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Mythbusters
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Mythbusters - January 15, 2005 4:09:00 AM
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bravocosta
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Mythbusters
Practicing physical therapy for several years now has been an exciting journey filled with part discovery/validation, and often with dead ends, nonsense, and time wasting whilst trying to cut to the chase. I would like to start this post with some P.T. "myths" that in my opinion are nonsense. For starters.....
1) PT's who claim to palpate the PSOAS (ouch)
2) PT's who claim to palpate the piriformis and implicate it in virtually every case of LBP that refers to the buttocks, and then propose to selectively stretch it. ie - piriformis stretches
3) Claims that the I.T.band can be "stretched"
4) Claims that you can "with practice"palpate the anterior aspect of vertebral bodies
5) PT's who "can" accurately asses the ubiquitous SI joint for left on right , torsion, upslip downslip, and West Himilayan preJurrassic slip
6) Specific diagnosis for nonspecific LBP without pain referral below buttock ie- facet joint syndrome (even though repeated BB is painfree)
7) Don't even start me on the Ultrasound !
Just for starters..........Would love to hear what others used to do/think earlier in their careers but now realize is nonsense. What apporach do you use now instead ?This could be a great learning post and save many of us a lot of wasted $$$, time, and ineffective approaches. Look forward to your replies !
Cheers.........Thomas
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Re: Mythbusters - January 15, 2005 5:12:00 AM
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ericm
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From: Nanaimo, BC
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2 more myths
8) That the culturally accepted definition of 'Good' posture correlates inversely with pain
9) That muscular strength correlates inversely with pain
eric
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Re: Mythbusters - January 15, 2005 5:59:00 AM
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SJBird55
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That patellar taping by precise gliding, sliding, yanking, rotating, tilting and putting that patella in place is the key to resolving patellofemoral pain. And on the same subject that the VMO is the primary culprit and thousands of straight leg raises solve the issue.
That you can precisely palpate and you have to know exactly how the lumbar vertebrae are positioned (bent, extended, rotated, shifted whatever) in order to effectively treat the lumbar spine.
That therapists with tons of letters behind their name or with a lot of years of clinical experience are always better therapists with better outcomes. All I'm saying is that credentials do not guarantee better results.
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Re: Mythbusters - January 15, 2005 6:25:00 AM
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chiroortho
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Hey, wait a minute! Maltracking patellae and VMO strenghtening...SJ, you think this is bogus?
Of all the LE problems that I see, the lateral tracking patella dealt with by VMO strengthening makes the most sense to me!
What am I missing here?
_____________________________
Greg Priest, DC, DABCO
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Re: Mythbusters - January 16, 2005 4:52:00 PM
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FLOrthoPT
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I love finding SI pathologies, and when i worked along side other biased manual PTs, we would check each other by having each other assess and not tell what we found adn we correllated like 95% of time, so do not think SI palpation and movement testing and treatment is that bogus...
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Re: Mythbusters - January 16, 2005 6:49:00 PM
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nari
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Patellar taping is hugely over-rated, due to the burgeoning diagnoses of PFSyndrome.
Sticking a piece of tape in an arbitrary position (say, across the pat tendon) or somewhere around the patella is quite useful for reducing pain, enabling more functional work to be done by the LL and hence strengthening by default...
Mechanism is unclear. Does anyone seriously believe that a piece of tape will alter the mechanics of how a patella, exposed to all sorts of forces, moves?
Yes, and the same goes for palpation onto vertebrae of various sizes and levels. I can feel a lack of movement, but to be quite sure that it is 'pathological', needing correction, and not just a bit of a stiff segment...well...
Thomas, I agree with all of your myths.
Particularly the silly Piriformis Syndrome (what a joke), the eastern Appalachian post-Ordivician slip of the SIJ(do not forget that) and that muscle strengthening is a prerequisite for alomost every condition under the sun, even when the muscle function is fairly normal....
Despite the rattles above, there is still a lot of physiotherapy that works when practised on the right condition for the right reason....I think.
Nari
PS - Despite rumours, I am not cynical all of the time - just when researched stuff is taken too seriously in a compartmentalised fashion, ignoring the many-facted aspects of a malfunctioning, and complex body...
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Re: Mythbusters - January 17, 2005 12:36:00 AM
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SJBird55
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Yep, Greg, it has to be bogus. If it wasn't, then there would be a higher percentage of patients that responded to straight leg raises.
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Re: Mythbusters - January 17, 2005 2:05:00 AM
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bravocosta
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Greetings all,
More myths.....(in my humble experience)
That you can palpate the transverse processes in the lumbar spine.
That pelvic obliquity correlates well with pain.
As for the maltracking patella /VMO argument, in my opinion it has some merit, do run into quite a few however that have excellent functional strength and great tone in the VMO so its not the be all end all. As for SLR's done in the supine position, I believe some studies show only 25% quad activation in the supine position and (guessing here)maybe 40% in the standing position. Have other thoughts, but would be far more interested in hearing yours. Does SI joint treatment approach work (sure it works in some cases),but not sure how it works without directly affecting the L-spine. Cheers.....Thomas
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Re: Mythbusters - January 17, 2005 3:01:00 AM
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jma
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Another myth that I hear patients tell me, is that they believe that if they have a disc reduced or removed, then there will be NO MORE radicular pain/paresthesias, once the procedure is done. Then they come to PT with the same complaints they had before the surgery.
JMA
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Re: Mythbusters - January 17, 2005 3:31:00 AM
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Diane
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The whole set of memes described above by all, myths and beliefs (mostly transferred to us holus bolus from chiro, and the orthopaedic branches of PT and MD) used to drive me crazy, until I came upon David Butler, who gently made sense out of them all with his peripheral nerve soft tissue entrapment or irritation ideas. He started out as a confused ortho practitioner too, getting taught all the myths about joint based dysfunction, but managed to find a way out of the woods by focusing on pain, and learning to base his clinical findings on whatever nervous tissue running in or near the vicinity of the area of pain, turning his interventions toward unloading IT rather than beating up on some innocent bone or joint nearby.
For example, that medial knee pain: Saphenous nerve. Continuous in some people from pelvis to big toe. Branch of the femoral. As soon as I started treating nerves the world started to make sense.
The body isn't simple, it is complex. Nerves aren't exactly the same in all people. They sometimes take creative anatomical detours. Pain isn't simple. A nerve can be irritated in one place and pain show up somewhere else. Trying to make it simple and bone&joint based because bones are easy to study while sitting at a desk rolling a bone around in your hands, or looking at a skeleton and examining joints and churning out recipies based on the easiest thing that there is in the body to find and grab and or shove on, is a ticket to confusion for most of us and a testiment to how capable:
1. the human nervous system is for gratefully grabbing onto any sort of input to try to right itself, in spite of how wrongly offered
2. the human mind for being able to contain paradox.
Great idea for a thread Thomas.
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Re: Mythbusters - January 17, 2005 4:23:00 AM
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KIDPT23
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I think the major issue here is that there are too many therapists that do not look at the individual and do not put their hands on the patients. Too many therapists follow protocols and of course a lot of the previous would not work in certain instances. I think there is a time and place for most of the previous treatments if they are performed at the right time of the treatment process. Piriformis stretching can be beneficial early stages of the recovery process, US performed while the patient is being stretched and with pressure in the wand to give soft tissue work will definetely give results, and work on the IT band will in fact provide a lengthening effect if performed correctly. This is to name a few. Now i also believe that you cannot work on the SI joint itself but other therapists i know swear by it. I feel that everyone has their opinion on certain treatments and if the therapist is confident in what they are doing then the patient will pick up on that confidence and results will be achieved. The main determinants of a patient improving is still exercise and how they are dealt with on a psychological basis. I believe with this and treating each patient individually and putting your hands on the patients regularly, you will succeed.
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Re: Mythbusters - January 17, 2005 7:17:00 AM
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chiroortho
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Trigger points. I don't like the the term, and have come to prefer the term 'trigger area', although that, too, is not totally satisfactory. But I love it when a patient comes in with vague, deep pain in the upper outer quadrant of the buttock with some 'radiation' of pain into the leg to the foot. I proceed to take my thumb and dig with gusto into the glut medius hunting for the mother lode, and when I hit it the patient yells two things at the top of his lungs:
'STOP, YOU'RE KILLING ME!', and 'PUSH HARDER, THAT'S IT!'
We also use the G5 unit over the area with some moist heat, and many times the 'radiculopathy' is gone, no MRI needed, no ongoing treatment required. Some patients require a few followups.
For those patients with persistent pain, yes, we get the scan.
_____________________________
Greg Priest, DC, DABCO
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Re: Mythbusters - January 17, 2005 12:55:00 PM
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bravocosta
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Dear KidPT23,
You are correct when you state that too many therapists follow protocols etc... . My contention is that you cannot SELECTIVELY stretch the piriformis (look at that large buttocks in the way and all of the other attachments). I am not advocating that you shouldn't use this method, but lets call it something else. Maybe it works by mobilizing the nerves in the surrounding area. (Why would the little piriformis get tight on its own?)Work on the IT band "may give results" indeed, but look at the anatomy of that band(you could probably hang a jeep from it)so how are you "stretching " it? (to be fair you do describe a lengthening it)
Ultrasound ....hmmm not too sure on that one. Remember as a new grad using an old machine (the kind with the manual turn timer) and for almost a week and a half forgetting to turn on the intensity (embarrassing). Well, almost every patient told me it felt better afterward,and some attributed their recovery to this ultrasound treatment. Most likely the circular pressure helped to relax the areas I was treating as nothing was happening with the intensity. You are very correct in stating that our confidence in our approach is powerful stuff ! (please forgive my lack of humility).
Diane, beautiful post......boy do I have a lot to learn!...........Cheers....Thomas
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Re: Mythbusters - January 17, 2005 1:18:00 PM
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ericm
Posts: 171
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From: Nanaimo, BC
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Thomas, as a student I too used the US without turning it on once. Worked beautifully.
eric
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Re: Mythbusters - January 17, 2005 4:35:00 PM
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FLOrthoPT
Posts: 85
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From: wellington, fl, usa
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is it possible that sacral torsions facilitate the surrounding area and change the muscle tone of the piriformis and make it tight? Granted then yes shouldn't your treatment be to treat the joint and the nerve tension, but couldn't this make a piriformis tight?
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Re: Mythbusters - January 17, 2005 4:37:00 PM
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FLOrthoPT
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From: wellington, fl, usa
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many times i have forgotten to turn up the US intensity. Once I had a guy claimining it was hurting him on 0 intensity, that was fun too!
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Re: Mythbusters - January 17, 2005 4:50:00 PM
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PTupdate.com
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HMMMMMMM, my favorite is "put your hands on someones head and feel that cranial pulse. AND, after taking 5 of our courses and giving us lots of money, we will TEACH you how to move the cranial bones on one another!!!!!
Always wanted to see that poor patient with a football shaped head from a therapist that moved them cranial bones too much.
Go Steelers
John Duffy, (initials deleted for SJ)
(website link also deleted for SJ)
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Mythbusters - January 17, 2005 5:54:00 PM
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Synergy
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From: Texas
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[QUOTE]..."put your hands on someones head and feel that cranial pulse. AND, after taking 5 of our courses and giving us lots of money, we will TEACH you how to move the cranial bones on one another!!!!! Always wanted to see that poor patient with a football shaped head from a therapist that moved them cranial bones too much.[/QUOTE]ROFL @ Duff!!! Smoke and mirrors...that is all!
I agree with you FLOrthoPT. What I was taught in school (by a well respected CFMT) was that the opposite piriformis drives the torsion...so to speak. However, Thomas brings up an interesting point as well...too many other muscles, ligaments, etc. superficial and adjacent to that 'facilitated' piriformis. Interesting points all around.
_____________________________
Chris Adams, PT, MPT
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Re: Mythbusters - January 17, 2005 6:32:00 PM
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FLOrthoPT
Posts: 85
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From: wellington, fl, usa
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hey duffy what about a friendly wager
I am from new england and die hard red sox, uconn basketball and patriotss fan, needless to say this has been a great sports year for me! Well, what about if steelers win i buy a membership to your site, pats win you give me one?
GO PATS
steelers better put maddox in if they hope to win
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Re: Mythbusters - January 17, 2005 6:51:00 PM
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Synergy
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From: Texas
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Prediction:
NFC Champion: Eagles (ugh!)
AFC Champion: Pats
NE's defense will hold Pittsburgh to 17 points and NE will score 24. Philly's 'D' will strangle Michael Vick and hold them to 13 points...Philly will win big and score 35.
Superbowl? A tight one to say the least, but the Pats will prevail with an Adam Vinateri field goal to clench it.
BTW...I'm a sad Cowboys fan :(
_____________________________
Chris Adams, PT, MPT
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