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Re: On guard
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Re: On guard - January 22, 2005 2:32:00 PM
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gary s
Posts: 74
Joined: March 24, 2001
From: wantagh, ny, usa
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Cneup,
I agree with you. What I was trying to say was that guarding causes altered biomechanics.
Gary
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Re: On guard - January 24, 2005 7:51:00 AM
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OrthoSam
Posts: 16
Joined: January 6, 2005
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Hi all,
I am not about to begin talking about evidence based medicine again, but John, you proved to me that there can be an inherent flaw in making the jump from the patient to evidence.
Firstly, heat has been shown in physiologic studies of collagen to cause denaturing of protein, and weakening of hydrogen bonds between tropocollagen molecules. There is a shortened time to failure under load, due to weakened collagen. Heat is the last thing that should be applied to immature collagen, especially if you plan on stretching collagen after that.
Why mobilize the joint if there is no joint to moblize? Most knees have a locking peg connecting the tibia and femur, so minimal translatoric motion occurs, if any. I suppose you could mobilize the patellofemoral joint, but consider considering that PF joint motion loss may be due to quad guarding, effusion, edema, its not just a "joint"issue, if pain is involved.
If you "could" mobilize, what are you mobilizing in the sub-acute phase anyway? The collagen is so immature that it should allow collagen yield easily in its plastic range, unless you rupture it by going in to "your feel" (unreliable) of end range.
There is evidence that exercise improves the "elastic" phase of collagen, by decreasing early cross bridging of collagen fibrils, stimulates the production of GAG and improves the efficiency of proteoglycan movement within the matrix, as well as stimulating the production of collagen through increased protein synthesis at a cellular level. Improved ability of collagen to withstand tension prior to micro-failure decreases pain, and therefore muscle guarding.
It has been shown also that recruitment of mechanoreceptors within the knee capsule also causes reflex quadricep contraction, even in the absence of pain. Effusion "pre-stretches" the knee capsule during knee flexion and causes an early recruitment of the quad. If the quad has just been "split" by the surgeon, then passive range should be a no-no( not at all for safety reasons.) Passive stretch as you know causes a mono-synaptic reflex facilitated by the muscle spindle.The reflex is stronger in the presence of pain, because of involvement of the higher levels and greater receptor recruitment. The patient therefore contracts their quad, fighting the PT all the way.
Exercise, dosed appropriately toward end range of collagen can be performed in the absence of pain i.e, don't break early collagen bonds.
We have not yet quantified the significance of "touch", but from a purely theoretical/logical standpoint, it makes sense that it may stimulate superficial mechanoreceptors in the knee, causing a mono-synaptic inhibition of guarding, allowing you
" access" to the patient. Manipulation is mechanoreceptor recruitment right?
I guess my point is John, when examining the literature, are you asking the right questions? We can only find answers to the questions we ask, not the questions we do not.
Cheers,
Sam
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Re: On guard - February 3, 2005 7:27:00 AM
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Yogi
Posts: 403
Joined: April 5, 2004
From: San Antonio, Tx., USA
Status: offline
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cneup, I doubt cognitively we are aware of guarding, except when we feel "stiff" or we know something is strained or "out of place", and then it is purposive, i. e., we consciously know not to move it. I think more of guarding as Jon so well defined it, "m. guarding is simply an automated behavioral response to aversive stimuli". I find it amazing sometimes how long "guarding" can persist. Months, sometimes, and I suspect years. I may be splitting hairs, I think guarding as defined isn't in our conscious awareness. As I've mentioned before, Srain/Counterstrain works well on some reflexive guarding corresponding to specific "tender points", and perhaps it "tricks the muscle". I offer as evidence of the subconcious level of guarding and effect from hypnosis. When the hypnotist says you cannot perform a movement, the antagonist for that movement contracts and prevents the movement, yet we (and the audience) are totally unaware of the contraction, and the reason we can't move. I discovered this during self hypnosis experiments years ago.
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Re: On guard - February 4, 2005 3:59:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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I have very few of those patients (at least knee and shoulder ones) who do not respond very well to mobilizations.
I have had a few people who did not, and therefore I had to use unorthodox methods, with some limited success. I have had some luck with that AAROM/Total gym type technique mentioned earlier, when mobs didn't work.
But mobs have done well for me. No surprise, they do well in the outcome studies also.
It seems like every thread is an EBM thread, to some degree...
I am disturbed by Diane's rather vitriolic attack on an evidence based practitioner, so I guess I sort of take umbrage by extension.
Just so as to re-phrase some earlier statements as to EBM...
Please don't confuse a preference for evidence based methods as a rejection of all others. That is simply not the case.
Where evidence exists, we should use it. Where evidence does not exist, we should do the best we can to integrate our training and clinical experience to provide the best care we can to our patients. That was Sackett's original definition (paraphrased).
EBM does not equal protocol based or cookbook therapy.
Using EBM methods FIRST, and falling back on impairments and paradigms second is not a rejection of methods. It is a prioritization of methods.
I think it’s foolish to not do something proven effective because you're not comfortable with it or it doesn't fit your paradigm or your theory of treatment.
I hope my family physician doesn't practice like that:
"well, Jason, the evidence supports using an antibiotic for your condition, but I don't really think that's a good idea...given what we know about your pain state and some neuroscience research, here's some Motrin instead..."
This criticism is not aimed at anyone in particular (I’ve met too many of these folks to be specific) but at many people I have met in our profession who hold fast to theories of treatment and do not pay close attention to, and regularly modify, their practice based on EVIDENCE.
This willingness to reject personal feelings of "success" in the face of evidence is the mark of a scientist.
And shouldn't we all be scientists?
Theories have their place, that's where tomorrow's interventions come from. But we are here TODAY, and we should not confuse that fact.
I think it is very dangerous to take the position that "when you're older and have more experience, you'll be able to feel things that people need and go with that, you need experience (and age, evidently) to pick up on these things."
Again, not aiming this at anyone in particular, I have heard this from many different people.
Isn't this sort of thinking what makes us laugh at things like Reiki, Chi-Gung healing, and some nonscientific spine pracitioners who claim to be able to feel all sorts of ridiculous things?
(not directed at our evidence based colleagues who happen to have "DC" after their names)
I think that we can honestly share our clinical experience about things we have found successful, even if they are not evidence based. I don't want to speak for any other posters, but it seems to me that that was what the thread was about. So I'm not suggesting we don't share anecdotal ideas about how to treat patients. But...
I only get my feathers in a ruffle when I see people deliberately avoiding EBM methods as first line treatments in favor of others. Especially when they make unsubstantiated claims about the efficacy of such methods. That is deliberately holding our profession (not to mention scientific progress) back.
To address OrthoSam's very good point about asking the right questions (and well said sir), I would say that right now, the only question worth asking is "does this method achieve better outcomes than that one?"
Note this has nothing to do with basic science research or theories/constructs of thought, though we certainly should base our proposed studies on basic science. But study the intervention for it's outcome (or lack thereof), not for it's theoretical underpinnings.
Sorry I'm going off like crazy again...
Maybe my wife's right, I need a vacation. :)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: On guard - February 4, 2005 5:54:00 AM
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Yogi
Posts: 403
Joined: April 5, 2004
From: San Antonio, Tx., USA
Status: offline
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Wifes are always right. Have a good relax and recharge on your vacation.
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