Posts

The Muscle Of The Soul, Or Just A Good Stabilizer?

It may be the most popular muscle in the world. 

For some reason, it gets a lot of credit for things and stirs up more debate than any other muscle (at least from what I’ve seen). 

Yes, we’re talking about the muscle of the soul! The wonderful Psoas. 

It’s been given credit for many a thing, including but not limited to: 

  • anterior pelvic tilt
  • breathing disruption
  • manifesting physical symptoms of fear
  • knee pain
  • digestive problems
  • low back pain
  • and even somehow is part of our reptilian brain?

Whoa, this muscle is doing a lot!

When we look at some of these statements, they are often prefaced with “believed to,” and while people are entitled to believe whatever they want, some of these things are also taken as fact within our profession. 

When I was in college, this was often touted as the main reason people have low back pain. 

The muscle’s biomechanics showed us how a tight psoas was creating an increased lumbar lordosis when it was in a “shortened” position in everyone from office workers to cyclists. 

But what does the updated research say? Well…let’s get into that!

Biomechanics

First, it’s probably important to do a quick review (and yes, I had to look this up). 

It starts on the transverse process of T12-L4 as well as the intervertebral discs and inserts on the lesser trochanter of the femur. 

This research article(1) takes that a bit deeper and shows there are attachments on the anterior part of all lumbar TVP’s and the anteromedial aspect of the lumbar discs and bodies except on the L5/S1 disc. Where it attaches to the TVP’s is considered the posterior attachments, whereas the disc and bodies’ connections are considered the anterior attachments. There was an argument that those anterior attachments would pull the lumbar spine into and increased lordosis, but that  was with an assumption the attachments were more on the anterior surface of the vertebral body, not the TVP. 

When I was in school (and granted that was quite a while ago), we were taught that Psoas was primarily a hip flexor that worked along with Iliacus to accomplish the movement. However, some more recent studies(1) have shown it plays some other roles, including: 

  • advancing the lower limb while walking
  • controlling deviation of the trunk while sitting
  • some action with rotation, abduction, and adduction of the hip
  • lumbar spine stabilization
  • hip stabilizer

Interestingly, the study (1) looked at how the Psoas influenced hip pain in a hockey player, but not much discussion around low back pain. 

So, is the Psoas a culprit for patients presenting with low back pain?

Size And Role

A couple of studies looked at Psoas under MRI to compare cross-sectional size between those with low back pain and those without, and the results are pretty to interesting. 

They found those patients dealing with low back pain had a larger Psoas Major than those without pain. (2)

One possible reason for this is that Psoas is a lumbar spine stabilizer; the muscle’s hypertrophy was due to increased activity in those with some degenerative disorders in the lumbar spine, so it’s working as a support or protection for the area. (2)

When they looked at fat infiltration and whether it plays a role, there was a correlation with some atrophy of the lumbar paraspinal muscles, which would cause Psoas to increase its activity as a stabilizer for the lumbar spine. However, there was minimal infiltration of fatty tissue within Psoas. 

One other study looked at how Psoas was affected in older generations and did show there was a difference in size between men and women, which is likely due to hormone deficiencies after menopause. (3)

When there were degenerative changes with the lumbar discs or segmental instability in the spine, they noticed that Psoas actually got smaller. However, this is likely because more pain is associated with these degenerative changes, so the size change is because of disuse. This could also directly correlate to fear avoidance, where a person stops certain activities because they’re worried about reinjuring the area or making it worse, especially after getting what sounds like a scary diagnosis. 

To me this is a little bit of a chicken or the egg. Could Psoas be causing pain, or is it’s size adapting because of pain resulting from something else? I’d argue it’s the latter.

So now we understand that Psoas is more of a support to the lumbar spine rather than something that is pulling it into lordosis or causing pain; the question remains…do we treat it?

Well, there’s a lot of controversy around this, and I’d say it depends.

Although I know if I do a treatment in this area in the way I was shown in school, I can definitely feel the psoas “pop up” under my fingers. However, we also know there is A LOT of stuff in the way to be able to palpate something that deep. Because in reality, we can’t palpate something that deep even though we can feel it “pop up”. 

I have a person who comes in once a month for treatment and really enjoys getting their Psoas worked on. They feel it benefits them greatly for the activities they participate in. So, yeah, I’ll treat it for them. However, if this was a new person coming in and saying their back pain is a result of the Psoas, well then I’d be digging a bit deeper into their reasoning and having more of a conversation to educate them on how Psoas is probably helping more than it is causing an issue. It’s one of those things where our clinical experience and decision making have to come in to play. Some say we should never treat the area but we also have to take patient preference into account and what they believe will help them. If you’ve been treating the area and having reasonable success and your patients like it, then keep on keeping on. But change the narrative around it. Take the time to educate a little and see if it’s really necessary. Especially if you’ve been giving this kind of treatment and the person is uncomfortable during the treatment (let’s be honest, it’s a pretty sensitive area), then offer to change things up and try something different. Just make it a joint decision between the two of you and strengthen that therapeutic relationship. 

If you haven’t subscribed yet, check out our new podcast HERE, we’ll be discussing Psoas this week and discussing some of the research around it. 

References

  1. Sajko S, Stuber K. Psoas Major: a case report and review of its anatomy, biomechanics, and clinical implications. The Journal of the Canadian Chiropractic Association. 2009 Dec;53(4):311.
  2. Arbanas J, Pavlovic I, Marijancic V, Vlahovic H, Starcevic-Klasan G, Peharec S, Bajek S, Miletic D, Malnar D. MRI features of the psoas major muscle in patients with low back pain. European spine journal. 2013 Sep;22(9):1965-71.
  3. Sions JM, Elliott JM, Pohlig RT, Hicks GE. Trunk muscle characteristics of the multifidi, erector spinae, Psoas, and quadratus lumborum in older adults with and without chronic low back pain. journal of orthopaedic & sports physical therapy. 2017 Mar;47(3):173-9.

Articles of the Week February 21, 2021

Tony Gentilcore makes some great points about beliefs surrounding “bad” workouts and self-efficacy with one’s routines. We can likely translate these points very well when it comes to programming home exercise programs for clients as well.

Do Bad Workouts Exist? – Tony Gentilcore

We wrote a similar blog to this one a few weeks ago, but the content bears repeating. The words we say and the way we say it can have a major impact on the outcomes we have with our patients. Let’s start to change not only the narrative around what we do, but also what we say.

Words Matter – Eric Purves

We talk lots about patient safety, but our safety is just as important (if not more). So when I saw this shared by one of our friends I knew it was worth the share (well…also cause I’m a firefighter).

Oily Linens – Massage Therapy – Fire Safety – Megan Crozier

Pretty cool review of the receptors in our bodies and what they do.

Types Of Receptors – Dr. Matt & Dr. Mike

There is many a frustrating debate online, no matter what the topic is. This is a pretty cool little flow chart on how we could handle some of these discussions. While Taylor meant this for himself, it might be something I use as well.

On Discussions And Debate – Taylor James Laviolette

 

5 Ways to Prevent Professional Burnout

A reader who works with a chronic pain, military population recently asked if I had any tips to prevent burnout. Here are some of mine and also some I gathered from Social Media.

 

1) Take Different Con Ed Courses

  • Most of us gravitate toward con-ed courses we are familiar with, have a certain reputation, etc
  • A good way to prevent burnout is to expose yourself to a good seminar on a topic that is novel and challenging
  • To most I would recommend Explain Pain or Therapeutic Neuroscience Education
  • Getting new ways to interact with patients, especially a chronic pain caseload that does not respond rapidly helps
    • Changing your mindset as to how you view these patients prevents the “I feel powerless to help”

 

2) Hangout and interact with like minded professionals

  • join a group like PT: Practice, Education, and Networking on facebook started by my buddy Rick Daigle of Medical Minds in Motion
  • participate in a forum like Manual Therapists, ask questions and chime in on other people’s posts
  • try to start a local Clinician’s group where you can practice techniques, assessments and discuss cases semi regularly
  • avoid arguing on the internet or with colleagues who are stuck in a model that disagrees with your practice (to a point)

 

3) Consider taking part time cases in a different setting

  • if you’re in outpatient, try home care
  • even 2 different cases in a different setting once a week really helps prevent burnout
  • prior to all my different endeavors, I worked full time in a private clinic (as a manager), did Clinical Peer Review, and taught at 3 different PT schools, needless to say, I did not get bored!

 

4) Don’t take your work home with you

  • obsessing over a case you think you could have done better often prevents you from relaxing at home
  • if you need help, ask online in a facebook group, twitter, or a forum, but otherwise enjoy your time away from work
  • just like I tell my chronic pain patients, make sure you take time to listen to your favorite music, have a glass of wine, or watch your favorite movie

5) Strive to change and adapt regularly

  • part of stagnation or burnout is a lack of change, we all need variability
  • if you have not changed the way you assess, treat, or the framework at which you make your clinical decisions at least every 2-3 years, it is time for you to rethink things!
  • finding a mentor, whether it’s online or in person really helps with this as you watch them in their patient interactions

Articles of the Week – February 14, 2021

We’ve got some big news this week! We’ve launched a podcast! Together with Eric Purves we’ll endeavour to put out a new podcast every two weeks. Give this one a listen as we look into some research that shows how client, community, and clinician can influence a persons pain. Subscribe on one of your favourite podcast platforms!

Client, Community, and ClinicianJamie Johnston & Eric Purves

 

There’s lots of talk about education in this week’s articles. This one specifically shows us the importance of the conversations researchers or doctors have with patients when discussing nocebo effects.

“Important Conversations” Are Needed to Explain the Nocebo EffectAnita Slomski

 

We are all taught to not chase pain and to avoid making assumptions purely based on palpation and tenderness. However, we have some emerging evidence that physical tenderness might be a more valid predictor for making return-to-activity decisions that we once though, once we learn how to quantify it.

Tenderness to palpation predicts return to sport following acute hamstring strain – Physio Network

 

Have you ever recommended that clients cease running in order to conserve the cartilage in their knees? Or are you on the other side, suggesting that it’s beneficial? Research is still working on a definite answer, but hopefully the current evidence can help you with an informed decision.

Why Don’t Runners’ Knees Fail More Often? – Alex Hutchinson

 

We understand there can be psychosocial factors associated with pain, however we have to be careful how we discuss this with our patients. While the title of this post lends itself to the idea that a doctor told someone their pain is all in their head, there’s much more to the pain education that is necessary and what was given.

My Doctor Told Me My Pain Was All in My Head. It Ended Up Saving Me. – Isobel Whitcomb

 

Mike Reinold provides us a good review of the literature regarding compression therapy and its effects on acute soreness and recovery following exercise.

Compression Therapy for Recovery – Mike Reinold

Rules and Recipes: Moving On From Older Models Of Manual Therapy

As I sat at the head of my treatment table this morning, looking down at my patient, I viewed their right leg in external rotation while at rest, I flashed back to my training. This patient is seeing me for sciatica-like symptoms on the right side.

My training taught that pelvic asymmetries might manifest as one leg presenting as internally rotated and the other side as externally rotated. I learned diagnostic measures in standing and supine to check for those pelvic asymmetries and treat them accordingly, both at the pelvis (wedges, pelvic balancing techniques, etc.) and the legs themselves. Often, when I applied the work based on the theories presented, my patient’s symptoms improved. Many times, their pelvic torsions and leg rotations also seemed to balance out. These changes, both in reported pain and noted postural changes, worked to validate the theories taught to me.

But today, I had a thought.

While my deconstruction of much of what I was taught in my MFR (and other) training is well known, I continue to reflect on my past’s good and bad. How do I know that my patient’s leg rotation deviations are new? How can I be confident they contribute to their pain and not just a manifestation of a life of living? Bunnell (1993) points to the “normalcy” of spinal asymmetry, with 98.4% of us having a rotational spinal curve (scoliosis/sub-scoliosis), and such spinal curves will, by association, create skeletal and postural changes up and down the body. If 98.4% of us have such changes, are 98.4% of us doomed to pain and other problems resulting from that spinal curvature?

Modality training teaches us recipes. They all do. Recipes are not causational-fact-based. MFR taught me to assess pelvic symmetry as if the pelvis is not balanced, then nothing we do will last. But other training lines teach different rules that often conflict with the rules I follow and with which I found success. My MFR training also taught that unless my patient realizes the emotion holding patterns that led to the pain/problem, they will never truly heal.

I used strategies taught to me in my MFR training to get my patient to become more aware of those past emotional holding patterns and how to help them free themselves, often “pre-training” them by posting such information on my website. I was taught that emotions are stored in restricted fascia and passed that belief onto my patients, speaking with a sense of knowing and authority. I applied these principles, and my patients felt better. The adherence to the recipe, to me at least, validated the explanatory information as it was taught to me.

Do you recognize yourself in all of the above? I’m not just speaking to MFR, as such recipes exist in nearly every manual intervention model we can use/learn. I’ve heard from clinicians that if one doesn’t spend an equal amount of time working both limbs, then the patient will somehow leave the session out of balance. I’ve heard that if the feet are not balanced/levelled, then nothing we do elsewhere will be retained. I hear from upper cervical proponents that if C1 is not put in the proper alignment with the skull, work elsewhere is useless or that if we get C1 back into place, this alone will cause the body to restore its balance. Craniosacral therapy (CST) teaches that we must restore normal movement to the spinal dural tube, change is not attainable. The recipes are nearly endless. When we use a recipe, it often works, which often causes us to believe that the recipe was the correct one and, in some cases, the best one.

Is there a “best” modality? Is one recipe superior to others? Some believe that there is. I was taught so, but what sort of external measurement is done to validate these claims? I’ve seen internal validation by many (including myself in the past). “I’ve been a therapist for 30 years, and ABC MFR is the most effective modality in the history of healthcare.” In today’s pollical climate, fact-checking has become both envied and vilified. How does one go about fact-checking a claim about the superiority of one intervention over another? That is the place of rigorous research studies. To my knowledge, there has not been a reputable study that shows one branded or unbranded manual therapy intervention superior to another.

In a recent The Thinking Practitioner” podcast, Til Luchau and Whitney Lowe interview Mark Bishop, PT, who talks about the science behind the factors at play that make our work useful. While we like to think our outcomes are due to our mastery of finding and impacting the tissues-at-fault, much more goes into the therapeutic interaction besides any tissue-based singular selection and impacts. The full transcript from the interview is available through the above link. Such conversations are becoming more common. Though many feel that their skills and education are being diminished, what is happening is there is a better understanding of how and why we, as manual therapists, influence our patient’s problems. There is dissonance from tissue-based believers, as it seems like these newer models detract from the positive outcomes they’ve seen using the recipe of their modality. If presented in a demeaning manner, few listen. But if presented constructively, one that does not put down the hands-on work we’ve done, growth can occur.

MFR, and all other modalities and styles of intervention, are helpful. On that, we can agree. But is the efficacy due to the reasons stated in those individual seminars or lines of training? Possibly. But there are aspects that are seldom discussed in those training as they are more generic and do not seem to contribute to an individual educator’s superiority claims. All of this disagreement can get ugly, I know. Continuing education is big business, and brand-building is an essential part of a big-budget model of training. If we all started speaking the same language, and acknowledging that there are marked similarities in our shared styles, the demand for any one model may diminish.

I learned some pretty hands-on skills in my MFR training and others, and I am thankful for that. What I now find less helpful is the rationales presented in those trainings, rationales that elude external validations. I learned recipes, not science. Recipes should not be discarded, but can you take that recipe and add a layer of credible understanding and utilization of neuroscience and behavioral science to form a more cohesive, universally accepted model? OI hope so.

So, as I sight down my patient’s body, I see that that externally rotated leg may be a part of her that may never change, nor may not need to. I cannot look back in time to see if it always existed in that fashion, and I no longer see the need to “correct” that deviation. I still use the hands-on intervention style taught to me in my MFR training; I just no longer force the recipe taught there. Should we, as physical therapists, massage therapists, etc., be telling our patients that their emotional holding patterns are the reason they cannot shed their pain? I believe that it is not my place, from a professional scope of practice perspective, nor do I think that this is even a credible interpretation of existing scientific understanding. Stay in your lane, folks.

Suggestions? Give a listen to The Thinking Practitioner podcast at the link above. That could be your gateway to a deeper and more thorough understanding of how manual therapy works. Don’t let detractors sway you; we mean well. Some of us, including myself, at times, get a bit pushy, but remember, we’ve all been where you are right now. I began crossing the chasm from tissue-based beliefs to a broader human-being-based understanding of pain and impacts 15 years ago, and I am still learning and evolving. If you’d like someone to walk across the bridge with you, please feel free to let me know.