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Articles Of The Week May 10, 2020

 

We are in an unprecedented time, which is about to get more confusing. Rumour is we’ll be allowed to go back to work soon and we aren’t really clear on what the rules surrounding that will be just yet. A lot of things will be left up to your clinical decision making and we have to be able to work with a clear conscience. And that will be entirely up to you.

“Your Governor Is Not A Massage Therapist” – Cal Cates

Whether we are using telehealth or seeing a patient in-person part of our job is to help motivate a patient with regards to their homecare. Here’s some great advice with regard to motivating patients for home workouts.

“How to Motivate Clients for Home Workouts” – Guillermo Munoz

During this social isolation, it can be hard to figure out ways to stay active. Here’s some great advice (with an infographic to share) on various ways we can not only stay active but also boost our mental health during this time.

“Stay Calm, Be Active: Simple Ways To Boost Your Physical Activity During COVID-19” – BJSM

I’m sure we’re all taking some online classes right now (or perhaps putting some on) just to kill the boredom. Here are some great tips around the etiquette of taking online classes…and yes, one of them is putting clothes on!

“The Etiquette of Online Classes” – Zeel

There is many a manual therapy myth out there when it comes to patients dealing with low back pain. Here’s another classic example along with the reasons why we need to stop blaming a specific muscle for back pain.

“Why We Need To Stop Blaming Transverse Abdominus For Back Pain” – Brendan Mouatt

 

Why Weak Glutes Aren’t A Reliable Predictor Of Low Back Pain

It seems we are constantly trying to find causes for low back pain with our patients.

Quite often we are caught up looking for biomechanical issues (which there often are) and avoiding other things that could influence a person’s pain.

One such instance is the possibility that weak glutes are a contributing factor.

I recall seeing one of my instructors demonstrate this (what I perceived to be) complicated movement test where my patient was lying prone and having them extend their leg. There was a specific pattern where the muscles in the low back down through the glutes and hamstrings were supposed to move.

This would be followed up with the comment: “your glutes aren’t firing”!

While I watched this all I could think was…”there’s no way I’m going to remember what order all of this goes in”!

But, when done with confidence and a really good explanation, it seemed to make sense to me, and the patient.

So, I worked through the low back, glutes, and hamstrings, and the patient felt better after the treatment.

I proceeded to pat myself on the back for a job well done!

However, the next time a patient came in for what I thought was the same issue, I couldn’t remember this specific pattern of movement and what it was supposed to tell me! Why couldn’t I get this!?

Well, in reality, I really didn’t have to and here’s why.

Limitations With Testing

There are a couple of tests used to see if the glutes are a contributing factor to low back pain, so let’s look at both of them.

The prone leg extension test1 is pretty commonly used to test for low back pain and lumbopelvic function (this is the one my instructor was demonstrating to me).

The pattern of movement you’re supposed to see is (if you were testing the right side) right glute max, right hamstring, left lumbar erector spinae, right lumbar erector spinae, left thoracolumbar erector spinae, then the right thoracolumbar erector spinae. A delay in glute max recruitment is supposed to show a dysfunctional pattern of movement.

There is a whole list of other patterns that are supposed to mean other things, but it’s a long list and more than I want to get into for the purposes of this post.

A studyshowed there was no consistent order of activation during the test and glute max was the last muscle to become activate with time ranging from 0.07 to 0.676 seconds in delay.

Now, these tests were done with proper EMG testing, so I have to wonder…how would we ever be able to properly assess this just using touch and vision!?

Another test we were taught was “Trendelenburg”, or “SLS” to assess for glute weakness possibly contributing to back pain. 

With this test, a practitioner stands behind the patient and has them raise one leg so the hip is between 60°-90° of flexion. A positive test shows lateral pelvic tilt on the stance leg, which is supposed to represent glute weakness on that side.

One study 2 compared the differences between those with chronic low back pain vs. a control group using Trendelenberg. It actually showed the number of positive tests was no different between the groups. There was also no difference in glute med strength between those who scored a positive and negative test.

Since there was an equal number of positive and negative tests between both groups it showed this test is unreliable to differentiate between those with chronic low back pain and those without, nor was it reliable for demonstrating a difference in glute med strength.

Another study 3 actually injected a superior gluteal nerve block to see if there were any alterations in different movement variables. They found after the injection there was no difference in contralateral pelvic drop, hip adduction, or hip abduction due to reduced strength of the glutes post-injection.

The researchers found this surprising as an impaired gluteal nerve has always been associated with the SLS test.

So, in other words, lateral pelvic drop is not associated with weak glute med muscles in our patients who are dealing with chronic low back pain. It was even suggested that glute med strength of less than 10% of body weight is required to actually get a positive SLS.

The suggestion was also made that in order to maintain your stance during this test it is because of all muscles attaching to the greater trochanter working together combined with the mechanical force of the iliotibial band. This shows a positive SLS is more likely a global issue rather than a specific spine and pelvis issue.

In light of their findings they showed how this test could not distinguish between who was experiencing low back pain and who wasn’t, nor could it identify those who had weak glutes, and in fact demonstrated the test was probably due to some other issue altogether.

Another study 4 showed the presence of low back pain was a combination of higher BMI, signs of hip abductor problems, significant glute med weakness, gluteal tenderness, and a positive SLS (but the strength testing was admittedly not reliable in the study). However, this study showed something else that is probably far more significant which we will look into next.

It was unclear if glute med muscle weakness was the cause of the low back pain…or just a consequence of it.

Muscle Activation, Weakness, Or Protection?

Quite often when discussing this kind of thing and it’s relation to low back pain, the discussion can revolve around not only issues with the glutes, but also hamstring length and activation patterns between the two.

Inevitably when discussing “weak glutes” it’s due to an S.I. joint “dysfunction”, or this dysfunction is causing the weak glutes. But really, what is dysfunctional with the S.I. joint in this case?

They 5 described S.I joint dysfunction as; low back pain below L5, pain over the posterior aspect of SI joint around PSIS and buttock with or without above the knee leg pain. They used a combination of three SI joint provocation tests (posterior shear, compression, distraction, and sacral thrust) that showed good sensitivity and specificity (although the sensitivity rating was much higher).

When we look at the discussion around which muscles are “activating” with certain movements it is usually centered around the context of the pain-spasm-pain model which suggests pain results in increased muscle activity, in turn creating more pain.4

Or, the pain adaptation model which suggests pain reduces activation of muscles when active as agonists and increases activation of muscles when active as antagonists.They say this will reduce movement and ROM which would, in turn, prevent mechanical pain and further damage to the tissues.

The funny thing is that while both of these models are trying to prove the same thing, they end up contradicting each other quite a bit and neither of these ideas can predict how back pain will affect muscle activation.

There is lots of discussion around both increased and decreased muscle activation due to pain which results in disrupting motor control. However, this systematic review 6 argues that increases in muscle activation is an adaptation that occurs for various reasons, and those changes are mainly to avoid harmful stress placed on already injured structures, and to increase stability around the spine.

In each case, they looked at any changes that were task-dependent, related to an individual problem, and highly variable between each patient. This also shows those changes are functional since they are trying to reduce unpleasant stress and provide stabilization to the spine.

One common thread through most of the research cited is glute weakness in relation to back pain. However, it’s a bit of a chicken or the egg, is the weakness a result of reduced use because of pain, or did the weakness cause the pain? I’d venture to say it’s due to the reduced use.

While this can all sound maybe a little complicated and like word salad, when we look at everything we know about pain, what is this actually telling us?

One thing we know for sure that pain is ALWAYS a protection mechanism. So, if something in our body has a decreased ROM for a period of time in order to prevent stress in a sensitive area, this is just simply a way to protect that area. If those altered movements are also providing extra support to stabilize something, it’s actually doing this to protect the area! With this understanding we have to ask, does it really matter what order a muscle fires in (especially because we’d never be able to accurately assess this with just the human eye)? What we should be concerned with is calming those sensitized areas down, reassuring the patient they aren’t broken, and educating them as to why they’ll be okay. Then get them moving in pain-free full ranges again and help strengthen the area, build up that resilience!

 

References

  1. Lehman GJ, Lennon D, Tresidder B, Rayfield B, Poschar M. Muscle recruitment patterns during the prone leg extension. BMC Musculoskeletal Disorders. 2004 Dec 1;5(1):3.
  2. Penney T, Ploughman M, Austin MW, Behm DG, Byrne JM. Determining the Activation of Gluteus Medius and the Validity of the Single Leg Stance Test in Chronic, Nonspecific Low Back Pain. Archives of Physical Medicine & Rehabilitation [Internet]. 2014 Oct [cited 2020 Apr 17];95(10):1969–76. Available from: https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=98597253&site=ehost-live
  3. Pohl MB, Kendall KD, Patel C, Wiley JP, Emery C, Ferber R. Experimentally reduced hip-abductor muscle strength and frontal-plane biomechanics during walking. Journal of athletic training. 2015 Apr;50(4):385-91.
  4. Cooper NA, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA. Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. European Spine Journal. 2016 Apr 1;25(4):1258-65.
  5. MassoudArab A, RezaNourbakhsh M, Mohammadifar A. The relationship between hamstring length and gluteal muscle strength in individuals with sacroiliac joint dysfunction. Journal of Manual & Manipulative Therapy. 2011 Feb 1;19(1):5-10.
  6. van Dieën JH, Selen LP, Cholewicki J. Trunk muscle activation in low-back pain patients, an analysis of the literature. Journal of electromyography and kinesiology. 2003 Aug 1;13(4):333-51.

 

 

 

Knee Tilt Mobilizations – Improve Knee Flexion Past 90

This is one of my favorite old school manual therapy techniques I learned while in Fellowship with the University of St. Augustine.

When my current techniques of tibial IR, lateral tibial glide, or other Functional Mobilizations I do in closed chain don’t work to improve knee flexion, I try this knee tilt.

It can be enhanced or made much more comfortable with an EDGE Mobility Band. Try this mobilization and let me know what your results are!

Articles Of The Week April 19, 2020

 

How often do you have a patient come in who is dealing with pelvic pain? I haven’t seen it much in my practice but I think this is also partially because it’s not common for a Massage Therapist to treat this area. Well, perhaps it’s time we change that.

“Treatment of Pelvic and Abdominal Pain for the RMT” – Jocelyn Kirton

We all know I have mad respect for Todd Hargrove, so when he puts on a master class about pain, movement, and play (while also doing it for free), I think we should all take advantage!

“Pain, Movement, And Play: Common Sense For Complex Problems” – Todd Hargrove

I haven’t had a chance to do this course myself but it was recommended by someone I have HUGE respect for, so it must be good. Another great way to get some learning done during the pandemic.

“Exercise And Physical Activity For Knee Osteoarthritis” – Rana Hinman

Still not sure where to start learning about pain? This is a phenomenal resource put together on some of the top pain resources available.

“Pain Resources: A Deeper Dive” – Rebecca Hall

We all know how important exercise is. As this review points out, it’s actually very important to help decelerate cognitive decline. Although exercise might not enhance cognitive function, it does effectively decelerate the decline in cognitive function.

“The Effect of Physical Exercise on Cognitive Functioning in Individuals with MCI and Dementia” – Scott Buxton

 

Looking at Pain From Different “Levels”

 

Pain can be a complex phenomenon, meaning that many different factors might contribute to pain, and that these factors can be interwoven in a way that makes it very hard to separate one from the other, either for purposes of explaining pain or intervening to treat it in some way.

This is a major theme of my recent book Playing With Movement, where I argue that complexity science has many concepts that are useful in understanding movement and pain.

One of these concepts is that complex systems are often nested. That means the system as a whole is composed of smaller subsystems, which are also composed of smaller subsystems and so forth.

 

Example of pain complexity

Where is the pain?

For example, people are made up of organ systems (like the nervous system or musculoskeletal system), which are in turn composed of organs (like the brain and spinal cord, muscles, and tendons), which are composed of cells (like nerve cells and muscle cells) and so forth. Further, people are parts of larger systems like families and communities and economies. This is interesting because each nested system provides a different level from which we can attempt to explain and treat pain.
Here’s a diagram to illustrate:
Screen Shot 2018-05-11 at 7.17.42 PM.png

At the “lower” levels, you can analyze the health status of cells and organs like muscles, tendons, discs or nerves. For example, maybe your foot hurts because of a stress fracture. This is where you can find “issues in the tissues”, which is where traditional pain treatment has focused most of its attention. This is often called the “biomedical approach” or the “bio” part of the biopsychosocial model. You find the structure that is damaged and work to repair it.

At the “higher” levels of analysis, such as the person or the environment, you are looking at more complex phenomena – the role of thoughts, emotions, or social relationships. These are the “psychosocial” issues that are known to have very important effects on chronic pain.

Problems in these areas are often relatively subtle, more about dysregulation or imbalance than something being broken or injured. These issues are also invisible if you look for them at a lower level. For example, you can’t see catastrophising by assessing a foot – you need to talk to a person.

Fields Of Study

There are many different formal disciplines you could study to get a better understanding at each level. Note that they are very different from one another, and very few people will have significant knowledge at more than one level.

Screen Shot 2018-05-11 at 7.19.35 PM.png

At the lower levels, you could study biomechanics, exercise physiology or neurodynamics. Each would give you a better understanding of how physical structures in the body respond to stress – either by breaking down and getting injured or adapting to get stronger.

You could move up a level to study the behavior of a larger system like the nervous system, immune system or endocrine system. This would help you see that pain functions like an alarm. The nervous, immune and endocrine systems help set the sensitivity of the alarm, and determine the kinds of events that cause it to go off. “Pain science” is mostly education in the basic physiology of these systems as they relate to pain. 

We can move up another level to the “person”, where we are studying the role of cognitions and emotions in pain. This is the realm of psychology, the relevance of which should be obvious – pain is a psychological event.

Psychological concepts can be very useful in understanding why movement and physical activity help with pain. For example, cognitive behavioral therapy can explain how exercise might extinguish fears or expectancies that contribute to pain. In many cases, this perspective is more helpful in choosing an exercise program than one focused on “lower-level” concerns about muscle groups, reps, and sets.   

You could move yet higher to study the role of social and economic systems. Many social critics argue that the real pathologies causing a wide variety of chronic diseases – including drug addiction, anxiety, depression, and even chronic pain – live more at the level of society than the individual. For example, low socioeconomic status is a big predictor of chronic pain. Most readers of this blog are not active in trying to solve problems at this level but are quite aware that they have a big impact on clinical outcomes.

Comparing The Different Levels

The terms “high level” and “low level” don’t reflect any value judgment. They merely indicate different perspectives: one is taking a “micro” view of relatively small and simple things like tendons or muscles, and the other is taking a “macro” or big picture look at larger complex things like nervous systems and emotions.

In general, if you’re moving down levels in your effort to explain some problem, you could call that “reductionist.” And if you’re moving up, that might be called a more “holistic” or “systems thinking” approach.

Screen Shot 2018-05-11 at 7.37.06 PM.png
Again, there is not necessarily any right or wrong here – the right level depends on the context.  Some problems with pain, especially those related to acute injuries, benefit from a lower-level approach – strengthen this, stretch that, do X sets of Y reps for Z weeks and then you will be fixed. Other pain problems can never really be “fixed” and may be hard to manage even with a whole team of psychotherapists, social workers, and attorneys.
Although each end of the spectrum has its costs and benefits, there is no doubt that until very recently, manual and movement therapists have spent way too much time at the lower levels, looking for issues in the tissues with their microscopes, while ignoring some very real big picture human issues sitting right in front of them. If the “pain science revolution” means anything, it is trying to improve basic literacy at the higher levels. “Playing with movement” means exploring a problem from as many different levels and perspectives as possible. To put it simply, finding physical activities that are challenging, meaningful and variable will go along way toward engaging us on almost any level that matters.

Articles Of The Week April 12, 2020

 

Right now we can all use a little help. While this is directed towards our friends in the U.S. there is some valuable advice for all of us during these trying times.

“Corona Virus And Massage Therapist Resources” – Laura Allen

With social distancing in place and many fitness facilities closed, we are seeing a lot more people outside running, biking, and hiking. However, during these activities we may need to actually increase our social distancing.

“Belgian-Dutch Study: Why In Times Of COVID-19 You Should Not Walk/Run/Bike Close To Each Other.” – Jurgen Thoelen

While everyone is dealing with their own issues around this new pandemic, it presents a new challenge for our patients dealing with chronic pain. Many of the treatments they use can affect their immune system and the effects of the virus itself can actually make their pain worse.

“Clinical Challenge: Chronic Pain and COVID-19 — Pain Patients May Be Hit Harder Than Others” – Judy George

While we are all concerned with our immune system right now, it’s important to know this system has a role in dealing with pain. While we cannot treat infections, it is important for us to know how the immune system plays a role in pain modulation.

How Immune System Contributes to Pain With Nervous System” – Nick Ng

Wondering what to do during isolation? Here’s a great list of videos which all contain the latest knowledge about pain from experts in modern pain science.

“Pain lectures with Pain Experts like Moseley, Stanton, Butler, O’Sullivan, Nijs, O´Connell, Zusman, Lehman, Reme, Thacker, Louw, Pearson and Dr. Kieran O’Sullivan” – Lars Avemarie