is the same sound you hear when a physiotherapist, chiropractor etc manipulates your spine.

The common advice that “cracking your knuckles gives you arthritis is not supported by any evidence to date. A 2011 study from the Journal of the American Board of family Physicians examined the hand X-rays of 215 people (aged 50 to 89) and compared the joints of those who regularly cracked their knuckles to those who did not. The study concluded that knuckle-cracking did not cause hand osteoarthritis, no matter how many years or how often a person cracked their knuckles. “The prevalence of OA in any joint was similar among those who crack knuckles and those who do not”

In 2009 a doctor by the name of Donald Unger won a Nobel Prize for a study of one participant…HIMSELF! He cracked the knuckles of his left hand every day for more than sixty years (that’s dedication), but he did not crack the knuckles of his right hand. In the end, no arthritis or other ailments formed in either hand after 60 years of cracking his left hand.

So all in all, cracking the hands is not a problem, and there is nothing that would lead me to say stop doing it. However (and it’s a big one)…If you have ANY pain or limitation with joint cracking, it is best to seek consultation with a health care professional. You may have a joint instability or hypermobility which may cause you problems down the road if not properly addressed.

Have a great week!

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist

DeWeber, Kevin, and Rebecca Ortolano. “The Journal of the American Board of Family Medicine.” Knuckle Cracking and Hand Osteoarthritis (2011): n. pag. Knuckle Cracking and Hand Osteoarthritis. Web. 22 July 2012. <http://www.jabfm.org/content/24/2/169&gt;.